Malignant Ascites
💡 Evidence suggests colloid/albumin replacement is not necessary to prevent haemodynamic deterioration after paracentesis.
⚠️ However, drain slowly - at most 4–6 L over ≥4 hours.
📖 About Ascites
- Malignant Ascites = accumulation of peritoneal fluid due to malignancy.
- Accounts for ~10% of all ascites cases.
- Common cancers: breast, colorectal, endometrial, gastric, ovarian, pancreatic.
🧬 Aetiology
- Peritoneal lymphatic obstruction (tumour spread).
- Low albumin → ↓ oncotic pressure.
- ↑ Capillary permeability (tumour inflammation).
- ↑ Portal venous pressure → activation of RAA system.
🩺 Clinical Presentation
- Abdominal bloating, distension, pain, nausea, vomiting.
- Other: anorexia, fatigue, peripheral oedema, reflux/heartburn, dyspnoea from raised diaphragm.
⚠️ Cautions for Paracentesis
- Coagulopathy: INR > 1.5, platelets < 40 × 10⁹/L.
- Hyponatraemia < 126 mmol/L.
- Poor renal function, hepatic impairment.
- Severe anaemia, albumin < 20 g/L.
- Neutropenia / immunosuppression.
⛔ Contraindications
- Local or systemic infection at drain site.
- Severe coagulopathy: platelets < 40 × 10⁹/L or INR > 1.4.
- Limit drainage to 4–6 L max if: renal failure (Cr > 250), albumin < 30 g/L, Na < 125 mmol/L.
🔬 Investigations
- Bloods: FBC, U&Es, LFTs, clotting. Monitor U&Es daily if repeated paracentesis.
- Ascitic tap: send for MCS, SAAG (serum–ascites albumin gradient), protein, glucose, LDH, cytology.
- Rule out SBP (spontaneous bacterial peritonitis) if fever or abdominal pain.
- ❌ Avoid serum CA-125 (often falsely ↑ in ascites).
🛠️ Management
- Poor prognosis → focus on comfort + quality of life (palliative intent).
- 💊 Diuretics: Spironolactone 100–400 mg/day (slow onset ~5 days). Watch for nausea, hyperkalaemia, hyponatraemia.
- 💉 Therapeutic paracentesis: Symptom relief with 4–6 L removed. Avoid excess drainage (hypovolaemia risk).
- 🚫 Albumin infusion: Not required in malignant ascites (unlike cirrhotic ascites).
- Other options: peritoneovenous shunts in selected cases.
📚 References
