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Malignant Ascites

Malignant Ascites attributable to portal hypertension usually is associated with an increased serum ascites-albumin gradient (> 1.1 g/dL), a variable total protein, and negative ascitic cytology. Ascites caused by peritoneal carcinomatosis does not respond to diuretics.

Patients may be treated with periodic large-volume paracentesis for symptomatic relief. Intraperitoneal chemotherapy is sometimes used to shrink the tumor, but the overall prognosis is extremely poor, with only 10% survival at 6 months. Ovarian cancers represent an exception to this rule. With newer treatments consisting of surgical debulking and intraperitoneal chemotherapy, long-term survival from ovarian cancer is possible.

Malignant ascites is a manifestation of advanced malignant disease that is associated with significant morbidity. Although lymphatic obstruction has been considered the major pathophysiologic mechanism behind its formation, recent evidence suggests that immune modulators, vascular permeability factors, and metalloproteinases are contributing significantly to the process. The mean survival in patients with malignant ascites is usually less than 4 months. These new observations offer the opportunity for development of new, more targeted therapies for the treatment of malignant ascites. Therefore therapy has concentrated on symptom control. Approaches have included sodium restricted diets, diuretics, serial paracentesis, peritoneal shunting and chemotherapy (systemic and intraperitoneal).

Malignant ascites is seen most commonly in patients with ovarian, endometrial, breast, colon, gastric, and pancreatic cancer. It has been shown that around 10 to 15% of all patients with gastrointestinal cancer develop ascites at some stage of their disease. Generally, the presence of malignant ascites is associated with poor prognosis, regardless of the cause. The diagnosis and management of this challenging medical problem are subsequently discussed, with emphasis on how these new pathophysiologic insights are being applied to the development of novel therapies that may soon change how we manage this troubling clinical condition.

Causes of Malignant Ascites

Here are the list of the possible Causes of Malignant Ascites:

  • Hepatic congestion, congestive heart failure, constrictive pericarditis, tricuspid insufficiency, Budd-Chiari syndrome
  • Protein-losing enteropathy
  • Low levels of albumin in the blood that cause a change in the pressure necessary to prevent fluid exchange (osmotic pressure).
  • A goal or principle served with dedication and zeal: “the cause of freedom versus tyranny” (Hannah Arendt).
  • Liver disease, cirrhosis, alcoholic hepatitis, fulminant hepatic failure, massive hepatic metastases
  • Cirrhosis ( Cirrhotic Ascites )
  • Cancer (Malignant ascites)
  • Bacterial, fungal or parasitic disease
  • Cancer (Malignant Ascites )

Symptoms of Malignant Ascites

Some sign and Symptoms related to Malignant Ascites:

  • Malignant ascites may produce a cluster of symptoms including abdominal distension, early satiety, respiratory embarrassment, impaired mobility and lethargy.
  • Rapid weight gain
  • Malignant ascites can result in very troublesome symptoms for patients who may otherwise have some time to live. Peritoneovenous shunting is a well tolerated relatively minor surgical procedure which can achieve excellent control of ascites in the majority of such patients.
  • The duration of symptomatic relief ranged from 4 days to 45 days (mean, 10.4 days).
  • A symptom can more simply be defined as any feature which is noticed by the patient. A sign is noticed by the doctor or others

Treatment of Malignant Ascites

  • Therapeutic paracentesis should be reserved for patients who need rapid symptomatic relief of tense ascites.
  • TIPS is an interventional radiologic technique that reduces portal pressure and may be the most efficacious for treatment of patients with diuretic-resistant ascites.
  • Azotemia (abnormally high blood levels of nitrogen-bearing materials)
  • If the patient consumes more salt than the kidneys excrete, increased doses of diuretics should be prescribed.
  • The response rate was 5/7 (77%) for combined modality therapy vs. 2/9 (22%) for intraperitoneal chemotherapy alone.
  • The current recommendations are that intravenous albumin should be administered when large-volume paracentesis is repeatedly performed.
  • The incidences of hyponatremia, hypotension, hepatic encephalopathy, and renal impairment are lower for patients treated with paracentesis than for those treated with diuretics.

 


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