Page 181 Guide to Pain Management in Low-Resource Settings

Chapter 22

Hematologic Cancer with Nausea and Vomiting

Justin Baker, Raul Ribeiro, and Javier Kane

Case report treatment or palliative treatment) or complications di-
rectly or indirectly related to the disease. More than half
Michael is a 23-year-old man with recurrent lympho- of cancer patients who are dying experience signifi cant
blastic lymphoma in his bone marrow and central ner- nausea, and nearly one-third experience vomiting. Th e
vous system (CNS) who is receiving end-of-life care with clinical picture of N/V is often multifactorial. Regardless
palliative chemotherapy. Five days ago, Michael started of the etiology, the symptoms of N/V can interfere with
on a course of oral cyclophosphamide (see Table 1 for patients’ nutritional status and their enjoyment of eat-
emetogenic properties of chemotherapy) with the inten- ing and drinking and can signifi cantly aff ect their quality
tion of prolonging a life of good quality. Michael’s chief of life and the quality of their death. When not properly
complaint at this time is severe nausea accompanied by managed, N/V interferes with a patient’s nutritional sta-
vomiting 2 or 3 times per day. Th e main concern of Mi- tus, hydroelectrolytic homeostasis, mental status, clinical
chael’s parents is his inability to eat or drink anything performance, and compliance with treatment. Clinicians
considerable. Michael is currently receiving morphine 30 therefore have an ethical imperative to prevent, screen,
mg orally every 4 hours, mostly to control his headaches. assess, treat, and follow up N/V to ensure the best pos-
He is on no other medications. Further history reveals sible care for dying cancer patients.
that Michael’s nausea and vomiting have been increasing
in severity over the past 3 days (he started the cyclophos- What are the main pathways
phamide 5 days ago). He has not had a bowel movement involved in the pathophysiology
for 7 days.
of nausea and vomiting?

Why is treatment of nausea Th e pathophysiology of nausea and vomiting is fairly
and vomiting so important? well characterized. Th e vomiting center receives aff erent
input from four neuronal pathways that carry emeto-
Nausea is defi ned as a feeling of sickness in the stomach genic signals:
and is characterized by an urge to vomit. Vomiting is the Peripheral pathways from the gastrointestinal
forceful expulsion of the contents of the stomach and (GI) tract through the vagus and splanchnic nerves. Th e
proximal small intestine. Nausea and vomiting (N/V) are GI tract may elicit nausea through sensations of irrita-

common symptoms in dying patients and arise as a re- tion by medications, tumor infi ltration, obstruction, dis-
sult of either treatment-related toxicity (disease-specifi c tension, or constipation or fecal impaction.
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 169
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
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