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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

TM. The EPEC-O Project Education in Palliative and End-of-life Care - Oncology. The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

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  1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3d: Symptoms – Ascites

  3. Malignant ascites . . . • Definition: accumulation of fluid in the abdomen

  4. . . . Malignant ascites Epidemiology • 10% ascites caused by malignancy • 80% malignant ascites are epithelial: • Ovaries • Endometrium • Breast • Colon • GI tract • Pancreas Runyon, et al. Hepatology. 1998.

  5. . . . Malignant ascites • Impact: dyspnea, early satiety, fatigue, abdominal pain • Prognosis: poor • Mean survival with malignant ascites less than 4 months • If chemoresponsive cancer (e.g., new diagnosis of ovarian cancer) 6 months to 1 year

  6. Key points • Pathophysiology • Assessment • Management

  7. Pathophysiology . . . • Normal physiology: • Intravascular pressure equals extravascular pressure • No extravascular fluid accumulation • Ascites: • Fluid influx increases • Fluid outflow decreases • Fluid accumulates

  8. . . . Pathophysiology • Elevated hydrostatic pressure (e.g., congestive heart failure, cirrhosis) • Decreased osmotic pressure (e.g., nephrotic syndrome, malnutrition) • Fluid production exceeds fluid resorption (infections, malignancy)

  9. Ankle swelling Weight gain Girth Fullness Bloating Discomfort Heaviness Indigestion Nausea Vomiting Reflux Umbilical changes Hemorrhoids Assessment . . . History & Symptoms:

  10. . . . AssessmentPhysical examination: • Bulging flanks • Flank dullness • Shifting dullness • Fluid wave

  11. Extra-abdominal signs of ascites • Enlarged liver • Hernias • Scrotal edema • Lower extremity edema • Abdominal venous engorgement • Flattened, protuberant umbilicus

  12. Diagnostic imaging • If physical exam is equivocal • Detects small amounts of fluid, loculation • “Ground glass” x-ray • CT scan

  13. Diagnostic paracentesis • Color • Cytology • Cell count • Total protein concentration • Serum-ascites albumin gradient Hoefs J. Lab Clin Med. 1983.

  14. Diagnosing ascites: Summary • Malignant etiology likely when ascitic fluid has: • Blood • Positive cytology • Absolute neutrophil count less than 250 cells/ml • Total protein concentration greater than 25 g/l • Serum-ascites albumin gradient less than 11 g/l

  15. Management • Goal: relieve the symptoms • If little or no discomfort: don’t treat • Before intervening, discuss prognosis, benefits, risks

  16. Therapeutic options • Dietary restriction • Chemotherapy • Diuretics • Therapeutic paracentesis • Surgery

  17. Dietary management • Sodium and severe fluid restriction

  18. When to treat? With these symptoms: Reduced exercise tolerance When difficult for patients Discuss benefits, burdens, other treatment options first • Dyspnea • Abdominal pain • Fatigue • Anorexia • Early satiety

  19. Diuretics • Effective • Well tolerated • Treatment goals: • Remove only enough fluid to manage the symptoms • Slow, gradual diuresis Pockros J, et al. Gastroenterology. 1992.

  20. Selecting a diuretic • Spironolactone 25 mg – 50 mg/day • Amiloride 5 mg/day • Furosemide 20 mg/day

  21. Precautions with diuretics • Avoid salt substitutes • Evaluate benefits & burdens • Not appropriate in patients with: • Limited mobility • Urinary tract flow problems • Poor appetite, poor oral intake • Polypharmacy problems

  22. Diuretic adverse effects • Problems with: • Sleep deprivation • Self-esteem • Skin • Safety • Fatigue • Hypotension

  23. Therapeutic paracentesis • Indications: • Respiratory distress • Diuretic failure • Rapid symptomatic relief needed • Safe • In clinic or home

  24. Patient supine or semi-recumbent Select site Cleanse, disinfect skin Insert catheter Attach 3-way connector Evacuate Reposition Therapeutic paracentesis technique

  25. Surgery • Peritoneovenous shunts • Drains ascitic fluid into internal jugular vein • Rarely done • Tenckhoff, other catheters • Requires local anesthesia • Used for large-volume ascites • Outpatient use Barnett TD, Rubins J. J VascIntery Radio. 2002. Burger JA, et al. Ann Oncol. 1997.

  26. Summary . . . • Ascites causes distress in patients with advanced cancer • Rule out non-malignant causes • Treatment is palliative • Dietary, pharmacologic, and interventional options are available

  27. . . . Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.

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