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Nausea and Vomiting (PDQ®)

  • Last Modified: 09/03/2014

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Overview

Introduction
Classifications

Prevention and control of nausea and vomiting (emesis) (N&V) are paramount in the treatment of cancer patients. N&V can result in the following:

  • Serious metabolic derangements.
  • Nutritional depletion and anorexia.
  • Deterioration of patients’ physical and mental status.
  • Esophageal tears.
  • Fractures.
  • Wound dehiscence.
  • Withdrawal from potentially useful and curative antineoplastic treatment.
  • Degeneration of self-care and functional ability.

(See Table 1 for criteria on grading severity.)

Despite advances in pharmacologic and nonpharmacologic management, N&V remain two of the more distressing and feared side effects to cancer patients and their families, and incidence may be underestimated by physicians and nurses.[1-5]

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

Introduction

Nausea is a subjective phenomenon of an unpleasant, wavelike sensation experienced in the back of the throat and/or the epigastrium that may culminate in vomiting (emesis). Vomiting is the forceful expulsion of the contents of the stomach, duodenum, or jejunum through the oral cavity. Retching is gastric and esophageal movements of vomiting without expulsion of vomitus and is also referred to as dry heaves.

Classifications

Various classifications of N&V have been used,[1,6] including acute, delayed, late or persistent, chronic, anticipatory, breakthrough, or refractory, as well as distinctions related to type of treatment (e.g., chemotherapy induced or radiation induced) and clinical course of disease (e.g., advanced or terminal disease).[7,8] Despite this variety, the most commonly described types of N&V are acute, delayed, and anticipatory chemotherapy-induced N&V and chronic N&V in advanced cancer patients. Although there are no standard definitions, the following are commonly used to classify the different types.

  • Acute N&V: N&V experienced during the first 24-hour period after chemotherapy administration is considered acute N&V.[1]

  • Delayed (or late) N&V: N&V that occurs more than 24 hours after chemotherapy administration is considered delayed, or late, N&V. Delayed N&V is associated with cisplatin, cyclophosphamide, and other drugs (e.g., doxorubicin and ifosfamide) given at high doses or on 2 or more consecutive days.

  • Anticipatory nausea and vomiting (ANV): ANV is nausea and/or vomiting that occurs prior to the beginning of a new cycle of chemotherapy in response to conditioned stimuli such as the smells, sights, and sounds of the treatment room. ANV is a classically conditioned response that typically occurs after three or four prior chemotherapy treatments, following which the person experienced acute or delayed N&V.

  • Chronic N&V in advanced cancer patients: Chronic N&V in the advanced cancer patient is N&V associated with a variety of potential etiologies. A definitive understanding of cause is neither well known nor well researched, but potential causal factors include gastrointestinal, cranial, metabolic, drug-induced (e.g., morphine), cytotoxic chemotherapy, and radiation-induced mechanisms.[9]

Table 1. National Cancer Institute’s Common Terminology Criteria for Adverse Events: N&Va
Adverse Event Grade Description 
Nauseab1Loss of appetite without alteration in eating habits
2Oral intake decreased without significant weight loss, dehydration, or malnutrition
3Inadequate oral caloric or fluid intake; tube feeding, TPN, or hospitalization indicated
4Grade not available
5Grade not available
Vomitingc11–2 episodes (separated by 5 min) in 24 h
23–5 episodes (separated by 5 min) in 24 h
3≥6 episodes (separated by 5 min) in 24 h; tube feeding, TPN, or hospitalization indicated
4Life-threatening consequences; urgent intervention indicated
5Death

N&V = nausea and vomiting (emesis); TPN = total parenteral nutrition.
aAdapted from National Cancer Institute.[10]
bDefinition: A disorder characterized by a queasy sensation and/or the urge to vomit.
cDefinition: A disorder characterized by the reflexive act of ejecting the contents of the stomach through the mouth.

References
  1. Wickham R: Nausea and vomiting. In: Yarbo CH, Frogge MH, Goodman M, eds.: Cancer Symptom Management. 2nd ed. Sudbury, Mass: Jones and Bartlett Publishers, 1999, pp 228-263. 

  2. Coates A, Abraham S, Kaye SB, et al.: On the receiving end--patient perception of the side-effects of cancer chemotherapy. Eur J Cancer Clin Oncol 19 (2): 203-8, 1983.  [PUBMED Abstract]

  3. Craig JB, Powell BL: The management of nausea and vomiting in clinical oncology. Am J Med Sci 293 (1): 34-44, 1987.  [PUBMED Abstract]

  4. Passik SD, Kirsh KL, Rosenfeld B, et al.: The changeable nature of patients' fears regarding chemotherapy: implications for palliative care. J Pain Symptom Manage 21 (2): 113-20, 2001.  [PUBMED Abstract]

  5. Grunberg SM, Deuson RR, Mavros P, et al.: Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer 100 (10): 2261-8, 2004.  [PUBMED Abstract]

  6. Pisters KM, Kris MG: Treatment-related nausea and vomiting. In: Berger A, Portenoy RK, Weissman DE, eds.: Principles and Practice of Supportive Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 1998, pp 165-199. 

  7. Fallon BG: Nausea and vomiting unrelated to cancer treatment. In: Berger A, Portenoy RK, Weissman DE, eds.: Principles and Practice of Supportive Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 1998, pp 179-189. 

  8. Allan SG: Nausea and vomiting. In: Doyle D, Hanks GW, MacDonald N, eds.: Oxford Textbook of Palliative Medicine. 2nd ed. New York, NY: Oxford University Press, 1998, pp 282-290. 

  9. Schwartzberg L: Chemotherapy-induced nausea and vomiting: state of the art in 2006. J Support Oncol 4 (2 Suppl 1): 3-8, 2006.  [PUBMED Abstract]

  10. National Cancer Institute: Common Terminology Criteria for Adverse Events (CTCAE), Version 4.0. Bethesda, Md: U.S. Department of Health and Human Services, National Institutes of Health, 2010. Available online. Last accessed August 28, 2014.