Clinical Review

ABC of palliative care: Nausea, vomiting, and intestinal obstruction

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7116.1148 (Published 01 November 1997) Cite this as: BMJ 1997;315:1148
  1. Mary J Baines

    Nausea and vomiting

    Nausea, vomiting, and retching are common and distressing complaints: surveys have found that 50-60% of patients with advanced cancer suffer from one or more of these. These symptoms are more common in patients under 65 years old, in women, and in those with cancer of the stomach or breast.

    The emetic process—pathways of emesis and the neurotransmitters involved

    Assessment

    An understanding of the emetic process and the main neurotransmitters involved is helpful in assessing and treating patients who are vomiting because antiemetic drugs are predominately neurotransmitter blocking agents. They are effective at different receptor sites and therefore treat different causes of vomiting.

    As well as the specific causes of vomiting resulting directly or indirectly from advanced malignancy, patients may develop unrelated conditions such as gastroenteritis or gall bladder disease. In most cases the cause of vomiting is multifactorial, but it is helpful in planning treatment to list all contributing factors.

    The causes of vomiting can usually be determined from a careful history and clinical examination. Note should be taken of the volume, content, and timing of vomits. A biochemical profile may be needed, but other investigations are often inappropriate.

    Management

    Common causes of vomiting in patients with advanced cancer

    • Drugs

    Especially opioids and chemotherapy

    • Gastric causes

    Gastritis or ulceration

    Functional gastric stasis due to external pressure

    Carcinoma of stomach

    Gastroduodenal obstruction

    • Constipation

    • Intestinal obstruction

    • Biochemical causes

    Renal failure

    Hypercalcaemia

    Infection

    Tumour toxins

    • Raised intracranial pressure

    • Vestibular disturbance

    • Abdominal or pelvic radiotherapy

    • Anxiety

    • Cough induced

    Nausea can be treated with oral drugs, but alternative routes are needed for patients with severe vomiting. It must be remembered, however, that persistent nausea may decrease gastric emptying, with a resultant decrease in drug absorption. An antiemetic injection is suitable to control a single episode, but with a persistent problem it is preferable to give drugs by subcutaneous infusion using an infusion device such as a …

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