Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
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On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2008 | Month : February | Volume : 2 | Issue : 1 | Page : 617 - 621 Full Version

Clinical Pattern Of Ascites Due To Malignancy In Qatar

Published: February 1, 2008 | DOI:

*Senior specialist, department of medicine, Hamad General Hospital/Doha-Qatar. **Specialist, department of oncology, Alamal Hospital/Doha-Qatar. ***Specialist, department of medicine, AlKhor Hospital/Doha-Qatar. ****Specialist, department of medicine, AlKhor Hospital/Doha-Qatar.

Correspondence Address :
Fahmi Yousef Khan, (MD), Senior specialist, Department of medicine, Hamad General Hospital, P.O.Box : 3050, Doha-Qatar. E-mail:, Tel 0974- 5275989, Fax:0974-4879228.


Background: The clinical characteristics of ascites due to malignancy are not fully known, and it appears as a variable entity with different types of clinical presentation and with a difficult diagnosis.
Objectives: the aim of this study is to describe the clinical pattern of ascites due to malignancy in Qatar and to evaluate the diagnostic efficacy of serum/ascitic albumin gradient in differentiating different types of ascites caused by malignancy.
Methods: a descriptive prospective study of patients admitted to Hamad general hospital with ascites due to malignancy.
Results: The total number of patients included in this study was 22 patients. Based on serum ascitic albumen gradient, ascites due to malignancy was divided into two main groups; first, with serum/ascitic albumin gradient < 1.1 g/dL, second, serum/ascitic albumin gradient > 1.1 g/dL. The firs group was consistent with carcinomatous peritonitis (Malignant ascites), while the second group represented tumors metastasizing to the liver leading to portal hypertension (malignancy related ascites). Ovarian carcinoma was the most common primary tumour in patients with malignant ascites while gall bladder cancer was most common primary tumour in patients with malignant related ascites.
Conclusion: serum/ascitic albumin gradient is effective in differentiating between malignant and malignancy related ascites. Along with the currently available, largely unsatisfactory treatment alternatives, these data might change our present clinical management of ascites due to malignancy.


Malignant ascites, malignancy related ascites, carcinomatous peritonitis.

Cancer accounts for about 10% of all cases of ascites and usually caused by ovarian, endometrial, breast, oesophageal, gastric, colorectal, lung, pancreatic, hepatobiliary and primary peritoneal carcinomas.(1),(2),(3) It has been shown that around 10 to 15% of all patients with gastrointestinal cancer develop ascites at some stage of their disease. Generally, the presence of malignant ascites is associated with poor prognosis, regardless of the cause.(4) It is a poor prognostic indicator, with a median survival time ranging from 1 to 4 months.(5)

Analysis of ascites plays a major role in the diagnostic workup of ascites due to malignancy. The incidences of ascites due to cancer vary from country to other, In Qatar it represents 21% of ascites cases. (6) Data on clinical patterns and outcome of ascites due to malignancy in the state of Qatar are still incomplete. This prospective study was conducted to describe the clinical patterns and outcome of ascites due to malignancy in the state of Qatar and to compare the results with previously reported studies.

Material and Methods

This prospective observational hospital based study was conducted at Hamad Medical Corporation (HMC), State of Qatar, which is a small country with an area of 11,521.0 Sq. km extending into the Persian Gulf from the eastern coast of Arabian Peninsula and has an estimated population size of 744,029 according to 2004 census and is densely populated at the capital city of Doha. HMC serves as a tertiary referral center with many hospitals, covering all medical and surgical disciplines including 6 intensive care units. So far, there are no private hospitals admitting patients with cirrhotic ascites. This study was conducted during one year, started from January 15, 2004 to January 14, 2005 at Hamad General Hospital. The aim of this study was to describe the clinical pattern of ascites due to malignancy in Qatar and to evaluate the diagnostic efficacy of serum/ascitic albumin gradient in differentiating different types of ascites caused by malignancy. It includes all patients admitted to the medical department of Hamad General Hospital with primary diagnosis of ascites due to malignancy and who had peritoneal paracentesis performed during admission. Detailed history and clinical examinations performed, in all patients, in particular those with a history of malignant disease. Routine hematological and biochemical investigations of serum were performed in all patients. Patients underwent abdominal paracentesis in the first 24 hours after the admission. Under aseptic conditions, a 22-gauge needle was used, in the left lower abdominal quadrant, and the samples of ascitic fluid were immediately sent to the biochemical, cytological and microbiological laboratories for analysis. At the same time, blood samples were taken for simultaneous ascitic fluid and blood determination of the levels of total protein, albumin, lactate dehydrogenase (LDH) and glucose. Smears of ascitic fluid were fixed and stained with Haematoxylin-eosin and Papanicolaou, and microscopically examined for their cellular content. Peritoneal biopsy (biopsy with laparoscopy) was sent to histopathological laboratories for the diagnosis of carcinomatous peritonitis. Patients were included in the study if they had had underwent abdominal paracentesis and had signed a consent form.

The development of ascites in patients with history of either intra-abdominal or extra-abdominal malignancy in the absence of liver cirrhosis and other causes of nonmalignant ascites was accepted as being ascites due to malignancy.

Malignant ascites (carcinomatous peritonitis):An ascites associated with malignancy in the peritoneal space as demonstrated by cytologic study and/or peritoneal biopsy specimen. Malignancy related ascites (massive hepatic metastasis): Ascites occurring as a result of portal hypertension due to hepatic infiltration by malignant cells in a patient with known malignancy but in whom the ascitic fluid cytologic study and peritoneal biopsy specimen did not demonstrate malignancy. (Malignant origin of the ascites in these patients was usually confirmed by one or more of cytological examination, imaging, laparoscopy or laparotomy).

Data analysis
Data were analyzed with soft ware EpiInfo 2000. Quantitative variables are expressed as mean ± standard deviations. Fisher exact test or Chi Square test were used when appropriate to compare between categorical groups. Results were considered significant if the P-value is less than 0.05. Accuracy of test results was investigated by using positive predictive value (PPV) and negative predictive value (NPV). To calculate the PPV and NPV of SAAG, a value of < 1.1 g/dL was assigned as diagnostic for malignant (non portal hypertension) ascites. Thus, diagnostic results < 1.1 g/dL were considered as positive while results ≥ 1.1 g/dL were negative. The PPV of SAAG was calculated by dividing the total number of non-portal hypertension with true positives by the total number of individuals with positive results in each ca


The total number of patients included in this study was 22 patients. 12 (54.5%) were females and 10 (45.5%) were males with a mean age of 52.9±14.75 years. There were 8 (36.4%) Qataris; the remaining 14 (63.6%) were of different nationalities. (Table/Fig 1) shows causes of ascites due to malignancy among Qatari and non-Qatari residents in relation to gender.

Based on serum-ascitic albumin gradient, ascites due to malignancy was divided into two groups: first, with serum/ascitic albumin gradient (SAAG) < 1.1 g/dL, second, serum/ascitic albumin gradient > 1.1 g/dL. The first group was consistent with carcinomatous peritonitis (malignant ascites), while the second group represented tumors metastasizing to the liver leading to portal hypertension (malignant related ascites). Moreover, ascitic total protein was high (≥ 2.5 gm/dL) in 11 (91.6%) patients of the first group, while it was low (< 2.5 g/dL) in 9 (90%) patients of the second group. The positive and negative predictive values of serum/ascites albumin gradient and ascitic total protein are shown in (Table/Fig 2).
In malignant ascites, ovarian cancer was found in four patients (33.3%), colon cancer in two patients (16.7%), gastric cancer in two patients (16.7%), breast cancer in one patient (8.3%), urinary bladder cancer in one patient (8.3%), renal cancer in one patient (8.3%), and primary peritoneal cancer in one patient (8.3%). On the other hand, causes of malignant related ascites included gall bladder cancer in five patients (50%), breast cancer in two patients (20%), pancreatic cancer in one patient (10%), gastric cancer in one patient (10%), and thyroid cancer in one patient (10%). Out of 22, 13 (59%) patients, presented with ascites, which required further investigations to find the primary tumour.

Cytopathological study of ascitic fluid in malignant ascites was positive in nine (75%) patients; while peritoneal biopsy (biopsy with laparoscopy) was required to confirm peritoneal carcinomatosis in the remaining three. On the other hand, malignant related ascites has disappointingly low yield; the frequency of positive result was zero. (Table/Fig 3) shows the comparison between malignant and malignancy related ascites.

After one year follow up, two patients with malignancy related ascites [one male and one female], and one male patient with malignant ascites were died, to result in a one-year mortality rate of 13.6%.


Two-thirds of cases of ascites due to malignancy are caused by peritoneal carcinomatosis, while the most common tumors causing peritoneal 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 diffuses hepatic metastases(7),(8).

In our study, ascites was caused by peritoneal carcinomatosis in 12 (54.5%) patients, whereas it was caused by malignant related ascites in the remaining 10 (45.5%) patients. We did not encounter any case of hepatocellular carcinoma causing ascites in this series. This may be due to low incidence of primary hepatocellular carcinoma in Qatar. There is a predominance of the female patient population (12 of 22) similar to previous studies(4), (7) and this is accounted for by the predominance of the ovarian and breast cancer entity.

In Thirteen (59%) of our patients, the presence of ascites was the first clinical sign of an underlying neoplastic process, which coincides with other reports.(4),(9),(10) These patients were mainly the ovarian and the GI cancer groups, while patients with breast cancer tended to develop ascites due to their cancers months or years after their primary cancer had been diagnosed and treated.

In agreement with other reports (7), (8), (11), (12), (13), ascitic fluid analysis of our patients with peritoneal carcinomatosis demonstrated a low serum /ascites-albumin gradient (< 1.1 mg/dL) in all patients, and an elevated white cell count with a lymphocyte predominance. In malignant ascites, ascitic fluid cytology was diagnostic in 50% to 90% in reported series. [2,8,11,14] laparoscopy can be used to obtain a tissue diagnosis. (15) In our study cytology was positive in over 75%, and laparoscopy was required in three patients with negative cytology to confirm the diagnosis of peritoneal carcinomatousis.

As noted in this study, serum/ascitic albumin gradient seems to be an effective tool in differentiating between malignant and malignancy related ascites in clinical practice, serum/ascitic albumin gradient showed high accuracy for the diagnosis of malignant ascites, as it has positive and negative predictive value of 100% and 100% respectively, compared to 91.6% and 90% for ascitic total protein.

This fact affects the management line of ascites. Malignancy related ascites can be controlled by administering higher doses of spironolactone similar to those seen in patients suffering form liver cirrhosis.(2),(9)

In many studies,(2), (10), (16), (17) ovarian carcinoma is the primary tumour in the majority of cancer patients with malignant ascites. The commonest cancer of origin leading to malignant ascites in our series was ovarian carcinoma; it represented 33.3% of the total patient population. We did not encounter any case of cancer of unknown primary (CUP), although previous studies had been reported the number of malignant ascites due to an unknown primary cancer (CUP) in the range of (8.1% - 22.6%). (2), (4), (9)

Imaging diagnostics such as CT, MRI or ultrasonography are able to detect even small amounts of fluid in the abdominal cavity but they cannot differentiate between a benign or malignant form of ascites. Despite this limitation, they are valuable techniques for discovering a primary tumour or metastases.


In conclusion, it is crucial to differentiate between malignant and malignancy related ascites in clinical practice. This fact will influence not only our understanding but the clinical management of these devastating conditions. Serum/ascitic albumin gradient is effective in differentiating between malignant and malignancy related ascites, since it is related to the genesis of this type of ascites. Moreover, cytological evaluation of ascitic fluid is helpful in the detection of malignant ascites; it was positive in 75% of our patients.


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Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988; 8: 1104–1109.
Ayantunde AA, Parsons SL. Pattern and prognostic factors in patients with malignant ascites: a retrospective study. Ann Oncol. 2007; 18:945-9.
Spratt JS, Edwards M, Kubota T, et al. Peritoneal carcinomatosis: anatomy, physiology, diagnosis, management.Curr Probl Cancer 1986;10:558–584.
Khan FY. Ascites in the state of Qatar: aetiology and diagnostic value of ascitic fluid analysis. Singapore Med J 2007; 48(5):434–439
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Garrison RN, Kaelin LD, Galloway RH, Heuser LS. Malignant ascites: clinical and experimental observations. Ann Surg 1986; 203: 644–651.
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Salerno F, Restelli B, Incerti Pet al. Utility of ascitic fluid analysis in patients with malignancy-related ascites. Scand J Gastroenterol 1990; 25 (3): 251-6.
Jungst D, Xie Y, Gerbes AL Pathophysiology of elevated ascites fluid cholesterol in malignant ascites. Increased ascites to serum relation of proteins and lipoproteins in patients with peritoneal carcinomatosis as compared to patients with cirrhosis of the liver. J Hepatol 1992, 14(2-3): 244-8
Tables and Figures
[Table / Fig - 1] [Table / Fig - 2] [Table / Fig - 3]

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