Pediatric emergency medicine trisk 2738 2738
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Nausea and vomiting are common symptoms in oncology patients. It is critical to
consider the differential diagnosis and not just attribute all such symptoms to
chemotherapy-induced nausea and vomiting (CINV). CINV can be divided into
three categories: acute (within 24 hours of emetogenic treatment), delayed (2 to 5
days after treatment), and anticipatory. Anticipatory symptoms are conditioned
symptoms that occur without emetogenic treatment with a variety of emotional or
sensory triggers. These anticipatory symptoms can become chronic in some patients.
Despite appropriate prophylactic therapy, almost all cancer patients experience some
nausea and vomiting. Radiation to the GI tract or the CNS is itself emetogenic.
Other causes of nausea and vomiting include GI injury from a variety of causes such
as gastritis from steroids, obstipation/constipation, medication side effects (e.g.,
narcotics), pancreatitis (from asparaginase), GI obstruction (e.g., adhesions from
prior surgery), or superior mesenteric artery syndrome in patients with severe
malnutrition.
Management of CINV (or radiation induced) is outlined in Table 98.10 . As with
pain management, all medications are less effective when treating established
symptoms. Standard hydration and electrolyte management should be employed for
all patients with severe nausea/vomiting. An abdominal x-ray can be helpful if
obstruction or obstipation/constipation is suspected. Amylase and lipase should be
measured in patients who are being treated with asparaginase.
Constipation is very common in oncology patients. Contributing factors included
decreased GI motility from vinca alkaloids, narcotics, poor oral intake, decreased
activity, and/or withholding due to rectal pain from mucositis. The evaluation should
include a detailed history to elicit any of the contributing factors as well as a specific
bowel history. Physical examination should not include a digital rectal examination
due to potential increased risk of bacteremia. Abdominal x-ray may be helpful in
establishing the amount of stool. Treatment of constipation in the oncology patient
should include only those agents that can be given by mouth. Rectal suppositories
and enemas should be avoided except in extreme circumstances. Patients with
severe symptoms may need to be admitted.
