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

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Abstract
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 Especially opioids and chemotherapy Gastritis or ulceration Functional gastric stasis due to external pressure Carcinoma of stomach Gastroduodenal obstruction Renal failure Hypercalcaemia Infection Tumour toxins 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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