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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 (emesis) (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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Overview

The Gerson therapy is a complex regimen that has been used to treat people with cancer and other diseases (see Question 1). The key parts of the Gerson therapy are a strict diet, dietary supplements, and enemas (see Question 1). The theory is that disease can be cured by removing toxins from the body, boosting the immune system, and replacing excess salt in the body's cells with potassium (see Question 3). The Gerson therapy requires that the many details of its treatment plan be followed...

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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 (SSRI) 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]

  • Raised intracranial pressure (from metastatic brain disease or primary brain tumors).
  • Metabolic abnormalities such as hypercalcemia, hyponatremia, and uremia.
  • Dehydration.
  • Malignant bowel obstruction.
  • Gastroduodenal ulcers.
  • Infections of the mouth, pharynx, or esophagus.

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 should be reviewed, and the frequency and nature of N&V should be documented. Examination should attempt to exclude 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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