Malignant Ascities

Question 1

Presentation of malignant ascities

Answer 1

Weight gain but cachexic
SOB
Abdominal swelling, peripheral edema
Anorexia, early satiety, indigestion
N+V
Ankle swelling
Fatigue

Question 2

Possible differentials

• non peritoneal
• peritoneal

Answer 2

Non peritoneal - causing PHTN
-cirrhosis, hepatitis, liver mets

Peritoneal

• peritonitis
• malignant ascities

Question 3

Investigations

Answer 3

A-E assessment
Bloods
-FBC - anemia, malignancy affecting BM
-U&E - kidney function and electrolytes
-cultures - infective causes
-ABG - resp/metabolic pH imbalances
-amylase, lipase - pancreas function
-HepB, C serology - rule out hepatitis

Urinalysis and MC&S - kidney function, sources of infection

Abdo US - large volume ascities, paracentesis

• albumin protein
• cell count
• MC&S
• cytology - malignancy
• Leukocyte count for empyema

Question 4

Is this a transudate or exudate?
How would you assess this
What are the most common causes

Answer 4

Serum albumin - ascitic albumin = serum to ascitic fluid gradient

• 11g+ - transudate - PHTN from cirrhosis
• U11g - exudate - non PHTN causes

Question 5

Management of malignant ascities

-exudate or transudate

Answer 5

Exudate - diuretics less effective
Transudates - diuretics useful in liver mets => PHTN

Repeated large volume paracentesis
-indwelling catheter may be useful

Treat primary malignancy

Question 6

How does LVP work

Complications of large volume paracentesis

Answer 6

Can safely drain 5L => reassess symptoms and haemodynamic status before repeating

Prehydrate if low BP, dehydrated, significant renal impairment

Complications

• low BP, PE
• infection
• loculation, adhesions
• bowel perforations