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Referral and warning signs
When to refer
Persistent N/V unresponsive to first-line antiemetics. Suspected bowel obstruction requiring specialist assessment/intervention. Need for complex antiemetic combinations or parenteral routes.
Red flags
- Signs of severe dehydration (tachycardia, hypotension, poor turgor).
- Persistent vomiting, inability to tolerate oral intake.
- Vomiting blood (haematemesis) or 'coffee grounds'.
- Signs of bowel obstruction (abdominal distension, pain, absent bowel sounds).
- Neurological signs suggesting raised ICP (headache, papilloedema, altered consciousness).
Signs and symptoms
- Subjective feeling of nausea (urge to vomit).
- Vomiting (emesis).
- Retching.
Risk factors
- Gastrointestinal issues (constipation, gastric stasis, obstruction).
- Metabolic disturbances (uraemia, hypercalcaemia, liver failure).
- Medications (opioids, chemotherapy, antibiotics).
- Raised intracranial pressure (brain tumours).
- Infections.
- Anxiety.
Diagnosis
Clinical assessment
Detailed history: Onset, frequency, timing (relation to meals/meds), triggers, volume/nature of vomitus, associated symptoms (pain, constipation, headache, dizziness). Physical exam: Abdominal assessment (distension, bowel sounds), hydration status, neurological exam (if ICP suspected). Identify likely mechanism/cause.
Investigations
- Directed by clinical suspicion:
- - Blood tests: Electrolytes, Urea, Creatinine, Calcium, LFTs.
- - Imaging: Abdominal X-ray/Ultrasound (if obstruction suspected), CT/MRI head (if raised ICP suspected).
Diagnostic criteria
Clinical assessment identifying likely cause to guide targeted antiemetic choice.
Management
Non-pharmacological management
- Treat the underlying cause if possible (e.g., manage constipation, correct electrolytes).
- Dietary modification: Small, frequent meals; avoid fatty, spicy, or strong-smelling foods.
- Maintain hydration (oral sips, IV/SC fluids if needed and appropriate).
- Ensure good oral hygiene.
- Acupressure/Acupuncture (limited evidence).
Pharmacological treatment
- Select antiemetic based on likely cause:
- - Gastric Stasis / Delayed Transit: Metoclopramide 10-20mg PO/SC/IV Q8H (30 mins before meals). Child doses in UCG.
- - Metabolic / Chemical / Drug-Induced (Chemoreceptor Trigger Zone - CTZ): Haloperidol 1.25-2.5mg PO/SC nocte. (Consider Ondansetron for chemotherapy-induced N/V - specialist guidance).
- - Raised Intracranial Pressure: Dexamethasone 8-16mg OD.
- - Visceral Stretch / Compression / Bowel Obstruction: Promethazine 25mg PO Q8H OR Hyoscine Butylbromide 20-40mg PO/SC Q8H.
- - Vestibular causes (less common in palliative): Consider antihistamines like Cinnarizine or Cyclizine.
- - Anxiety-related: Lorazepam or Diazepam may help.
- Combine antiemetics with different mechanisms if needed.
Monitoring
Assess effectiveness of antiemetic therapy. Monitor hydration status and electrolytes. Monitor for side effects of antiemetics (e.g., extrapyramidal effects with metoclopramide/haloperidol, sedation).
Complications
- Dehydration.
- Electrolyte imbalance (hypokalaemia, metabolic alkalosis).
- Aspiration pneumonia.
- Malnutrition.
- Poor quality of life, distress.
Prevention
- Prophylactic antiemetics when using known emetogenic drugs (opioids, chemo).
- Manage constipation proactively.
- Address underlying causes promptly.
Patient education
- Explanation of likely cause.
- How to take antiemetic medication correctly (timing).
- Dietary and hydration advice.
- Importance of reporting persistent symptoms.
- Side effects to watch for.
Uganda-specific notes
Common antiemetics like Metoclopramide, Haloperidol, Promethazine are usually available. Identifying the likely cause helps choose the most effective agent. Consider empirical treatment if investigations limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 13, Section 13.2.2