lucy adkinson. case history reminder of different causes update on recent nice guidance
TRANSCRIPT
CASE Joe Locally advanced pancreatic cancer Admission February for pain control Whilst inpatient accumulating ascites
Trial diuretics with no improvementParacentesis performed Discharged home on increased diuretics
2 weeks later readmitted with tense ascites again BRI for PleurX ascitic drain insertion
REVISION... Ascites
75% cirrhosis10% malignancy3 % heart failure2% TB
Estimated problems associated with ascites present in 3.6 – 6% of hospice inpatients
PATHOPHYSIOLOGY OF MALIGNANT ASCITES Two principal mechanisms in malignant
ascites divided into transudates and exudatesTransudates
Low proteinExudates
High protein
Multiple hepatic mets or single large tumour causing Budd-chiari
syndrome
Increased hepatic venous pressure
? Increased vascular permeability
Peritoneal tumour deposits and tumour neovasculature = leaky
Extravasation of fluid
BUT Ascitic fluid can also arise from unaffected peritoneum:
Observed marked neovascularisation of peritoneum in malignant ascites and ovarian ascites - ? Cytokine and VEGF in ovarian cancer related leaky
capillaries
Fluid leakage into peritoneum from sinusoids
Increase in plasma renin conc and thus salt and water
retention Indicative of portal hypertension Similar to cirrhosis
CHYLOUS ASCITES Complication of retroperitoneal tumour
spread or its treatment Either due to damage of lymphatic
vessels or obstruction of lymphatic flow through lymph nodes or pancreas
ALBUMIN GRADIENT Serum-ascites albumin gradient= serum
albumin (same day) – ascites albumin High gradient “transudate” > 11g/l
Indicative of portal hypertension Important because can help assess the
likelihood response to diuretic therapy with aldosterone antagonist
DIURETICS In malignancy role is controversial and
slim evidence base BSG Guidelines on management of
ascites in cirrhosis
CLINICAL EVIDENCE 9 observational studies
6 were case series 10+ patients1 qualitative case series3 case reports
ROSENBERG ET AL 2004 N = 40 (pleurX) assessing treatment
complication rates compared with large volume paracentesis
Complications same for both types Infection n=1 Leakage n=1 Loculations n=1 N=27 working at death but 11 lost to
follow up
COURTNEY ET AL 2008 34 patients over 12 weeks (or death) 100% technical success 2 catheters needed to be removed Infection n=2, loculations n=14, leakage
n=7, dizziness n=5, SOB n=1 Mean number of drainage sessions 23.3 28% performed by patient, 58% by carer Improved QoL at 12 weeks 28%
respondents
COSTPer pt PleurX IP
paracentesisOP paracentesis
£2466 £3146 £1457
• Saving of £679 per patient in comparison with inpatient paracentesis•7.4 hospital days saved per patient•23.5 more community nurse visits