1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3d Symptoms – Ascites Module 3d Symptoms – Ascites EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Malignant ascites... l Definition: accumulation of fluid in the abdomen

4. ... Malignant ascites Epidemiology l 10% caused by malignancy l 80% of malignant ascites is epithelial: OvariesEndometriumBreastColon GI tract PancreasEpidemiology l 10% caused by malignancy l 80% of malignant ascites is epithelial: OvariesEndometriumBreastColon GI tract Pancreas Runyon, et al. Hepatology, 1998.

5. ... Malignant ascites l Impact: dyspnea, early satiety, fatigue, abdominal pain l Prognosis: poor Mean survival with malignant ascites < 4 months If chemo-responsive cancer, eg, newly Dx ovarian ca, mean survival = 6 months – 1 year l Impact: dyspnea, early satiety, fatigue, abdominal pain l Prognosis: poor Mean survival with malignant ascites < 4 months If chemo-responsive cancer, eg, newly Dx ovarian ca, mean survival = 6 months – 1 year

6. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

7. Pathophysiology... l Normal physiology: Intravascular pressure = extravascular pressure No extravascular fluid accumulation l Ascites: Fluid influx increases Fluid outflow decreases Fluid accumulates l Normal physiology: Intravascular pressure = extravascular pressure No extravascular fluid accumulation l Ascites: Fluid influx increases Fluid outflow decreases Fluid accumulates

8. ... Pathophysiology l Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis) l Decreased osmotic pressure (eg, nephrotic syndrome, malnutrition) l Fluid production > fluid resorption (infections, malignancy) l Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis) l Decreased osmotic pressure (eg, nephrotic syndrome, malnutrition) l Fluid production > fluid resorption (infections, malignancy)

9. Assessment... History & symptoms l Ankle swelling l Weight gain l Girth l Fullness l Bloating l Discomfort l Heaviness l Ankle swelling l Weight gain l Girth l Fullness l Bloating l Discomfort l Heaviness l Indigestion l Nausea l Vomiting l Reflux l Umbilical changes l Hemorrhoids

10. ... Assessment Physical examination l Bulging flanks l Flank dullness l Shifting dullness l Fluid wave l Bulging flanks l Flank dullness l Shifting dullness l Fluid wave

11. Extra-abdominal signs of ascites l Enlarged liver l Hernias l Scrotal edema l Lower extremity edema l Abdominal venous engorgement l Flattened, protuberant umbilicus l Enlarged liver l Hernias l Scrotal edema l Lower extremity edema l Abdominal venous engorgement l Flattened, protuberant umbilicus

12. Diagnostic imaging l If physical exam is equivocal l Detects small amounts of fluid, loculation l ‘Ground Glass’ X-ray l CT scan l If physical exam is equivocal l Detects small amounts of fluid, loculation l ‘Ground Glass’ X-ray l CT scan

13. Diagnostic paracentesis l Color l Cytology l Cell count l Total protein concentration l Serum-ascites albumin gradient l Color l Cytology l Cell count l Total protein concentration l Serum-ascites albumin gradient Hoefs J. Lab Clin Med, 1983.

14. Diagnosing ascites - Summary l Malignant etiology likely when ascitic fluid has: Blood Positive cytology Absolute neutrophil count < 250 cells / ml Total protein concentration > 25 gm / L Serum-ascites albumin gradient < 11 gm / L l Malignant etiology likely when ascitic fluid has: Blood Positive cytology Absolute neutrophil count < 250 cells / ml Total protein concentration > 25 gm / L Serum-ascites albumin gradient < 11 gm / L

15. Management l Goal: to relieve the symptoms l With little or no discomfort: don’t treat l Before intervening, discuss prognosis, benefits, risks l Goal: to relieve the symptoms l With little or no discomfort: don’t treat l Before intervening, discuss prognosis, benefits, risks

16. When to treat? l With these symptoms: Dyspnea Abdominal pain FatigueAnorexia Early satiety Reduced exercise tolerance l With these symptoms: Dyspnea Abdominal pain FatigueAnorexia Early satiety Reduced exercise tolerance

17. Therapeutic options l Dietary restriction l Chemotherapy l Diuretics l Therapeutic paracentesis l Surgery l Dietary restriction l Chemotherapy l Diuretics l Therapeutic paracentesis l Surgery

18. Dietary management l Sodium and severe fluid restriction Difficult for patients Discuss benefits, burdens & other treatment options first l Sodium and severe fluid restriction Difficult for patients Discuss benefits, burdens & other treatment options first

19. Diuretics l Effective l Well-tolerated l Treatment goals: Remove only enough fluid to manage the symptoms Slow & gradual diuresis l Effective l Well-tolerated l Treatment goals: Remove only enough fluid to manage the symptoms Slow & gradual diuresis Pockros J, et al. Gastroenterology, 1992.

20. Selecting a diuretic l Spironolactone 25 mg – 50 mg / day l Amiloride 5 mg / day l Furosemide 20 mg / day l Spironolactone 25 mg – 50 mg / day l Amiloride 5 mg / day l Furosemide 20 mg / day

21. Precautions with diuretics l Avoid salt substitutes l Evaluate benefits & burdens l Not appropriate in patients with: Limited mobility UT flow problems Poor appetite, poor oral intake Polypharmacy problems l Avoid salt substitutes l Evaluate benefits & burdens l Not appropriate in patients with: Limited mobility UT flow problems Poor appetite, poor oral intake Polypharmacy problems

22. Diuretic adverse effects l Problems with Sleep deprivation Self-esteemSkinSafetyFatigueHypotension l Problems with Sleep deprivation Self-esteemSkinSafetyFatigueHypotension

23. Therapeutic paracentesis l Indications: Respiratory distress Diuretic failure Rapid symptomatic relief l Safe l In clinic or home l Indications: Respiratory distress Diuretic failure Rapid symptomatic relief l Safe l In clinic or home

24. Therapeutic paracentesis technique l Patient supine or semirecumbent l Select site l Cleanse, disinfect skin l Patient supine or semirecumbent l Select site l Cleanse, disinfect skin l Insert l Attach 3-way connector l Evacuate l Reposition

25. Surgery l Peritoneovenous shunts Drains ascitic fluid into internal jugular vein Rarely done l Tenckhoff, other catheters Local anesthesia Large volume ascites Outpatient use l Peritoneovenous shunts Drains ascitic fluid into internal jugular vein Rarely done l Tenckhoff, other catheters Local anesthesia Large volume ascites Outpatient use Barnett TD, Rubins J. J Vasc Intery Radio, 2002. Burger JA, et al. Ann Oncol, 1997.

26. Summary... l Ascites causes distress in patients with advanced cancer l Rule out nonmalignant causes l Treatment is palliative l Dietary, pharmacological, and interventional options are available l Ascites causes distress in patients with advanced cancer l Rule out nonmalignant causes l Treatment is palliative l Dietary, pharmacological, and interventional options are available

27. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO... Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience