Lucy Adkinson

 Case history  Reminder of different causes  Update on recent NICE guidance

 Joe  Locally advanced pancreatic cancer  Admission February for pain control  Whilst inpatient accumulating ascites  Trial diuretics with no improvement  Paracentesis performed  Discharged home on increased diuretics  2 weeks later readmitted with tense ascites again   BRI for PleurX ascitic drain insertion

 Ascites  75% cirrhosis  10% malignancy  3 % heart failure  2% TB  Estimated problems associated with ascites present in 3.6 – 6% of hospice inpatients

 Two principal mechanisms in malignant ascites divided into transudates and exudates Transudates Low protein Exudates 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

 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

 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

 In malignancy role is controversial and slim evidence base  BSG Guidelines on management of ascites in cirrhosis

 9 observational studies  6 were case series 10+ patients  1 qualitative case series  3 case reports

 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

 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

 50 patients  8 complications  100% patency at death

Per pt PleurXIP 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

 Different causes of ascites in malignancy  If diuretics don’t work +/- ascites reaccumulates after paracentesis consider referral for pleurX ascitic drain (via oncology in BRI for costing)