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home - Liver - Ascites - Malignant Ascites Written by Dr Sebastian Zeki

Defines the causes (both hepatic and non hepatic) of ascites and
has a clear understanding of their pathogenesis

Recognises how to define resistant and refractory ascites
Understands the management of patients with ascites (including fluid
restriction use of colloids diuretics) as well as the indications for and
the role of interventional procedures such as paracentesis TIPS

Knows the value of laboratory investigation of acites including
diagnosis of spontaneous bacterial peritonitis its prognosis and

Appreciates the evidence for the prophylactic use of albumin
infusions to reduce risk of hepatorenal syndrome

Understands the indications for alternative interventions (e g TIPS
surgical shunt peritoneal–venous shunt and transplantation) and the
criteria for appropriate referral

Can perform safely both diagnostic and large volume paracentesis
Can refer patients in a timely manner to specialist liver services
Understand the implications on quality of life as well as the nutritional
impact of resistant ascites

Shows ability to develop and sustain supportive relationships with
patients and their families

Malignant Ascites

Management Patients usually need repeated paracentesis. Patients dont need albumin replacement. Peritoneal ports and catheters can also be placed to facilitate repeated paracentesis. Diuretics only work if portal hypertension present. Depending in part upon the tumor type, specific tumour-targeted treatments may be appropriate. For pancreatic cancer -systemic administration of gemcitabine may be of benefit, and the success of such treatment appears to correlate with ascitic fluid VEGF levels. For CML related ascites- Intraperitoneal administration of imatinib mesylate. For lymphoma related ascites- Rituximab may be of benefit. For peritoneal mesothelioma - aggressive cytoreductive therapy combined with intraperitoneal hyperthermic chemotherapy can be useful. Aetiology and Pathogenesis -Ovaries, bladder, peritoneal mesothe - lioma can cause peritoneal carcinomato - sis. with blockage of the draining lymphatic channels. -Colonic, gastric, breast, pancreatic, and lung cancers cause peritoneal carcino - matosis and/or massive liver metastases. -Most lymphomas tend to cause lymph node obstruction and the accumulation of chylous ascites. -The malignant cells of primary effusion lymphoma involve the serosal surface leading to symptomatic serous effusions containing high-grade, malignant lymphocytes, but with no detectable mass lesion. Malignant Ascites Appearance Ascitic fluid tests The total WBC count is >500 cells/mm3 in 75 % of patients with peritoneal carcinomatosis, 80 % of those with perito - neal carcinomatosis plus massive liver metastases, and 60% with cirrhosis and HCC. It is predominantely lymphocytic but can still have an absolute neutrophil counts >250 cells/mm3. A gradient >1.1 g/dL (11 g/L) indicates portal hypertension (97 % accurate). A gradient <1.1 g/dL (<11 g/L) indicates the absence of portal hypertension. Cultures are usually negative- it is unusual to have SBP if have peritoneal carcinomatosis. The ascitic fluid [protein] may provide a clue as to the cause of the malignancy-related ascites. In peritoneal carcinomatosis the mean ascitic fluid total protein= 4.0 g/dL, (95 % have >2.5 g/dL). <2.5 g/dL protein is more usual with massive liver metastases/ HCC complicating cirrhosis. If the fluid to serum LDH ratio is > 1.0, LDH is being produced in or released into the peritoneal cavity, usually because of tumour cells or infection. Cytology is 75 % sensitive. Only get malignant cells in fluid if have peritoneal carcinomatosis (occurs in 2/3rds of malignant ascites). Cytology is 100% sensitive for peritoneal carcinomatosis. Cytology is not sensitive for non-peritoneal carcinomatosis related malignant ascites. Pink or bloody — Pink fluid usually has a red cell concentr - tion of >10,000 cells/mm3. Frankly bloody fluid typically has a red cell count of tens of thousands of cells/ mm3. . Ascitic fluid is bloody in about one-half of patients with HCC and in about 20 % of malignancy-related ascites overall. Milky — Occurs if triglycerides> 200 mg/dL (2.26 mmol/L), and often > 1000 mg/dL =chylous ascites Turbid or cloudy — Cloudiness due to cells. Protein does not make it cloudy/ turbid Turbid if infected or pancreatic ascites Clear fluid — If uninfected- usually translucent and yellow Water clear if the ascitic fluid bilirubin concentr - tion is normal and the protein concentration is very low (eg, <1 g/dL). Tumour markers CEA and CA 125 — CA 125 is usually elevated in all causes of ascites (due to shear forces on mesothelial cells). Patients with chronic liver disease and ascites have average serum CA 125 of 321 U/mL. Ascitic fluid CA 125 levels can’t differentiate between ovarian cancer from ascites due to tumours or benign causes. Omental biopsy Can be done with transabdominal ultrasound-guided biopsy of the greater omentum if it is thickened. Serum-to-ascites albumin gradient — Cell count and differential — Laparoscopy Laparoscopy + biopsy of peritoneal implants has a sensitivity for peritoneal carcinomatosis 100 %. General approach — Written by Dr Sebastian Zeki Tumour-targeted treatment —

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