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Cancer Health Center

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Nausea and Vomiting (PDQ®): Supportive care - Health Professional Information [NCI] - Nausea, Vomiting (Emesis), Constipation, and Bowel Obstruction in Advanced Cancer

Frequency

Nausea and vomiting (N&V) are common symptoms in patients with advanced cancer, occurring in approximately 21% to 68% of these patients.[1,2] The underlying pathophysiology and treatment differs somewhat from nausea related to radiation treatment or chemotherapy. Chronic nausea can significantly impair a patient's quality of life.

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General Information About Adult Primary Liver Cancer

Incidence and Mortality Estimated new cases and deaths from liver and intrahepatic bile duct cancer in the United States in 2014:[1] New cases: 33,190. Deaths: 23,000. Hepatocellular carcinoma (HCC) is relatively uncommon in the United States, although its incidence is rising, principally in relation to the spread of hepatitis C virus (HCV) infection.[2] HCC is the most common solid tumor worldwide and the third leading cause of cancer-related deaths.[3,4] Both local extension...

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Pathophysiology and Causes

Chronic nausea in the advanced cancer setting is often multifactorial in origin.[1,2,3] Medications, including some that are frequently prescribed in this setting-such as opioids, nonsteroidal anti-inflammatory drugs, and selective serotonin reuptake inhibitor antidepressants-may be responsible.

In the case of opioids, nausea frequently resolves spontaneously a few days after initiation of treatment. In some cases, however, it may persist. Nausea resulting from the accumulation of active opioid metabolites (morphine-6-glucuronide) has been described,[4] and patients with impaired renal function may be at increased risk. Opioids invariably produce constipation if prophylactic measures are not taken (namely, the use of a regular laxative regimen), and constipation is one of the most common causes of nausea in patients with advanced cancer.[5,6,7,8]

Opioid-induced gastrointestinal (GI) motility problems may compound the problem of diminished GI motility that many patients experience as part of the anorexia-cachexia syndrome of advanced cancer. The autonomic dysfunction that often accompanies this syndrome results in decreased GI motility, early satiety, and chronic nausea.[9,10,11] Other causes of chronic nausea in these patients include the following:[12]

Nausea, like many other symptoms, may have psychological undercurrents that either exacerbate or induce chronic nausea.

Assessment

A comprehensive history that includes determining the frequency and effectiveness of bowel movements and laxative therapy is essential. Concurrent medications are reviewed, and the frequency and nature of N&V is documented. Examination will assess for bowel obstruction, fecal impaction, dehydration, and raised intracranial pressure. History and physical examination are poor at determining the extent of constipation.[5] A plain flat-plate x-ray of the abdomen can be very useful to this end.[13] Surgical x-ray views of the abdomen may be helpful if a bowel obstruction is suspected. Investigations to determine blood levels of electrolytes, calcium, and renal parameters may also be helpful.

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