BY DR TANVEER ALAMSKMCH.RC

Emesis /CINV

Key points

DefinitionHow to approach a child with emesisCausesExcluding possible causesInvestigationManagementCINVStudies done

introduction

Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting.

Vomiting: Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature.

Regurgitation: The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting.

Differential diagnosis

Clues on physical examination — Certain physical findings may offer diagnostic clues that can aid

in narrowing the differential diagnosis: Gastroparesis /gastroenteritis. Constipation : Meningitis : A tense, bulging fontanels in neonates ,headache ,neck stiffness projectile vomiting

level of suspicion for meningitis. Pyloric stenosis: Projectile vomiting in an infant three to six weeks of age suggests pyloric

stenosis as a diagnosis. Acute appendicitis : Alvarado scoring(apgar scoring) CINV

•Metabolic cause:An unusual odor emanating from the patient should be investigated for metabolic causes of vomiting.

•ObstructionMarked distension, visible bowel loops, absent bowel sounds,bile staining in the vomitus

•Trauma relatedVomiting in association with trauma should leads to imaging studies to rule out intracranial or intraabdominal injury.

•Miscellaneous causes: Cholecystitis , uti ,motion sickness,pregnancyetc, sepsis, excessive feeding volume, pneumonia ,etc

How Vomitus helps in diagnosis

Clinical Approach

Referrels

Patients should be referred to a pediatric gastroenterologist or other appropriate specialist (eg, pediatric surgeon, neurologist) when there are symptoms or physical findings that are of particular concern.

These include an abnormal neurologic exam, peritoneal signs on abdominal examination, severe abdominal pain, gastrointestinal bleeding, or significant weight loss.

Immediate pediatric surgical consultation is warranted if appendicitis, bowel obstruction, or bowel perforation are suspected.

Laboratory Investigations

management

ExaminationVitalsdiagnosisIV fluids bolus (NS +R/L +dextrose)Antiemetic (dimenhydrinate ,metoclopramide, (ondansetron,

granisetron,palonosetron Serotonin (5-HT3) aprepitant ,corticosteroide ,domperidone

Reassess ( vitals + exam +oral trial)

Treat the cause

CINV: types & Definitions

Acute (post-treatment)Occurs within first 24 hours after administration of cancer

chemotherapy Delayed

CINV that begins after first 24 hoursMay last for 120 hours

AnticipatoryLearned or conditioned response from poorly controlled nausea

and vomiting associated with previous chemotherapy Breakthrough

CINV that occurs despite prophylaxis and requires rescue Refractory

Occurs during subsequent treatment cycles when prophylaxis and/or rescue has failed in previous cycles

Emetogenic Potential of Single Antineoplastic Agents

HIGH Risk in nearly all patients (> 90%)

MODERATE Risk in 30% to 90% of patients

LOW Risk in 10% to 30% of patients

MINIMAL Fewer than 10% at risk

1st Generation 5HT3 RAs Are Therapeutically Equivalent

Pts receiving MEC* (N=1,085)

80% of pts received prophylactic steroids*Cyclophosphamide 500 - 1200 mg/m2, carboplatin ≥300 mg/m2

59.0 60.071.0

58.0 58.072.0

Total Nausea Emesis

Oral granisetron 2 mgIV ondansetron 32 mg

Com

plet

e C

ontr

ol (%

)

•Highest Level Evidence & Not Debated

•MASCC 2004•NCCN 2009•ASCO 2006

•1st Generation Agents are Therapeutically Equivalent

•Dolasetron•Ondansetron•Granisetron

•1st Generation oral and IV doses equally effective

Perez et al. J Clin Oncol 1998;16:754

1st vs 2nd generation 5-HT3 antagonist

• Pharmacologic differences from older 5-HT3 antagonists• prolonged half-life (~40 hours)• enhanced receptor binding affinity (30-fold)• Comparable tolerability • 1st Generation Oral 5HT3 RAs Not Effective for

Delayed CINV

Palonosetron vs. 1st gen 5HT-3:Complete Response on Day of Chemo & Beyond

Palonosetron 0.25 mg (n=378)Ondansetron/Dolasetron 32/100 mg (n=376)

46.842.0

*57.7

*64.0

*72.0

60.6

0

20

40

60

80

100

Time (hr)

Acute: 0-24(Day 1)

Delayed: 24-120(Days 2-5)

Overall: 0-120(Days 1-5)

Com

plet

e R

espo

nse

(CR

)(%

of P

atie

nts)

*p<0.025 for pairwise difference (2-sided Fisher’s exact test) between palonosetron and ondansetron/dolasetron.

Gralla R et al. Ann Oncol. 2003; Eisenberg P et al. Cancer. 2003.Rubenstein EB et al. Proc Am Soc Clin Oncol. 2003. Abstract 2932.

CR = no emetic episodes or use of rescue medications

A JOURNAL OF PAKISTAN PAEDIATRIC ASSOCIATION

ABSTRACTObjectives: The objective of the study is to evaluate gastrointestinalproblems in cancer patients during treatment.

Patients and methods: In a sample of 150 children having differentchildhood malignancies, the frequency, pattern and risk factors ofgastrointestinal (GIT) symptoms were analyzed.

Results: Almost 30% of pediatric cancer patients experienced one ormore episode of GIT problems. Overall prevalence of anticipatoryvomiting was 12%, acute vomiting was 51.33%; delayed vomiting was26% that was highest on day 2 with 18% experiencing vomiting anddecreased to 8% by day 5. Expectancy of nausea was found to be astrong predictor of subsequent occurrence of nausea and vomiting(P=0.047) as well as the chemotherapeutic regimen potentiality thatsignificantly affected delayed vomiting (P=0.02).

continue

•Other predictive factors•as age, gender, did not affect various forms of vomiting •40 %of the enrolled patient suffered from mucositis, ranging from grade 1 to 3 •Clinical features of oral candidiasis werepresent in 10% of patients•. 28% of the enrolled patients had attacks of•diarrhea •while 11.33% experienced constipation mostly due to vincristine• opioids, 18% had altered perception of taste or smell.

Conclusion: The gastrointestinal symptoms are common in cancerpatients. Early recognition of GIT symptoms is essential for earlyintervention and guide nutritional support.

Clinical research of Olanzapine for prevention of chemotherapy-induced nausea and vomiting

by journal of experimental & clinical research background

This study was designed to mainly evaluate the activity and safety of olanzapine compared with 5-hydroxytryptamine3(5-HT3) receptor antagonists for prevention of (CINV) + QOLMethods229 patients receiving highly or moderately emetogenic chemotherapy were randomly assigned to the test group [olanzapine(O) 10 mg p.o. plus azasetron (A) 10 mg i.v. and dexamethasone (D) 10 mg i.v. on day 1;

ResultsIn summary, this study demonstrated that olanzapine has obtained the better efficacy on being safely used for preventing the CINV. Olanzapine can improve the complete response of delayed nausea and vomiting in patients receiving the highly or moderately emetogenic chemotherapy comparing with the standard therapy of antiemesis, as well as improve the QoL of the cancer patients during chemotherapy. Olanzapine is a safe and efficient drug for prevention of CINV. Further study should be done to compare the efficacy of olanzapine with aprepitant or palonosetron on prevention of CINV through large sample studyPub med