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The EPEC-O Curriculum is produced by the EPECTM 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
ProjectEPEC-O
TM
EEPPEECC
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EEPPEECC
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Module 3dModule 3dSymptoms – AscitesSymptoms – Ascites
Module 3dModule 3dSymptoms – AscitesSymptoms – Ascites
EPEC – Oncology Education in Palliative and End-of-life Care – Oncology
EPEC – Oncology Education in Palliative and End-of-life Care – Oncology
Malignant ascites . . .Malignant ascites . . .
Definition: accumulation of fluid in Definition: accumulation of fluid in the abdomenthe abdomen
Definition: accumulation of fluid in Definition: accumulation of fluid in the abdomenthe abdomen
. . . Malignant ascites. . . Malignant ascitesEpidemiologyEpidemiology 10% caused by malignancy10% caused by malignancy 80% of malignant ascites is epithelial:80% of malignant ascites is epithelial:
OvariesOvariesEndometriumEndometriumBreastBreastColonColonGI tractGI tractPancreasPancreas
EpidemiologyEpidemiology 10% caused by malignancy10% caused by malignancy 80% of malignant ascites is epithelial:80% of malignant ascites is epithelial:
OvariesOvariesEndometriumEndometriumBreastBreastColonColonGI tractGI tractPancreasPancreas
Runyon, et al. Hepatology, 1998.
. . . Malignant ascites. . . Malignant ascites
Impact: dyspnea, early satiety, fatigue, Impact: dyspnea, early satiety, fatigue, abdominal pain abdominal pain
Prognosis: poorPrognosis: poor
Mean survival with malignant ascitesMean survival with malignant ascites< 4 months< 4 months
If chemo-responsive cancer, If chemo-responsive cancer, eg, newly Dx ovarian ca, eg, newly Dx ovarian ca, mean survival = 6 months – 1 yearmean survival = 6 months – 1 year
Impact: dyspnea, early satiety, fatigue, Impact: dyspnea, early satiety, fatigue, abdominal pain abdominal pain
Prognosis: poorPrognosis: poor
Mean survival with malignant ascitesMean survival with malignant ascites< 4 months< 4 months
If chemo-responsive cancer, If chemo-responsive cancer, eg, newly Dx ovarian ca, eg, newly Dx ovarian ca, mean survival = 6 months – 1 yearmean survival = 6 months – 1 year
Key pointsKey points
1.1. PathophysiologyPathophysiology
2.2. AssessmentAssessment
3.3. ManagementManagement
1.1. PathophysiologyPathophysiology
2.2. AssessmentAssessment
3.3. ManagementManagement
Pathophysiology . . .Pathophysiology . . .
Normal physiology:Normal physiology:
Intravascular pressure = extravascular Intravascular pressure = extravascular pressurepressure
No extravascular fluid accumulationNo extravascular fluid accumulation
Ascites:Ascites:
Fluid influx increasesFluid influx increases
Fluid outflow decreasesFluid outflow decreases
Fluid accumulatesFluid accumulates
Normal physiology:Normal physiology:
Intravascular pressure = extravascular Intravascular pressure = extravascular pressurepressure
No extravascular fluid accumulationNo extravascular fluid accumulation
Ascites:Ascites:
Fluid influx increasesFluid influx increases
Fluid outflow decreasesFluid outflow decreases
Fluid accumulatesFluid accumulates
. . . Pathophysiology. . . Pathophysiology
Elevated hydrostatic pressure Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis)(eg, congestive heart failure, cirrhosis)
Decreased osmotic pressureDecreased osmotic pressure(eg, nephrotic syndrome, malnutrition) (eg, nephrotic syndrome, malnutrition)
Fluid production > fluid resorption Fluid production > fluid resorption (infections, malignancy) (infections, malignancy)
Elevated hydrostatic pressure Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis)(eg, congestive heart failure, cirrhosis)
Decreased osmotic pressureDecreased osmotic pressure(eg, nephrotic syndrome, malnutrition) (eg, nephrotic syndrome, malnutrition)
Fluid production > fluid resorption Fluid production > fluid resorption (infections, malignancy) (infections, malignancy)
Assessment . . . History & symptomsAssessment . . . History & symptoms Ankle swellingAnkle swelling
Weight gainWeight gain
GirthGirth
FullnessFullness
BloatingBloating
DiscomfortDiscomfort
HeavinessHeaviness
Ankle swellingAnkle swelling
Weight gainWeight gain
GirthGirth
FullnessFullness
BloatingBloating
DiscomfortDiscomfort
HeavinessHeaviness
IndigestionIndigestion
NauseaNausea
VomitingVomiting
RefluxReflux
Umbilical changesUmbilical changes
HemorrhoidsHemorrhoids
IndigestionIndigestion
NauseaNausea
VomitingVomiting
RefluxReflux
Umbilical changesUmbilical changes
HemorrhoidsHemorrhoids
. . . AssessmentPhysical examination. . . AssessmentPhysical examination
Bulging flanksBulging flanks
Flank dullnessFlank dullness
Shifting dullnessShifting dullness
Fluid waveFluid wave
Bulging flanksBulging flanks
Flank dullnessFlank dullness
Shifting dullnessShifting dullness
Fluid waveFluid wave
Extra-abdominal signs of ascitesExtra-abdominal signs of ascites Enlarged liverEnlarged liver
HerniasHernias
Scrotal edema Scrotal edema
Lower extremity edemaLower extremity edema
Abdominal venous engorgementAbdominal venous engorgement
Flattened, protuberant umbilicusFlattened, protuberant umbilicus
Enlarged liverEnlarged liver
HerniasHernias
Scrotal edema Scrotal edema
Lower extremity edemaLower extremity edema
Abdominal venous engorgementAbdominal venous engorgement
Flattened, protuberant umbilicusFlattened, protuberant umbilicus
Diagnostic imagingDiagnostic imaging
If physical exam is equivocalIf physical exam is equivocal
Detects small amounts of fluid, Detects small amounts of fluid, loculationloculation
‘‘Ground Glass’ X-rayGround Glass’ X-ray
CT scan CT scan
If physical exam is equivocalIf physical exam is equivocal
Detects small amounts of fluid, Detects small amounts of fluid, loculationloculation
‘‘Ground Glass’ X-rayGround Glass’ X-ray
CT scan CT scan
Diagnostic paracentesisDiagnostic paracentesis
ColorColor
CytologyCytology
Cell countCell count
Total protein concentrationTotal protein concentration
Serum-ascites albumin gradient Serum-ascites albumin gradient
ColorColor
CytologyCytology
Cell countCell count
Total protein concentrationTotal protein concentration
Serum-ascites albumin gradient Serum-ascites albumin gradient
Hoefs J. Lab Clin Med, 1983.
Diagnosing ascites - SummaryDiagnosing ascites - Summary
Malignant etiology likely when ascitic Malignant etiology likely when ascitic fluid has:fluid has:
BloodBlood
Positive cytologyPositive cytology
Absolute neutrophil count < 250 cells / mlAbsolute neutrophil count < 250 cells / ml
Total protein concentration > 25 gm / LTotal protein concentration > 25 gm / L
Serum-ascites albumin gradient < 11 gm / LSerum-ascites albumin gradient < 11 gm / L
Malignant etiology likely when ascitic Malignant etiology likely when ascitic fluid has:fluid has:
BloodBlood
Positive cytologyPositive cytology
Absolute neutrophil count < 250 cells / mlAbsolute neutrophil count < 250 cells / ml
Total protein concentration > 25 gm / LTotal protein concentration > 25 gm / L
Serum-ascites albumin gradient < 11 gm / LSerum-ascites albumin gradient < 11 gm / L
ManagementManagement
Goal: to relieve the symptomsGoal: to relieve the symptoms
With little or no discomfort: don’t With little or no discomfort: don’t treattreat
Before intervening, discuss Before intervening, discuss prognosis, benefits, risksprognosis, benefits, risks
Goal: to relieve the symptomsGoal: to relieve the symptoms
With little or no discomfort: don’t With little or no discomfort: don’t treattreat
Before intervening, discuss Before intervening, discuss prognosis, benefits, risksprognosis, benefits, risks
When to treat?When to treat?
With these symptoms:With these symptoms:
DyspneaDyspnea
Abdominal painAbdominal pain
FatigueFatigue
AnorexiaAnorexia
Early satietyEarly satiety
Reduced exercise toleranceReduced exercise tolerance
With these symptoms:With these symptoms:
DyspneaDyspnea
Abdominal painAbdominal pain
FatigueFatigue
AnorexiaAnorexia
Early satietyEarly satiety
Reduced exercise toleranceReduced exercise tolerance
Therapeutic optionsTherapeutic options
Dietary restrictionDietary restriction
ChemotherapyChemotherapy
DiureticsDiuretics
Therapeutic paracentesisTherapeutic paracentesis
SurgerySurgery
Dietary restrictionDietary restriction
ChemotherapyChemotherapy
DiureticsDiuretics
Therapeutic paracentesisTherapeutic paracentesis
SurgerySurgery
Dietary managementDietary management
Sodium and severe fluid restrictionSodium and severe fluid restriction
Difficult for patientsDifficult for patients
Discuss benefits, burdens & other Discuss benefits, burdens & other treatment options firsttreatment options first
Sodium and severe fluid restrictionSodium and severe fluid restriction
Difficult for patientsDifficult for patients
Discuss benefits, burdens & other Discuss benefits, burdens & other treatment options firsttreatment options first
DiureticsDiuretics
EffectiveEffective
Well-toleratedWell-tolerated
Treatment goals:Treatment goals:
Remove only enough fluid to manage Remove only enough fluid to manage the symptomsthe symptoms
Slow & gradual diuresisSlow & gradual diuresis
EffectiveEffective
Well-toleratedWell-tolerated
Treatment goals:Treatment goals:
Remove only enough fluid to manage Remove only enough fluid to manage the symptomsthe symptoms
Slow & gradual diuresisSlow & gradual diuresis
Pockros J, et al. Gastroenterology, 1992.
Selecting a diureticSelecting a diuretic
Spironolactone 25 mg – 50 mg / day Spironolactone 25 mg – 50 mg / day
Amiloride 5 mg / dayAmiloride 5 mg / day
Furosemide 20 mg / dayFurosemide 20 mg / day
Spironolactone 25 mg – 50 mg / day Spironolactone 25 mg – 50 mg / day
Amiloride 5 mg / dayAmiloride 5 mg / day
Furosemide 20 mg / dayFurosemide 20 mg / day
Precautions with diureticsPrecautions with diuretics
Avoid salt substitutesAvoid salt substitutes
Evaluate benefits & burdensEvaluate benefits & burdens
Not appropriate in patients with:Not appropriate in patients with:
Limited mobilityLimited mobility
UT flow problemsUT flow problems
Poor appetite, poor oral intakePoor appetite, poor oral intake
Polypharmacy problemsPolypharmacy problems
Avoid salt substitutesAvoid salt substitutes
Evaluate benefits & burdensEvaluate benefits & burdens
Not appropriate in patients with:Not appropriate in patients with:
Limited mobilityLimited mobility
UT flow problemsUT flow problems
Poor appetite, poor oral intakePoor appetite, poor oral intake
Polypharmacy problemsPolypharmacy problems
Diuretic adverse effectsDiuretic adverse effects
Problems withProblems with
Sleep deprivationSleep deprivation
Self-esteemSelf-esteem
SkinSkin
SafetySafety
FatigueFatigue
HypotensionHypotension
Problems withProblems with
Sleep deprivationSleep deprivation
Self-esteemSelf-esteem
SkinSkin
SafetySafety
FatigueFatigue
HypotensionHypotension
Therapeutic paracentesisTherapeutic paracentesis
Indications:Indications:
Respiratory distressRespiratory distress
Diuretic failureDiuretic failure
Rapid symptomatic reliefRapid symptomatic relief
SafeSafe
In clinic or home In clinic or home
Indications:Indications:
Respiratory distressRespiratory distress
Diuretic failureDiuretic failure
Rapid symptomatic reliefRapid symptomatic relief
SafeSafe
In clinic or home In clinic or home
Therapeutic paracentesis techniqueTherapeutic paracentesis technique
Patient supine Patient supine or or semirecumbentsemirecumbent
Select siteSelect site
Cleanse, Cleanse, disinfect skindisinfect skin
Patient supine Patient supine or or semirecumbentsemirecumbent
Select siteSelect site
Cleanse, Cleanse, disinfect skindisinfect skin
InsertInsert
Attach 3-way Attach 3-way connector connector
EvacuateEvacuate
RepositionReposition
InsertInsert
Attach 3-way Attach 3-way connector connector
EvacuateEvacuate
RepositionReposition
SurgerySurgery Peritoneovenous shuntsPeritoneovenous shunts
Drains ascitic fluid into internal jugular Drains ascitic fluid into internal jugular veinvein
Rarely doneRarely done
Tenckhoff, other cathetersTenckhoff, other catheters
Local anesthesiaLocal anesthesia
Large volume ascitesLarge volume ascites
Outpatient useOutpatient use
Peritoneovenous shuntsPeritoneovenous shunts
Drains ascitic fluid into internal jugular Drains ascitic fluid into internal jugular veinvein
Rarely doneRarely done
Tenckhoff, other cathetersTenckhoff, other catheters
Local anesthesiaLocal anesthesia
Large volume ascitesLarge volume ascites
Outpatient useOutpatient use
Barnett TD, Rubins J. J Vasc Intery Radio, 2002.Burger JA, et al. Ann Oncol, 1997.
Summary . . .Summary . . .
Ascites causes distress in patients Ascites causes distress in patients with advanced cancerwith advanced cancer
Rule out nonmalignant causesRule out nonmalignant causes
Treatment is palliativeTreatment is palliative
Dietary, pharmacological, and Dietary, pharmacological, and interventional options are availableinterventional options are available
Ascites causes distress in patients Ascites causes distress in patients with advanced cancerwith advanced cancer
Rule out nonmalignant causesRule out nonmalignant causes
Treatment is palliativeTreatment is palliative
Dietary, pharmacological, and Dietary, pharmacological, and interventional options are availableinterventional options are available
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. . . Summary. . . Summary
Use comprehensive Use comprehensive assessment and assessment and
pathophysiology-based therapy pathophysiology-based therapy
to treat the cause and improve to treat the cause and improve the cancer experiencethe cancer experience
Use comprehensive Use comprehensive assessment and assessment and
pathophysiology-based therapy pathophysiology-based therapy
to treat the cause and improve to treat the cause and improve the cancer experiencethe cancer experience