Background
Nausea and vomiting cause distress to many palliative care patients. Nausea can either be acute, or persistent and chronic, and is not always associated with vomiting. In many cases it is possible to identify a cause, although in the palliative care population nausea is frequently multifactorial.
Palliative conditions that frequently cause nausea and/or vomiting include intra-abdominal or gastrointestinal malignancy, central nervous system malignancy (due to raised intracranial pressure, cerebellar or vestibular symptoms), and HIV AIDS.
This topic covers:
Other factors that contribute to nausea and/or vomiting that should be sought, and treated where possible, include:
- Metabolic imbalance, including hypercalcemia, uraemia, liver failure
- Sepsis (including urinary tract and respiratory tract infection)
- Conditions affecting gastrointestinal motility, including previous surgery
- Reflux or peptic ulcer disease
- Medication and treatment side effects, including opioids and other drugs, chemotherapy, and radiotherapy
- Anxiety and depression
- Constipation
- Inappropriate presentation of food.
Key messages
- The choice of an antiemetic may be either empirical or related to the inferred mechanism of nausea and / or vomiting. Both approaches appear to be equally effective, based on a systematic review of randomised controlled trials [1].
- A recent systematic review [1] has identified evidence to support the use of metoclopramide and serotonin antagonists in advanced cancer.
- Clinical practice guidelines for managing malignant bowel obstruction are available [2]
- It is likely that steroids hasten the resolution of bowel obstruction [3], although this conclusion is based on very small studies and the effect size was small.
- The option of rectal or gastroduodenal stenting in malignant obstruction appears to offer good palliation in selected patients [4-6].
Active research areas / controversies
- There are no widely accepted assessment tools for nausea and vomiting, particularly for research. However nausea is routinely clinically assessed using the ESAS scale in Australian palliative care services which participate in the PCOC data collection system.
- An evidence-based Clinical Practice Guideline for managing nausea in advanced cancer is currently in development
- Many of the antiemetics in common use are unlikely to be subjected to placebo controlled trials for ethical reasons. However comparative trials between different medications are still needed and are possible [1].
- The potential role of octreotide in bowel obstruction is currently being studied.
- No high level evidence was found to support the common clinical practice of avoiding prokinetic antiemetic drugs such as metoclopramide or domperidone in complete bowel obstruction, due to the possible risk of adverse effects including worsening abdominal pain. This recommendation continues to be based on expert opinion. [7]
References
- Glare P, Pereira G, Kristjanson LJ, Stockler M, Tattersall M. Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer. Supportive Care in Cancer. 2004 Jun;12(6):432-40.
- Ripamonti C, Twycross R, Baines M, Bozzetti F, Capris S, De Conno F, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Supportive Care in Cancer. 2001 Jun;9(4):223-33.
- Feuer DJ, Broadley KE.Corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database of Systematic Reviews, 2000;2:CD001219.
- Khot U, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. British Journal of Surgery. 2002 Sep;89(9):1096-102.
- Watt A, Faragher IG, Griffin TT, Rieger NA, Maddern GJ. Self-expanding metal stents for relieving malignant colorectal obstruction: a systematic review. Annals of Surgery. 2007 Jul;246(1):24-30.
- Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. Journal of Gastroenterology. 2007 Apr;42(4):283-90.
- Ripamonti C. Malignant bowel obstruction in advanced and terminal cancer patients. European Journal of Palliative Care, 1994;1(1):16-9.
This page was created on 24 May 2008 and is due for review in May 2010