1. Bowel Symptoms 1: Nausea & Vomiting Dr Iain Lawrie

2. Nausea, vomiting & retching Nausea – unpleasant feeling of the need to vomit Vomiting – forced expulsion of gastric contents through the mouth Retching – rhythmic, laboured, spasmodic movements of the diaphragm unpleasant symptoms rated as highly distressing by sufferers Occurs in 40-70% of patients with advanced cancer

3. Case Study Malcolm is a 56 year old man with widespread lung cancer. He has liver, bone and adrenal metastases. He is cachectic, with no appetite. He has been admitted with vomiting.

4. Causes of nausea & vomiting Drugs Constipation Infection Hypercalcaemia Severe pain Cough Raised ICP Radiotherapy Anxiety / distress Other

5. Assessment - history Pattern throughout the day Exacerbating & relieving factors Effects of medication Response to previous antiemetics Appetite, weight loss, bowel movements Headache, neurological symptoms Is it vomiting?

6. Examination & investigation Examination Mouth Abdomen Rectum Investigation Biochemistry Plain abdominal X-ray Endoscopy ?CT scan

7. Vomit Vomiting Centre Cortical Structures Gut MucosaVestibular Apparatus D 2 5-HT 3 ACh H 1 5-HT 2 ACh Chemoreceptor Trigger Zone D 2 5-HT 3 Ach H 1, ACh

8. Vomit Vomiting Centre Cortical Structures Gut MucosaVestibular Apparatus D 2 5-HT 3 ACh H 1 5-HT 2 ACh H 1 ACh Motion Emotions, sights, smells, raised ICP GI obstruction, bowel colic, tumour mass, constipation Chemoreceptor Trigger Zone D 2 5-HT 3 ACh Drugs, toxins, uraemia, hypercalcaemia

9. Vomit Vomiting Centre Cortical Structures Gut MucosaVestibular Apparatus D 2 5-HT 3 ACh H 1 5-HT 2 ACh H 1 ACh Motion Emotions, sights, smells, raised ICP GI obstruction, bowel colic, tumour mass, constipation Chemoreceptor Trigger Zone D 2 5-HT 3 ACh Drugs, toxins, uraemia, hypercalcaemia Metoclopramide, Levomepromazine Granisetron Haloperidol Metoclopramide Levomepromazine Granisetron Dexamethasone Cyclizine, Hyoscine HBr Cyclizine, Levomepromazine, Hyoscine HBr

10. Antiemetics Metoclopramide Domperidone Haloperidol Prochlorperazine Cyclizine Hyoscine hydrobromide Ondansetron Granisetron Tropisetron Aprepitant Dexamethasone

11. Summary Think multiple causes >70% of the solution to nausea & vomiting is in the history Choose antiemetics - likely cause/receptors, side effects, routes Be very familiar with metoclopramide, haloperidol, cyclizine, (levomepromazine) Remember, causes change! Mechanical causes need mechanical solutions