Malignant Ascites: Causes, Symptoms, Diagnosis and Treatment

Introduction

Ascites refer to the condition in which excess fluid accumulates in the abdomen. This is caused by various conditions, such as liver cirrhosis (scarring), pancreatitis, cancer, and heart failure.

What Is Ascites?

Ascites are the abnormal or excess accumulation of peritoneal fluid in the abdomen or belly. As a result, the fluid gets built up in the space within the walls of the abdomen and abdominal organs. It is most commonly seen in patients with liver disease and cirrhosis. Malignant cells are found in the fluid-filled cavity due to some secondary or underlying disorder (cancer) called malignant ascites.

What Are Malignant Ascites?

Malignant ascites are when the malignant cells or cancer-causing cells reach the peritoneum and accumulate in the excess (ascites) peritoneal fluid. Malignant ascites have a very poor prognosis, with an average survival time of 20 weeks after their diagnosis.

What Are the Causes of Ascites?

Various conditions can cause ascites, such as cirrhosis and other benign (noncancerous) conditions. Some of the conditions that can cause liver damage and lead to cirrhosis. This can cause ascites, which include:

• Liver disease.

• Chronic hepatitis B or C.

• Heavy alcohol use.

• Kidney failure.

• Portal hypertension.

• Heart failure.

• Infection.

• Pancreatitis (inflammation of the pancreas).

Most cirrhosis cases occur due to heavy alcohol consumption or chronic hepatitis C. Ascites can be seen in 60 percent of cirrhosis cases. In about ten percent of cases, ascites are caused by cancer. Some of the cancers that can cause ascites are -

• Ovarian cancer.

• Colon cancer.

• Pancreatic cancer.

• Uterine cancer.

• Liver cancer.

What Is the Cause of Ascites in Patients With Cancer?

Generally, there are two main reasons for ascites in patients with cancer: -

• Cancer can spread to the lining of the organs and peritoneum, causing malignant ascites.

• Cancer might spread to the liver and cause increased pressure in the liver, such as ovarian, pancreatic, liver, and colon cancers.

What Are the Symptoms of Malignant Ascites?

Ascites usually cause a lot of discomfort, which cannot be seen in the case of mild ascites. The common symptoms of ascites include -

• Weight gain.

• Shortness of breath.

• Abdominal swelling.

• Feeling full quickly when eating.

• Sense of fullness or bloating.

• Sense of heaviness.

• Constipation.

• Indigestion.

• Nausea or vomiting.

• Hemorrhoids (painful swelling near the anus).

• Ankle swelling.

• Fatigue.

• Loss of appetite.

What Are the Risk Factors for Ascites?

Cirrhosis is one of the most common causes of ascites, and people infected with cirrhosis are at much greater risk of getting ascites. Some of the other conditions that lead to ascites are -

• Non-alcohol-associated fatty liver disease.

• Hepatitis B.

• Hepatitis C.

• Alcohol use disorder.

• Autoimmune hepatitis.

Other uncommon conditions that lead to ascites are -

• Congestive heart failure.

• Kidney failure.

• Cancers in the organs of the abdomen and pelvis.

• Infections.

How Are Ascites Diagnosed?

To diagnose ascites, the following tests may be prescribed by the healthcare provider -

• Blood tests.

• Ultrasound (usually the first imaging test).

• Computed tomography (CT).

• Magnetic resonance imaging (MRI).

• Paracentesis is a procedure in which a small needle is inserted in the abdomen to collect a sample, which is then examined under a microscope. After that, white blood cells, bacteria, or cancer cells are checked to determine the cause of ascites. This test helps in differentiating between benign or malignant ascites.

For diagnosis of malignant ascites, positive ascitic fluid cytology is needed. The overall sensitivity of the fluid cytology should be 58 to 75 percent to confirm the diagnosis of malignancy-related ascites. The parameters examined in this test are -

• Cell count and white blood cells differential.

• Bacterial culture.

• Albumin (for serum-to-ascites albumin gradient).

• Total protein.

• Glucose.

• LDH (lactate dehydrogenase - a type of enzyme).

The sample should be more than 200 milliliters (ml).

How Are Ascites Treated?

The main objective of the treatment is to provide relief from uncomfortable symptoms. A person might not need treatment if ascites are not causing discomfort. A patient should consult all the treatment options with the doctor. The treatment options for ascites include -

• Catheter - A catheter can be used to drain the excess fluid in the abdomen. A catheter is a thin plastic tube that is inserted into the pleural fluid (fluid between the lungs and chest) in the abdomen. The excess fluid is then drained out into a container. Occasionally, a catheter might be used to bypass or divert the fluid from the abdomen to another body part; this procedure is known as a peritoneovenous shunt.

• Diuretics - Diuretics can also be used to help reduce the amount of fluid in the abdomen, as these drugs increase the process of urination. Diuretics can cause sleep loss, skin problems, fatigue, and low blood pressure in some patients. So, in case of any of these side effects, patients should consult their doctor and try to reduce the dosage or change the medicine.

• Change in Diet - Patients are advised to eat less salt and drink less water or other liquids in case of mild discomfort. As salt makes the body hold onto water, the diet should be changed by consulting the doctor.

• Paracentesis - As mentioned above, this procedure helps drain the fluid from the abdomen to differentiate between the actual cause of ascites. It is up to the healthcare team to perform paracentesis or use a catheter to drain the excess fluid.

• Treating Cancer - Surgery or chemotherapy are the best options to treat cancer. These procedures can also help in relieving the ascites symptoms.

• Managing Discomfort - Even with the treatment, the symptoms might keep coming back, causing discomfort to the patient, which the health care professional can treat to avoid complications; the symptoms include constipation, swelling in the legs, nausea, or breathing problems.

How to Manage Ascites?

If a person has ascites, the following steps can help them control the condition: -

1. Regular Weight Checks - Patients should weigh themselves regularly. If more than two pounds per day of weight gain is noticed for three consecutive days, a patient immediately contacts the health professional.

2. Reduce Alcohol Consumption - A patient should stop alcohol intake to reduce the risks of ascites.

3. Avoid Taking Nonsteroidal Anti-inflammatory Drugs (NSAID) - These drugs affect the kidneys and can cause the body to retain excess water and salt, increasing fluid accumulation.

4. Take Low Salt Diet - A patient should stick to a low salt diet of not more than 2,000 to 4,000 milligrams per day.

Conclusion

In conclusion, malignant ascites require a multidisciplinary effort involving oncologists, palliative care specialists, interventional radiologists, and other healthcare professionals. The emphasis should not only be on alleviating physical symptoms but also on providing emotional support and enhancing the overall well-being of the patient. Ascites is a distressing and uncomfortable condition, and with an underlying cause like cancer, it can be fatal. Therefore, patients should know the symptoms and seek medical advice promptly.