Ascites, Malignant

KEY FEATURES

• Two-thirds of cases are caused by peritoneal carcinomatosis from adenocarcinomas of the

  • Ovary

  • Uterus

  • Pancreas

  • Stomach

  • Colon

  • Lung

  • Breast

• One-third of cases are due to lymphatic obstruction or portal hypertension from

  • Hepatocellular carcinoma

  • Diffuse hepatic metastases

CLINICAL FINDINGS

• Nonspecific abdominal discomfort and weight loss

• Increased abdominal girth

• Nausea or vomiting caused by partial or complete intestinal obstruction

DIAGNOSIS

• Abdominal CT

  • Useful to demonstrate primary malignancy or hepatic metastases

  • Seldom confirms diagnosis of peritoneal carcinomatosis

• Paracentesis in abdominal carcinomatosis demonstrates

  • Low serum ascites–albumin gradient (< 1.1 mg/dL)

  • Increased total protein (> 2.5 g/dL)

  • Elevated white blood cell count (often both neutrophils and mononuclear cells but with a lymphocyte predominance)

  • Ascitic fluid cytology that is positive in > 95%

• Paracentesis in malignant ascites from portal hypertension usually demonstrates

  • Increased serum ascites-albumin gradient (> 1.1 g/dL)

  • Variable total protein

  • Negative ascitic cytology

• Laparoscopy is diagnostic in patients with negative cytology and excludes tuberculous peritonitis

TREATMENT

• Diuretics not useful in controlling ascites caused by peritoneal carcinomatosis

• Periodic large-volume paracentesis for symptomatic relief

• Indwelling catheters can be left in place for patients approaching end of life who require periodic paracentesis for symptomatic relief

• Intraperitoneal chemotherapy sometimes used

• Prognosis is extremely poor: only 10% survival at 6 months

• Ovarian cancer is an exception; with surgical debulking and intraperitoneal chemotherapy, long-term survival is possible