Less common symptom in palliative care: assessment and management --Ascites
Author:zplhelen | Time: 2009-7-21 21:25:291. Pathophysiology and cause:
Abnormal accumulation of fluid in the abdomen cavity caused by cancer is called malignant ascites. 10% of ascites are caused by malignancies (malignant ascites),in which 50% develop secondary to invasion of the parietal or visceral peritoneum, 15% are caused by liver and portal system involvement.[1]
Fluid accumulation in the peritoneal cavity depends on the amount of fluid generated and that cleared in the abdominal cavity. When fluid production exceeds its clearance, extra fluid will accumulate. Under physiologic conditions, fluid is produced by transudation of plasma through the capillary membranes of the peritoneal serosa. This fluid production is influenced by portal pressure, plasma oncotic pressure, sodium and water retention, hepatic lymph production, and microvascular permeability for macromolecules. At least two-thirds of such fluid is reabsorbed into open-ended lymphatic channels of the diaphragm. The fluid then proceeds through mediastinal lymph vessels into the right thoracic duct and drain into the right subclavian vein.[2]
In malignant ascites, pathophysiology is multifactorial. I summarized main relevant factors in the following diagram[1,2,3]:
2. Assessment tools
The volume of ascites can be assessed by measuring circumference of abdomen or by B-ultrasound or CT. Measurement of circumference of abdomen is the simplest one but not accurate. CT could be quite accurate but it is expensive. B-ultrasound is the most frequent used one in my settings because it is relatively cheap, convenient, and non-invasive. But if in home care settings, measuring circumference of abdomen may be more appropriate because no special instrument is required.
3. Evidence-based interventions
Non-drug treatment
Paracentesis is used to move as much fluid as possible. Patients would get short term relief after paracentesis and it can be done repeatedly or continuously. Peritoneovenous shunt is another option for patient in better condition, but it is not often used in malignant ascites and if used, it may function for only a few weeks.[4]
Drug treatment
Chemotherapy can be used for ascites control if appropriate, either intraperitoneal or systematic.
Diuretics should be used in patients with ascites. Spironolactone is most often used. Two thirds of patient can be controlled with spironolactone 300mg or less. Furosemide is recommended if spironolactone 300-400mg/d is not effective.[4]
Patients with malignant ascites can be divided into two categories: those with shorter (<3 months) and those with relatively longer life expectancy. Peritoneovenous shunts will relieve ascites in 75% of patients with longer life expectancy but should be contraindicated in patients with bloody, loculated, or viscous ascites due to the risk of emobolization. Only anecdotal data suggest that systemic dissemination of malignant cells may be caused by peritoneovenous shunts and results in shortened survival, and autopsy data do not substantiate this common misconception. Patients with a shorter life expectancy should be treated with repeated symptomatic paracentesis and those with a treatable cancer, of course not Mrs. Smith, if good surgical candidates, should undergo debulking operations or adjuvant intraperitoneal or systemic chemotherapy, or both.[5]
For Mrs. Smith, I would like to use oral diuretics, if her ascites is severe and oral diuretics are not effective, concurrent continuous paracentesis may be considered.
4.An article published in 2006 summarized managements of malignant ascites in the form of systematic review, and came out with the following guidelines:
1. Paracentesis is indicated for patients with increased intra-abdominal pressure due to ascites. Good, but temporary relief of symptoms in most patients has been reported. Drainage of up to 5 L of fluid could relieve symptoms like discomfort, dyspnoea, nausea and vomiting. (Grade of Recommendation: D) When up to 5 L of fluid is drained, intravenous fluids are not routinely required. (Grade of Recommendation: D)
2. Intravenous hydration should be considered before paracentesis if patient is hypotensive or dehydrated or has severe renal impairment. Infusion therapy has not been sufficiently studied. Only infusion of dextrose 5% has been investigated in malignant ascites. There is no evidence of concurrent albumin infusions in patients with malignant ascites. (Grade of Recommendation: D)
3. Peritoneovenous shunting can be used to avoid repeated paracenteses. Incidence of major complications (pulmonary oedema, pulmonary emboli, clinically relevant disseminated intravascular coagulation, and infection) is about 6%. (Grade of Recommendation: D)
4. No randomized controlled trials have been done to assess the efficacy of diuretic therapy in malignant ascites. The available data are controversial and there are no clear predictors to identify suitable patients. The use of diuretics therefore should be considered in all patients. Diuretics seem more effective in patients with malignant ascites due to massive hepatic metastasis than those with malignant ascites caused by peritoneal carcinomatosis or chylous ascites. (Grade of Recommendation: D) There is no study comparing one diuretics to another. It is suggested that the efficacy of diuretics in malignant ascites depends on plasma renin/aldosterone concentration, aldosterone antagonists like spironolactone should be used, either alone or in combination with a loop diuretic. (Grade of Recommendation: D) Different doses of diuretics are not evaluated in patients with malignant ascites. Therefore doses should be decided according to the instructions and be individualized. (Grade of Recommendation: D)[3]
As the authors found no randomized controlled trial, and most of the articles are non-analytic studies like case series, the evidences provided were quite weak, all the managements suggested above are quite low in recommendation grade. Transjugular intrahepatic portosystemic shunt was found not to improve survival but worsen encephalopathy in a meta-analysis of 5 randomized trials.[6] However, another more recent article mentioned four prospective randomised controlled trials comparing repeated paracentesis with insertion of a TIPS, in which, two trials showed a significant advantage regarding survival, one a trend and the other trial no difference at all. And it is suggested that careful selection of patients is essential for a TIPS benefit.[7]
5.What would work in my settings?
In my practice, oral diuretics are the first line choices for ascites. We usually start with spironolactone 60mg qm. And PRN furosemide 20mg iv. is used if daily urine volume is still less than 800ml or after albumin infusion or in patients with severe ascites (no evidence, I’m just told to do that). For patient who is suffering from a very distended abdomen, paracentesis would be done with a soft tube and averagely 800ml-1L fluid would be drained daily. Sometimes, we will put dexamethasone into the tube after daily drainage (maybe part of intra-peritoneal chemotherapy?).
Peritoneovenous shunt and TIPs are never done in my department because almost all the patients here can not survive an operation---they come only a few days or weeks before death. Chemotherapy is hardly done, other than intraperitoneal dexamethasone I mentioned above. The reason is similar: patients are too weak to afford chemotherapy. Intravenous hydration is not often considered before paracentesis because patients and their family always think the more infused the more ascites.
6.Explaination for Mrs. Smith
Hello, Mrs. Smith. I’m Dr. Han. As your tummy is becoming bigger and bigger, I think you may like to know what’s going on with it.
First I’d like to make it clear to you that actually everybody is having fluid in his tummy. There are vessels carrying fluid and leaving some in the tummy and other vessels absorb the fluid and take it away. The fluid is absorbed quickly after it is produced, so there’s only a little fluid left in the belly to act as lubricant.
However, as you know, you are in a late stage of cancer, and things are changed in you. The spread cancer has broken the balancer between the secretion and clearance of the fluid: the cancer is putting out some substances that make the vessels in your tummy into “leaking water pipes”, and fluid in these vessels comes out into your tummy. On the other hand, the cancer spread into your tummy and may have pressed or blocked some of the vessels that should take away the fluid in your tummy. So more fluid is coming out of the vessels and less is taken away. The result is accumulation of the fluid, we call it “ascites”.
At present, it is impossible to reduce the substances cancer putting out, or to mend the “leaking pipes” because the leakages are widely spread. But we will try to help you reduce the fluid by passing more urine or by draining the fluid. We are sure we can reduce your discomfort to some extent.
References:
1. Lyle Walton and James M. Nottingham. Palliation of Malignant Ascites. Journal of Surgical Education, Volume 64, Issue 1, January-February 2007, Pages 4-9
2. Rony A Adam and Yehuda G Adam. Malignant ascites: past, present, and future. Journal of the American College of Surgeons, Volume 198, Issue 6, June 2004, Pages 999-1011
3. Gerhild Becker, Daniel Galandi and Hubert E. Blum. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer, Volume 42, Issue 5, March 2006, Pages 589-597
4. Robert Twycross and Andrew Wilcock. Symptom management in advanced cancer. Third Edition, P132-133
5. Alexander L. Gerbes. The patient with refractory ascites. Best Practice & Research Clinical Gastroenterology, Volume 21, Issue 3, June 2007, Pages 551-560
6. Agustín Albillos, Rafael Bañares, Mónica González, María-Vega Catalina and Luis-Miguel Molinero. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. Journal of Hepatology, Volume 43, Issue 6, December 2005, Pages 990-996
7. Emmanuel E. Zervos and Alexander S. Rosemurgy. Management of medically refractory ascites. The American Journal of Surgery, Volume 181, Issue 3, March 2001, Pages 256-264
Abnormal accumulation of fluid in the abdomen cavity caused by cancer is called malignant ascites. 10% of ascites are caused by malignancies (malignant ascites),in which 50% develop secondary to invasion of the parietal or visceral peritoneum, 15% are caused by liver and portal system involvement.[1]
Fluid accumulation in the peritoneal cavity depends on the amount of fluid generated and that cleared in the abdominal cavity. When fluid production exceeds its clearance, extra fluid will accumulate. Under physiologic conditions, fluid is produced by transudation of plasma through the capillary membranes of the peritoneal serosa. This fluid production is influenced by portal pressure, plasma oncotic pressure, sodium and water retention, hepatic lymph production, and microvascular permeability for macromolecules. At least two-thirds of such fluid is reabsorbed into open-ended lymphatic channels of the diaphragm. The fluid then proceeds through mediastinal lymph vessels into the right thoracic duct and drain into the right subclavian vein.[2]
In malignant ascites, pathophysiology is multifactorial. I summarized main relevant factors in the following diagram[1,2,3]:
2. Assessment tools
The volume of ascites can be assessed by measuring circumference of abdomen or by B-ultrasound or CT. Measurement of circumference of abdomen is the simplest one but not accurate. CT could be quite accurate but it is expensive. B-ultrasound is the most frequent used one in my settings because it is relatively cheap, convenient, and non-invasive. But if in home care settings, measuring circumference of abdomen may be more appropriate because no special instrument is required.
3. Evidence-based interventions
Non-drug treatment
Paracentesis is used to move as much fluid as possible. Patients would get short term relief after paracentesis and it can be done repeatedly or continuously. Peritoneovenous shunt is another option for patient in better condition, but it is not often used in malignant ascites and if used, it may function for only a few weeks.[4]
Drug treatment
Chemotherapy can be used for ascites control if appropriate, either intraperitoneal or systematic.
Diuretics should be used in patients with ascites. Spironolactone is most often used. Two thirds of patient can be controlled with spironolactone 300mg or less. Furosemide is recommended if spironolactone 300-400mg/d is not effective.[4]
Patients with malignant ascites can be divided into two categories: those with shorter (<3 months) and those with relatively longer life expectancy. Peritoneovenous shunts will relieve ascites in 75% of patients with longer life expectancy but should be contraindicated in patients with bloody, loculated, or viscous ascites due to the risk of emobolization. Only anecdotal data suggest that systemic dissemination of malignant cells may be caused by peritoneovenous shunts and results in shortened survival, and autopsy data do not substantiate this common misconception. Patients with a shorter life expectancy should be treated with repeated symptomatic paracentesis and those with a treatable cancer, of course not Mrs. Smith, if good surgical candidates, should undergo debulking operations or adjuvant intraperitoneal or systemic chemotherapy, or both.[5]
For Mrs. Smith, I would like to use oral diuretics, if her ascites is severe and oral diuretics are not effective, concurrent continuous paracentesis may be considered.
4.An article published in 2006 summarized managements of malignant ascites in the form of systematic review, and came out with the following guidelines:
1. Paracentesis is indicated for patients with increased intra-abdominal pressure due to ascites. Good, but temporary relief of symptoms in most patients has been reported. Drainage of up to 5 L of fluid could relieve symptoms like discomfort, dyspnoea, nausea and vomiting. (Grade of Recommendation: D) When up to 5 L of fluid is drained, intravenous fluids are not routinely required. (Grade of Recommendation: D)
2. Intravenous hydration should be considered before paracentesis if patient is hypotensive or dehydrated or has severe renal impairment. Infusion therapy has not been sufficiently studied. Only infusion of dextrose 5% has been investigated in malignant ascites. There is no evidence of concurrent albumin infusions in patients with malignant ascites. (Grade of Recommendation: D)
3. Peritoneovenous shunting can be used to avoid repeated paracenteses. Incidence of major complications (pulmonary oedema, pulmonary emboli, clinically relevant disseminated intravascular coagulation, and infection) is about 6%. (Grade of Recommendation: D)
4. No randomized controlled trials have been done to assess the efficacy of diuretic therapy in malignant ascites. The available data are controversial and there are no clear predictors to identify suitable patients. The use of diuretics therefore should be considered in all patients. Diuretics seem more effective in patients with malignant ascites due to massive hepatic metastasis than those with malignant ascites caused by peritoneal carcinomatosis or chylous ascites. (Grade of Recommendation: D) There is no study comparing one diuretics to another. It is suggested that the efficacy of diuretics in malignant ascites depends on plasma renin/aldosterone concentration, aldosterone antagonists like spironolactone should be used, either alone or in combination with a loop diuretic. (Grade of Recommendation: D) Different doses of diuretics are not evaluated in patients with malignant ascites. Therefore doses should be decided according to the instructions and be individualized. (Grade of Recommendation: D)[3]
As the authors found no randomized controlled trial, and most of the articles are non-analytic studies like case series, the evidences provided were quite weak, all the managements suggested above are quite low in recommendation grade. Transjugular intrahepatic portosystemic shunt was found not to improve survival but worsen encephalopathy in a meta-analysis of 5 randomized trials.[6] However, another more recent article mentioned four prospective randomised controlled trials comparing repeated paracentesis with insertion of a TIPS, in which, two trials showed a significant advantage regarding survival, one a trend and the other trial no difference at all. And it is suggested that careful selection of patients is essential for a TIPS benefit.[7]
5.What would work in my settings?
In my practice, oral diuretics are the first line choices for ascites. We usually start with spironolactone 60mg qm. And PRN furosemide 20mg iv. is used if daily urine volume is still less than 800ml or after albumin infusion or in patients with severe ascites (no evidence, I’m just told to do that). For patient who is suffering from a very distended abdomen, paracentesis would be done with a soft tube and averagely 800ml-1L fluid would be drained daily. Sometimes, we will put dexamethasone into the tube after daily drainage (maybe part of intra-peritoneal chemotherapy?).
Peritoneovenous shunt and TIPs are never done in my department because almost all the patients here can not survive an operation---they come only a few days or weeks before death. Chemotherapy is hardly done, other than intraperitoneal dexamethasone I mentioned above. The reason is similar: patients are too weak to afford chemotherapy. Intravenous hydration is not often considered before paracentesis because patients and their family always think the more infused the more ascites.
6.Explaination for Mrs. Smith
Hello, Mrs. Smith. I’m Dr. Han. As your tummy is becoming bigger and bigger, I think you may like to know what’s going on with it.
First I’d like to make it clear to you that actually everybody is having fluid in his tummy. There are vessels carrying fluid and leaving some in the tummy and other vessels absorb the fluid and take it away. The fluid is absorbed quickly after it is produced, so there’s only a little fluid left in the belly to act as lubricant.
However, as you know, you are in a late stage of cancer, and things are changed in you. The spread cancer has broken the balancer between the secretion and clearance of the fluid: the cancer is putting out some substances that make the vessels in your tummy into “leaking water pipes”, and fluid in these vessels comes out into your tummy. On the other hand, the cancer spread into your tummy and may have pressed or blocked some of the vessels that should take away the fluid in your tummy. So more fluid is coming out of the vessels and less is taken away. The result is accumulation of the fluid, we call it “ascites”.
At present, it is impossible to reduce the substances cancer putting out, or to mend the “leaking pipes” because the leakages are widely spread. But we will try to help you reduce the fluid by passing more urine or by draining the fluid. We are sure we can reduce your discomfort to some extent.
References:
1. Lyle Walton and James M. Nottingham. Palliation of Malignant Ascites. Journal of Surgical Education, Volume 64, Issue 1, January-February 2007, Pages 4-9
2. Rony A Adam and Yehuda G Adam. Malignant ascites: past, present, and future. Journal of the American College of Surgeons, Volume 198, Issue 6, June 2004, Pages 999-1011
3. Gerhild Becker, Daniel Galandi and Hubert E. Blum. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer, Volume 42, Issue 5, March 2006, Pages 589-597
4. Robert Twycross and Andrew Wilcock. Symptom management in advanced cancer. Third Edition, P132-133
5. Alexander L. Gerbes. The patient with refractory ascites. Best Practice & Research Clinical Gastroenterology, Volume 21, Issue 3, June 2007, Pages 551-560
6. Agustín Albillos, Rafael Bañares, Mónica González, María-Vega Catalina and Luis-Miguel Molinero. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. Journal of Hepatology, Volume 43, Issue 6, December 2005, Pages 990-996
7. Emmanuel E. Zervos and Alexander S. Rosemurgy. Management of medically refractory ascites. The American Journal of Surgery, Volume 181, Issue 3, March 2001, Pages 256-264
Author:zplhelen | Categories:Health related | Comments:0 | Quote:0
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