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Palliative care: Assessment and management of nausea and vomiting

Egidio Del Fabbro, MD
Section Editor
Eduardo Bruera, MD
Deputy Editor
Diane MF Savarese, MD


Nausea and vomiting are common symptoms near the end of life that can cause substantial physical and psychological distress for patients and their families, and significantly impact quality of life (QOL). Nausea, the unpleasant sensation of being about to vomit, can occur alone or can accompany vomiting, dyspepsia, or other gastrointestinal symptoms. Vomiting is the expulsion of gastric contents through the mouth caused by forceful and sustained contraction of the abdominal muscles and diaphragm. Retching differs from vomiting in the absence of expulsion of gastric contents.  

There are many potential causes of nausea and vomiting in palliative care populations, and the etiology is often multifactorial, particularly in patients with cancer. In such patients, nausea and vomiting might be caused by anti-tumor treatment (radiation therapy or chemotherapy), represent an acute complication of the malignancy (hypercalcemia, malignant bowel obstruction), be due to gastroparesis (eg, from autonomic dysfunction), or be from drug-induced constipation (opioids, type 3 serotonin receptor [5HT3] antagonists). These various causes of nausea and vomiting may occur simultaneously or sequentially in any individual patient.

This topic review will cover the prevalence, etiology/pathophysiology, assessment, and management of nausea and vomiting in palliative care populations. Chemotherapy- and radiation therapy-induced nausea and vomiting are covered in detail elsewhere. (See "Pathophysiology and prediction of chemotherapy-induced nausea and vomiting" and "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults" and "Radiotherapy-induced nausea and vomiting: Prophylaxis and treatment".)


Cancer patients — Symptom research in patients who have a serious and/or life-threatening illness has largely been conducted in those with cancer. Cancer treatment is one of the more common causes of nausea and vomiting in such patients. Despite adherence to published guidelines on prophylactic antiemetics, breakthrough nausea and vomiting affects up to 40 percent of patients treated with either chemotherapy or radiation therapy (RT).

Radiation therapy — The incidence and severity of RT-induced nausea and vomiting (RINV) are both treatment-related (irradiated site and volume, single and total dose, fractionation schedule, techniques) and patient-related (table 1). The most important factor appears to be the radiation field. Between 90 and 100 percent of patients receiving total body or total nodal irradiation, 60 to 90 percent of those undergoing abdominopelvic, upper abdominal, or mantle irradiation, and 30 to 60 percent of those receiving craniospinal, pelvic, thoracic, or head and neck irradiation will develop RINV. Irradiation to the breast or extremities produces only a 0 to 10 percent risk. Risk categories for emesis that are based upon the site of irradiation have been combined with patient-related factors to stratify a patient’s risk for RINV into four categories (figure 1). This subject is discussed in detail elsewhere. (See "Radiotherapy-induced nausea and vomiting: Prophylaxis and treatment", section on 'Risk classification'.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 17, 2017.
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