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

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

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

4. ... Malignant ascites Epidemiology l 10% ascites caused by malignancy l 80% malignant ascites are epithelial: o Ovaries o Endometrium o Breast o Colon o GI tract o Pancreas Runyon, et al. Hepatology. 1998.Epidemiology l 10% ascites caused by malignancy l 80% malignant ascites are epithelial: o Ovaries o Endometrium o Breast o Colon o GI tract o 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 less than 4 months  If chemoresponsive cancer (e.g., new diagnosis of ovarian cancer) 6 months to 1 year l Impact: dyspnea, early satiety, fatigue, abdominal pain l Prognosis: poor  Mean survival with malignant ascites less than 4 months  If chemoresponsive cancer (e.g., new diagnosis of ovarian cancer) 6 months to 1 year

6. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

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

8. ... Pathophysiology l Elevated hydrostatic pressure (e.g., congestive heart failure, cirrhosis) l Decreased osmotic pressure (e.g., nephrotic syndrome, malnutrition) l Fluid production exceeds fluid resorption (infections, malignancy) l Elevated hydrostatic pressure (e.g., congestive heart failure, cirrhosis) l Decreased osmotic pressure (e.g., nephrotic syndrome, malnutrition) l Fluid production exceeds 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 Hoefs J. Lab Clin Med. 1983. 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 less than 250 cells/ml  Total protein concentration greater than 25 g/l  Serum-ascites albumin gradient less than 11 g/l l Malignant etiology likely when ascitic fluid has:  Blood  Positive cytology  Absolute neutrophil count less than 250 cells/ml  Total protein concentration greater than 25 g/l  Serum-ascites albumin gradient less than 11 g/l

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

16. 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

17. Dietary management l Sodium and severe fluid restriction

18. When to treat? With these symptoms: l Dyspnea l Abdominal pain l Fatigue l Anorexia l Early satiety l Reduced exercise tolerance l When difficult for patients l 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 Pockros J, et al. Gastroenterology. 1992. 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: o Limited mobility o Urinary tract flow problems o Poor appetite, poor oral intake o Polypharmacy problems l Avoid salt substitutes l Evaluate benefits & burdens l Not appropriate in patients with: o Limited mobility o Urinary tract flow problems o Poor appetite, poor oral intake o Polypharmacy problems

22. Diuretic adverse effects l Problems with: o Sleep deprivation o Self-esteem o Skin o Safety o Fatigue o Hypotension l Problems with: o Sleep deprivation o Self-esteem o Skin o Safety o Fatigue o Hypotension

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

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

25. Surgery l Peritoneovenous shunts o Drains ascitic fluid into internal jugular vein o Rarely done l Tenckhoff, other catheters o Requires local anesthesia o Used for large-volume ascites o Outpatient use Barnett TD, Rubins J. J Vasc Intery Radio. 2002. Burger JA, et al. Ann Oncol. 1997. l Peritoneovenous shunts o Drains ascitic fluid into internal jugular vein o Rarely done l Tenckhoff, other catheters o Requires local anesthesia o Used for large-volume ascites o 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 non-malignant causes l Treatment is palliative l Dietary, pharmacologic, and interventional options are available l Ascites causes distress in patients with advanced cancer l Rule out non-malignant causes l Treatment is palliative l Dietary, pharmacologic, and interventional options are available

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