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Two-thirds of cases of malignant ascites are caused by peritoneal carcinomatosis. The most common tumors causing carcinomatosis are primary adenocarcinomas of the ovary, uterus, pancreas, stomach, colon, lung, or breast. The remaining one-third is due to lymphatic obstruction or portal hypertension due to hepatocellular carcinoma or diffuse hepatic metastases. Patients present with nonspecific abdominal discomfort and weight loss associated with increased abdominal girth. Nausea or vomiting may be caused by partial or complete intestinal obstruction. Abdominal CT may be useful to demonstrate the primary malignancy or hepatic metastases but seldom confirms the diagnosis of peritoneal carcinomatosis. In patients with carcinomatosis, paracentesis demonstrates a low serum ascites-albumin gradient (less than 1.1 mg/dL), an increased total protein (greater than 2.5 g/dL), and an elevated white cell count (often both neutrophils and mononuclear cells) but with a lymphocyte predominance. Cytology is positive in over 95%, but laparoscopy may be required in patients with negative cytology to confirm the diagnosis and to exclude tuberculous peritonitis, with which it may be confused. Malignant ascites attributable to portal hypertension usually is associated with an increased serum ascites-albumin gradient (greater than 1.1 g/dL), a variable total protein, and negative ascitic cytology. Ascites caused by peritoneal carcinomatosis does not respond to diuretics.

Patients may be treated with periodic large-volume paracentesis for symptomatic relief. Indwelling catheters can be left in place for patients approaching the end of life who require periodic paracentesis for symptomatic relief. Intraperitoneal chemotherapy is sometimes used to shrink the tumor, but the overall prognosis is extremely poor, with only 10% survival at 6 months. Ovarian cancers represent an exception to this rule. With newer treatments consisting of surgical debulking and intraperitoneal chemotherapy, long-term survival from ovarian cancer is possible.

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