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Case History

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Image not available. A 66-year-old woman with known advanced ovarian cancer has repeated emergency admission to her local district general hospital with symptomatic large-volume ascites. On each occasion, the patient is assessed in the emergency unit and subsequently admitted to a general medical ward for percutaneous drainage and symptomatic relief. The patient presents once again despite the recent completion of third-line chemotherapy.

What is ascites and what is the differential diagnosis?

What investigations would you perform?

What are the treatment options?

How would you manage this patient?

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Background

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What is ascites and what is the differential diagnosis?

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Image not available. Ascites is the accumulation of fluid within the peritoneal cavity, with the commonest cause being secondary to benign liver cirrhosis and portal hypertension. Approximately 10% of ascites cases are due to malignancy,1 most commonly from primary ovarian, colon, stomach, pancreas, lung and breast cancers, but it can also be associated with primary liver or peritoneal mesothelial cancers. Ascites can be caused by occlusion of the draining lymphatic channels by malignant cells, massive liver metastases causing portal hypertension, or primary liver cancer in the setting of cirrhosis. Mean survival once malignant ascites is diagnosed is approximately one to four months.

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Differential diagnosis
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For patients presenting acutely with ascites, a high index of suspicion for an underlying process of malignancy should be countenanced. Benign causes should be excluded, including ascites secondary to liver cirrhosis (approximately 80% of cases), congestive cardiac failure, portal hypertension and chronic pancreatitis.

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What investigations would you perform?

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The aim of initial investigation is to diagnose the underlying condition causing ascites, whether benign or malignant; and, in the acute oncology setting, to also direct investigations which will lead to diagnosing the primary malignancy. Studies have shown that a serum-ascites albumin gradient (SAAG) of >1.1 g/dl is a useful test because it can identify patients with benign portal hypertension who will benefit from diuretic therapy (Figure 37.1).2 The SAAG only needs to be determined at the first presentation with albumin measurements in the serum and ascitic fluid. Blood tests for complete blood count, liver function tests, and urea and electrolytes are helpful to exclude anaemia, infection, hypoalbuminaemia, liver dysfunction and renal dysfunction. If infection is suspected, ascitic fluid can be analysed for cell counts and culture of microorganisms. On first presentation, cytology of ascitic fluid can be performed, but tissue diagnosis following biopsy of solid tumour is more helpful in establishing the diagnosis. Therefore, on initial presentation, a computed tomography (CT) scan is required to further identify the disease process, and, in the case of malignancy, aid identification of a primary tumour and stage disease. If paracentesis is planned, a coagulation profile is also recommended. Tumour markers, such as CA125 (MUC16) and carcinoembryonic antigen (CEA), have poor sensitivity and specificity and their use in the diagnostic pathway for ...

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