Makindo Medical Notes

💡 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

• DBTH Paracentesis for Malignant Ascites Procedure
• Guidelines for Management of Malignant Ascites
• NWC SCN: Ascites in Palliative Care