Nausea and Vomiting

Key Terms: Antiemetics, Emesis, Retching.

Description

Nausea and vomiting are recognized as two separate and distinct conditions. Nausea is the subjective, unpleasant feeling or urge to vomit, which may or may not result in vomiting. Vomiting is the forceful expelling of the contents of the stomach and intestines through the mouth. To some, nausea is a more distressing symptom than vomiting. Nausea and vomiting are major problems for patients being treated with cancer, with approximately 50% of patients experiencing nausea and vomiting as a result of cancer treatments even though antiemetics (anti-nausea and vomiting medications) were used. In addition, more than 50% of cancer patients experience nausea and vomiting as a result of progression of the disease, or as a result of exposure to other therapies used to treat the cancer.

Not all patients diagnosed with cancer will experience nausea and vomiting. However, nausea and vomiting remain two of the side effects associated with cancer and cancer treatment that patients and their families fear the most. The negative aspects of nausea and vomiting can influence all facets of a patient's life. If nausea and vomiting are not controlled in the patient with cancer, the result can be serious metabolic problems such as disturbances in fluid and electrolyte balance and nutritional status. Psychological problems associated with nausea and vomiting include anxiety and depression. Uncontrolled nausea and vomiting can also lead to the decision by the patient to stop potentially curative cancer therapy.

Causes

The most common causes of nausea and vomiting in cancer patients include treatment with chemotherapy and radiation therapy; tumor spread to the gastrointestinal tract, liver, and brain; constipation; infection; and use of some opioids, which are drugs used to treat cancer pain. The mechanisms that control nausea and vomiting are not fully understood, but both are controlled by the central nervous system. Nausea is thought to arise from stimulation of the autonomic nervous system. It is theorized that chemotherapy causes vomiting by stimulating areas in the gastrointestinal tract and the brain. The areas in the brain that are stimulated are the chemoreceptor trigger zone (CTZ) and the emetic or vomiting center (VC). When the VC is stimulated, muscular contractions of the abdomen, chest wall, and diaphragm occur, which result in the expulsion of stomach and intestinal contents.

Chemotherapy-Induced Nausea and Vomiting

Not all chemotherapeutic agents cause nausea and vomiting. Chemotherapy drugs vary in their ability or potential to cause nausea and vomiting. This variation is known as the emetogenic potential of the drug, or the potential of the drug to cause emesis. Chemotherapy drugs are classified as having severe (greater than 90% of patients exposed to this drug will experience nausea and vomiting), high (60–90% of patients will experience nausea and vomiting), moderate (30–60% will experience nausea and vomiting), low (10–30% will experience nausea and vomiting), and very low (less than 10% experience nausea and vomiting) emetogenic potential.

The incidence and severity of chemotherapy-induced nausea and vomiting varies and is related to the following factors: the emetogenic potential of the drug, the drug dosage, the schedule of administration of the drug, and the route of the drug. For example, even a drug with a low emetogenic potential may cause nausea and vomiting if given at higher doses. Factors that are associated with increased nausea and vomiting after chemotherapy include female gender, age greater than six in children, age less than 50 in adults, history of motion sickness, and history of vomiting in pregnancy.

When nausea and vomiting result from chemotherapy administration, the nausea and vomiting can be classified as anticipatory, acute, or delayed. Anticipatory nausea and vomiting occur prior to the actual chemotherapy treatment and are a response primarily to an environmental stimulus, such as a specific odor, which is then associated with the chemotherapy treatment in the future. That is, the smell of the odor alone can be enough to induce or trigger nausea and vomiting in the sensitized patient. Acute nausea and vomiting occur within 24 hours of administration of the chemotherapeutic agent. Delayed nausea and vomiting occur after the acute phase and may last 48 or more hours after chemotherapy administration.

Radiation Therapy Induced Nausea and Vomiting

Although not all patients receiving radiation therapy will experience nausea and vomiting, patients receiving radiation therapy to the gastrointestinal tract and brain are most likely to experience those side effects. Radiation therapy to the brain is believed to stimulate the CTZ, the VC, or both. The higher the radiation therapy dose and the greater the body surface area irradiated, the higher the potential for nausea and vomiting. Also, the larger the amount of gastrointestinal tract tissue exposed to radiation the more likely nausea and vomiting will occur. Nausea and vomiting associated with radiation therapy usually occurs one-half hour to several hours after treatment and usually does not occur on the days when the patient is not undergoing treatment.

Treatments

Pharmacologic Management

The most commonly used intervention to manage nausea and vomiting in cancer patients is the use of antiemetic drugs. Many of these drugs work by inhibiting stimulation of the CTZ and perhaps the VC. Most of the drugs used today to clinically treat nausea and vomiting are classified into one of the following groups: dopaminergic antagonists, neurokinin receptor antagonists, corticosteroids, cannabinoids, and serotonin receptor antagonists. Antiemetics can be utilized as single agents or several drugs can be prescribed together as combination therapy.

Examples of dopaminergic antagonists include phenothiazines such as prochlorperazine (Compazine), substituted benzamides such as metaclopramide (Reglan), and butyrophenones such as droperidol (Inapsine) and haloperidol (Haldol). Side effects of the dopaminergic antagonists include extrapyramidal reactions (e.g., tremors, slurred speech, anxiety, distress, paranoia) and sedation. In 2004, the FDA approved a new drug called aprepitant (Emend) for use in cancer patients. It is used in combination with other antiemetics for relief of acute and delayed nausea and vomiting caused by high-dose chemotherapy, most often caused by the chemotherapy drug cisplatin. Side effects of aprepitant include fatigue, dizziness, stomach pain, nausea, hiccups, diarrhea, constipation, and loss of appetite.

Steroids may be used to treat mild to moderately emetogenic chemotherapy. However, long-term corticosteroid use is considered inappropriate due to the multiple adverse effects associated with long-term use. Cannabinoids (substances similar to, or derived from, marijuana) may be effective in selected patients but are usually not prescribed as first line therapy due to generally low rates of effectiveness. Controversy continues to exist related to the use of cannabinoids, which may not be accepted cultural or societal practice for some patients. Side effects of cannabinoids include physical and psychogenic effects such as acute withdrawal syndrome, dizziness, dry mouth, sedation, depression, anxiety, paranoia, and panic.

The newest class of antiemetics is the serotonin or 5-HT₃ antagonists. In 2001, three serotonin receptor antagonists were available in the United States: granisetron (Kytril), ondansetron (Zofran), and dolasetron (Anzemet). Serotonin receptor antagonists are better tolerated, are generally more effective, and result in fewer side effects than previously available antiemetics. A common adverse effect of the serotonin antagonists is asthenia, a state of unusual fatigue and weakness. Asthenia usually occurs two to three days after treatment with serotonin antagonists and may last one to four days. Serotonin receptor antagonists may not be offered or made available to all patients due to the relatively high cost of the drugs. Controversy exists related to the optimal role of serotonin receptor antagonists. Some clinicians argue there is the potential for overuse of the serotonin receptor antagonists when used to treat patients who are not receiving chemotherapeutic agents with moderate to severe emetogenic potential and when less expensive agents would be as effective.

Another class of drugs, the benzodiazepines including lorazepam (Ativan), midazolam (Versed), and alprazolam (Xanax), may be used in conjunction with antiemetics in the prevention and treatment of anxiety and expected chemotherapy-induced nausea and vomiting. These agents appear to be especially effective in highly emetogenic regimens administered to children. The benzodiazepines have only modest antiemetic properties. Therefore, they are usually used as adjuncts to antiemetic agents. Adverse effects of the benzodiazepines include sedation, confusion, hypotension (unusually low blood pressure), and visual disturbances.

Alternative and Complementary Therapies

The use of antiemetics is considered the cornerstone of therapy to treat chemotherapy-induced vomiting. Nonpharmacologic therapies may be used in conjunction with pharmacologic agents to enhance the effects of the drugs. Nonpharmacologic strategies include behavioral interventions such as guided imagery, hypnosis, systematic desensitization, and attentional distraction. Dietary interventions such as eating cold or room temperature foods and foods with minimal odors while avoiding spicy, salty, sweet, or high-fat foods may be beneficial to some patients while undergoing chemotherapy treatments. Another dietary recommendation is the use of ginger or ginger capsules to decrease episodes of nausea and vomiting. Acupressure, specifically stimulation of the Nei-Guan point (P6) of the dominant arm or stimulation of the Inner Gate and ST36 or Three Miles point (below the knee and lateral—outside area—to the tibia) has proven helpful to some patients. Music therapy interventions have also been effective as diversional interventions to reduce incidence and severity of chemotherapy-induced nausea and vomiting.

Resources

Books

Wickham, R. "Nausea and Vomiting." In Cancer Symptom Management, edited by C. H. Yarbro, M. H. Frogge, and M. Goodman. Boston: Jones and Bartlett Publishers, 1999, pp. 228–253.

Periodicals

American Society of Health-System Pharmacists. "ASHP Therapeutic Guidelines on the Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving Chemotherapy or Radiation Therapy or Undergoing Surgery." American Journal of Health System Pharmacy 56 (1999): 729–764.

Boothby, Lisa A., and Paul L. Doering. "New Drug Update 2003: Part 1." Drug Topics February 23, 2004: 54.

Other

"Nausea and Vomiting." WebMDHealth. WebMD. [cited June 26, 2005]. .

"Symptom Management: Nausea/Vomiting." Oncolink. Oncolink. [cited June 26, 2005]. .

—Melinda Granger Oberleitner, R.N., D.N.S.; Teresa G. Odle

Definition

Nausea is the sensation of being about to vomit. Vomiting, or emesis, is the expelling from the stomach of undigested food through the mouth.

Description

Nausea is a reaction to a number of causes that include overeating, infection, or irritation of the throat or stomach lining. Persistent or recurrent nausea and vomiting should be checked by a doctor.

A doctor should be called if nausea and vomiting occur in the following instances:

• after eating rich or spoiled food or taking a new medication
• repeatedly or for 48 hours or longer
• following intense dizziness

It is important to see a doctor if nausea and vomiting are accompanied by the following:

• yellowing of the skin and whites of the eyes
• pain in the chest or lower abdomen
• trouble with swallowing or urination
• dehydration or extreme thirst
• drowsiness or confusion
• constant, severe abdominal pain
• a fruity breath odor

Demographics

Nausea and vomiting are commonly experienced. There are no distinctive patterns of age, gender, or race.

Causes and Symptoms

Persistent, unexplained, or recurring nausea and vomiting can be symptoms of a variety of serious illnesses. They can be caused by overeating or drinking too much alcohol. These symptoms can be due to stress, certain medications, or illness. For example, people who are given morphine or other opioid medications for pain relief after surgery sometimes feel nauseated by the drug. Such poisonous substances as arsenic and other heavy metals cause nausea and vomiting. Morning sickness is a consequence of pregnancy-related hormone changes. Motion sickness can be induced by traveling in a vehicle, plane, or on a boat. Many people experience nausea after eating spoiled food or foods to which they are allergic. Individuals who suffer migraine headache often experience nausea. Cancer patients receiving chemotherapy are often nauseated. Gallstones, gastroenteritis, and stomach ulcer may cause nausea and vomiting. These symptoms should be evaluated by a physician.

Nausea and vomiting may also be psychological in origin. Some people vomit under such conditions of emotional stress as family arguments, academic tests, airplane travel, losing a job, and similar high-stress situations. In addition, some eating disorders are characterized by self-induced vomiting.

When to Call the Doctor

A doctor should be notified if vomiting is heavy and/or bloody, if the vomitus looks like feces, or if the affected person has been unable to keep food down for 24 hours. Most vomiting episodes should stop in eight to 12 hours of onset. The pediatrician should be consulted if vomiting continues beyond that time, if the child shows signs of dehydration, seems extremely lethargic, or if the child is a very young infant.

An ambulance or emergency response number should be called immediately if the following occurs:

• The child's mouth and tongue are very dry.
• The child has very rapid heartbeat and breathing.
• The child cries but has no tears.
• The child has sunken eyes.
• Diabetic shock is suspected.
• Nausea and vomiting continue after other symptoms of viral infection have subsided.
• The person has a severe headache.
• The person is sweating and having chest pain and trouble breathing.
• The person is known or suspected to have swallowed a drug overdose or poisonous substance.
• The person has a high body temperature, muscle cramps, and other signs of heat exhaustion or heat stroke.
• Nausea, vomiting, and breathing problems occur after exposure to a known allergen.

Diagnosis

Diagnosis is based on the severity, frequency, and duration of symptoms, and other factors that could indicate the presence of a serious illness.

Diagnosis is based on a careful medical history that includes foods recently eaten, travel, and occupation. In some cases, the doctor may order laboratory tests or imaging studies to determine the presence of drugs or poisonous substances in the person's blood or urine, or evidence of head injuries or abnormalities in the digestive tract. If the nausea and vomiting appear to be related to anxiety, stress, or an eating disorder, the doctor may refer the person to a psychiatrist for further evaluation.

Treatment

Getting a breath of fresh air or getting away from whatever is causing the nausea can solve the problem. Eating olives or crackers or sucking on a lemon can calm the stomach by absorbing acid and excess fluid. Cola syrup is another proven remedy.

Vomiting relieves nausea quickly but can cause dehydration. Sipping clear juices, weak tea, and some sports drinks helps replace lost fluid and minerals without irritating the stomach. Infants and small children under age two do best with an oral rehydration solution like Pedialyte. The solution should be given a teaspoon at a time, at frequent intervals, starting 30–60 minutes after vomiting has ceased. Food should be reintroduced gradually, several hours after vomiting stops, beginning with small amounts of dry, bland food like crackers and toast.

Medications that are given to relieve nausea and vomiting are called antiemetics. Meclizine (Bonine), a medication for motion sickness, also diminishes the feeling of queasiness in the stomach. Dimenhydrinate (Dramamine), another motion-sickness drug, is not effective on other types of nausea and may cause drowsiness.

Other drugs that have been developed to treat postoperative or post-chemotherapy nausea and vomiting include ondansetron (Zofran) and granisetron (Kytril). Intravenous administration of supplemental fluid before the operation can lower the risk of nausea after surgery.

Alternative Treatment

Advocates of alternative treatments suggest biofeedback, acupressure and the use of herbs to calm the stomach. Biofeedback uses exercise and deep relaxation to control nausea. Acupressure (applying pressure to specific areas of the body) can be applied by wearing a special wristband or by applying firm pressure to the following:

• the back of the jawbone
• the webbing between the thumb and index finger
• the top of the foot
• the inside of the wrist
• the base of the rib cage

Acupuncture is an alternative treatment found to be effective in relieving nausea. A few people, however, experience nausea as a side effect of acupuncture.

Chamomile (Matricaria recutita) or lemon balm (Melissa officinalis) tea may relieve symptoms. Ginger (Zingiber officinale), another natural remedy, can be ingested as tea or taken as candy, cookies, or powdered capsules.

Prognosis

Most instances of nausea and vomiting respond well to appropriate treatment, including removing any substance or condition that precipitates the nausea.

Prevention

Massage, meditation, yoga, and other relaxation techniques can help prevent stress-induced nausea. Antinausea medication taken before traveling can prevent motion sickness. Sitting in the front seat, focusing on the horizon, and traveling after dark can also minimize symptoms.

Food should be fresh, properly prepared, and eaten slowly. Overeating, tight-fitting clothes, and strenuous activity immediately after a meal should be avoided.

Vomiting related to emotional upsets may be avoided by forms of psychotherapy that teach people to manage stress in healthier ways.

Nutritional Concerns

Prolonged vomiting can lead to fluid and electrolyte depletion. Nausea can curtail appetite. Over time, this can lead to nutritional problems.

Parental Concerns

Parents should be especially concerned about prolonged vomiting in children younger than two years of age. This concern intensifies if the vomiting is accompanied by diarrhea that accelerates fluid and electrolyte depletion. Parents should consult a pediatrician for treatment options if an infant younger than six months of age vomits multiple times within several hours.

Resources

Books

Diagnostic and Statistical Manual of Mental Disorders,4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

"Functional Vomiting." Section 3, Chapter 21 in The Merck Manual of Diagnosis and Therapy. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Hasler, Willliam L. "Nausea, Vomiting, and Indigestion." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald, et al. New York: McGraw-Hill, 2001, pp. 236–40.

Pelletier, Kenneth R. The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster, 2002.

Periodicals

Antonarakis, E. S., and R. D. Hain. "Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice." Archives of Disease in Childhood 89, no. 9 (2004): 220–3.

Baggley A., et al. "Determinants of women's decision making on whether to treat nausea and vomiting of pregnancy pharmacologically." Journal of Midwifery and Women's Health 49, no. 4 (2004): 350–4.

Czeizel, A. E., et al. "Association between severe nausea and vomiting in pregnancy and lower rate of preterm births." Pediatric and Perinatal Epidemiology 18, no. 4 (2004): 253–9.

Donohew, B. E., and M. J. Griffin. "Motion sickness: effect of the frequency of lateral oscillation." Aviation, Space, and Environmental Medicine 75, no. 8 (2004): 649–56.

Einarson, A., et al. "The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study." British Journal of Obstetrics and Gynecology 111, no. 9 (2004): 940–3.

Hockenberry, M. "Symptom management research in children with cancer." Journal of Pediatric Oncology Nursing 21, no. 3 (2004): 132–6.

Shin, Y. H., et al. "Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients." Cancer Nursing 27, no. 4 (2004): 267–74.

Organizations

American Academy of Emergency Medicine. 611 East Wells Street, Milwaukee, WI 53202. Web site: www.aaem.org/.

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: www.aafp.org/.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: www.aap.org/default.htm.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611–3604. Web site: www.aapmr.org/.

American Association of Poison Control Centers. 3201 New Mexico Avenue NW, Washington, DC 20016. Web site: www.aapcc.org/.

American Board of Obstetrics and Gynecology. 2915 Vine Street Suite 300, Dallas TX. 75204. Web site: www.abog.org/.

American College of Gastroenterology. 4900 B South 31st Street, Arlington VA 22206. Web site: www.acg.gi.org/.

Web Sites

"About Nausea and Vomiting." Cleveland Clinic. Available online at www.clevelandclinic.org/health/health-info/docs/1800/1810.asp?index=8106 (accessed November 30, 2004).

"Nausea and Vomiting." National Cancer Institute. Available online at (accessed November 30, 2004).

"Nausea and Vomiting." National Library of Medicine. Available online at www.nlm.nih.gov/medlineplus/nauseaandvomiting.html (accessed November 30, 2004).

"Nausea and Vomiting, Age 4 and Older." Web MD. Available online at (accessed November 30, 2004).

[Article by: L. Fleming Fallon, Jr., MD, DrPH]