Nausea + Vomiting

Question 1

Large volume of vomitus, infrequent vomiting, relief of symptoms after vomiting, oesophageal reflux, epigastric fullness, early satiation, hiccups. Succussion splash in some people =

Answer 1

Gastric stasis

Question 2

Symptoms similar to gastric stasis, but also forceful vomiting and rapid dehydration

Answer 2

Gastric outflow obstruction

Question 3

Symptoms similar to gastric stasis, but low-volume vomiting

Answer 3

‘Squashed stomach syndrome’ (reduction in gastric cavity by tumour or external compression)

Question 4

Vomiting soon after eating or drinking, vomitus comprising what has just been swallowed, sensation of food sticking

Answer 4

Oesophageal blockage

Question 5

Intermittent nausea (often relieved by vomiting), worsening nausea and/or faeculent vomiting as obstruction progresses, abdominal pain (may be colicky), abdominal distention (may be absent if high obstruction)

Answer 5

Bowel obstruction

Question 6

Effortless vomiting, often in the morning, which may be associated with headache (diurnal) and papilloedema; nausea (may be diurnal). Neurological signs and photophobia may be absent

Answer 6

Increased intracranial pressure

Question 7

Nausea and/or sudden vomiting on movement (for example turning in bed)

Answer 7

Motion-associated emesis

Question 8

Nausea present in waves — may be triggered by a previously experienced stimulus and may be relieved by distraction

Answer 8

Anxiety-related nausea

Question 9

Nausea worse in the morning, may be associated with headache and drowsiness

Answer 9

Raised intra-cranial pressure

Question 10

Constant nausea, variable vomiting

Answer 10

Chemically induced nausea

Question 11

What should I ask about the nausea and vomiting in palliative care?

Answer 11

Ask about:
Features of:
Nausea: onset, frequency, intensity, relieving and exacerbating factors, and relationship to vomiting.
Vomiting: onset, frequency, quantity, force, colour, timing, and pattern.
Other symptoms such as:
Dyspepsia, heartburn, reflux symptoms, fullness, early satiety, constipation, diarrhoea, flatus, cough, headache, or confusion.
Treatment history, including:
Simple measures — what has been tried and its effectiveness.
Current medication — recent changes and coinciding symptoms (especially with opiates, anticholinergics, digoxin, and antibiotics).
Chemotherapy — regimen and timing of last treatment.
Anti-emetics — current and past use, and effectiveness.
Radiation — area treated and number of treatments received.
Medical history (for example ulcers or bowel surgery).
Effect on nutrition (for example fluid and food intake in the past 24 hours).
Effect on quality of life.

Question 12

If increased intracranial pressure is a possibility, check the fundi for …

Answer 12

If increased intracranial pressure is a possibility, check the fundi for papilloedema

Question 13

Anti-emetics: receptor site affinities.

Answer 13

Question 14

What simple measures may help nausea and vomiting in palliative care?

Answer 14

Make sure the person has access to a large bowl, tissues, and water.
The sight and smell of food or drink may provoke nausea:
Provide a calm environment away from where food is usually prepared or consumed.
If the person is usually responsible for cooking, make alternative arrangements.
Make sure that meals are small and palatable — snacks consisting of a few mouthfuls are less challenging than big meals.
Carbohydrate meals are often better tolerated.
Offer cool, fizzy drinks (citrus flavours are often preferred) — these are more palatable than still or hot drinks.
Consider the use of complementary therapies; relaxation and acupressure bands may be useful to relieve symptoms.
Consider cognitive behavioural therapy for anticipatory nausea or vomiting.
In general, avoid nasogastric suction. It has no role in the management of most causes of nausea and vomiting.

Question 15

How should I treat toxicity-related nausea and vomiting from drug-induced or metabolic upset?

Answer 15

For chemically induced nausea and vomiting (most drugs, including opioids) there are three options:

Haloperidol via the most appropriate route of administration.
Metoclopramide
Levomepromazine

Question 16

How should I treat movement-related nausea and vomiting?

Answer 16

For vestibular disturbance (for example diseases of the inner ear and motion sickness): give cyclizine via the most appropriate route of administration.

Question 17

How should I treat nausea and vomiting due to bowel obstruction?

To manage bowel obstruction due to peristaltic failure:

Answer 17

If possible, stop drugs that decrease peristalsis (for example cyclizine, tricyclic antidepressants, or opioids).

If there is no colic: start a prokinetic anti-emetic (for example metoclopramide, 30–100 mg/24 hours) via continuous subcutaneous infusion (CSCI).
If colic develops: stop the prokinetic anti-emetic and treat as for mechanical obstruction.

Question 18

How should I treat nausea and vomiting due to bowel obstruction?

To manage bowel obstruction due to mechanical obstruction:

Answer 18

Exclude constipation, or treat if present:
To relieve and prevent constipation, docusate or Movicol® should be titrated to produce a comfortable stool without colic. For more information, see the CKS topic on Palliative care - constipation.
Treat nausea with cyclizine, 50–150 mg/24 hours via CSCI:
If nausea persists, add haloperidol, 2.5–10 mg/24 hours or as a single night-time dose, or levomepromazine, 5–25 mg/24 hours or as a single night-time dose.
Avoid prokinetics.
Treat colic with an antimuscarinic drug (for example hyoscine butylbromide, 20 mg immediately by subcutaneous injection, then 60–100 mg/24 hours via CSCI).
Manage large-volume vomiting with an antisecretory drug (for example hyoscine butylbromide or octreotide).
Hyoscine will reduce secretions and treat colic, but its full antisecretory effect is achieved after about 3 days.
If large volume vomiting persists, consider using octreotide if a more rapid or profound antisecretory effect is required. This may require admission, depending on the experience of the primary healthcare professional and the availability of octreotide in the community.

Question 19

Managing nausea and vomiting with an unknown cause

The options for a therapeutic trial include:

Answer 19

Levomepromazine

Metoclopramide

Haloperidol

Cyclizine