Management of Intractable Nausea and Vomiting

Dr. Stecher presented a very thought provoking case of intractable nausea in a patient with end stage esophageal cancer on palliative chemotherapy.

We reviewed the neural pathways that mediate nausea:

1. Chemoreceptor trigger zone (CTZ):

  • Functionally outside the blood-brain barrier

  • Exposed to toxins in the bloodstream and cerebrospinal fluid that can stimulate vomiting

2. Cortex:

  • cause nausea due to input from the 5 senses, anxiety, meningeal irritation, and increased intracranial pressure

  • supplies many afferents to the vomiting center

3. Peripheral pathways:

  • triggered by mechanoreceptors and chemoreceptors in the GI tract, serosa, and viscera

  • transmitted via the vagus and splanchnic nerves, sympathetic ganglia, and glossopharyngeal nerves

4. Vestibular system:

  • mediated through labyrinthine inputs into the vomiting center via the vestibulocochlear nerve, triggered by motion

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The take-home points:

  1. A good history is really important when thinking about etiologies (BMs, meds, surgery, PMH, etc)

  2. Pathophysiology of nausea and receptors can help guide therapy (i.e. 5HT3, histamine, dopamine)

  3. Most frequent causes in hospice pts:

    1. metabolic, drug, infection

    2. impaired gastric emptying

    3. visceral causes (bowel obstruction, constipation)

For more information and a more in-depth review on causes of nausea and specifics on the pharmacology of anti-emetic, check out our reference:

Wood GJ, Shega JW, Lynch B, Von roenn JH. Management of intractable nausea and vomiting in patients at the end of life: "I was feeling nauseous all of the time . nothing was working". JAMA. 2007;298(10):1196-207.