Nausea and Vomiting

Causes:

• Metastasis- Especially in brain
• Meningial irritation
• Movement- Motion sickness, vestibular dysfunction
• Mental- Anxiety, anticipatory nausea
• Medications- opiates, antibiotics, chemotherapy
• Mucosal irritation- Peptic ulcer
• Mechanical obstruction
• Motility problems- Gastroparesis
• Metabolic- Uremia, ketoacidosis, hypercalcemia, hyponatremia
• Microbes- Gastroenteritis, hepatitis
• Myocardial ischemia

Classification of drugs based on emetogenic potential

• High (>90%)- Cisplatin, Cyclophosphamide (>1500mg/m2), Carmustine
• Moderate (30-90%)- Cytarabine (>1gm/m2), Ifosphamide, Cyclophosphamide (< 1500mg/m2)
• Low (10-30%)- Mitoxantrone, etoposide, methotrexate
• Minimal (<10%)- Busulfan, Fludarabine

Principles of treatment:

• It is far easier to prevent vomiting than treat
• Therapy must be adjusted to emetogenic potential of drug
• Risk of emesis lasts for about 4 days. Hence antiemetics must be given for atleast 4 days following chemotherapy.
• Oral and IV formulations have equal efficacy.

Treatment/ Prevention:

• 5HT3 Receptor antagonist: Ondansetron
• Neurokinin 1 receptor antagonist- 
  • Aprepitant (125mg stat, then 80mg OD on days 2 and 3), Fosapretant (150mg- IV-Stat)- To be started 1 hour prior to chemo and should be combined with 5HT3R antagonist
  • Used in case of chemotherapy with high emetic risk
• Dopamine antagonist- Metoclopramide (10mg-TDS), Domperidone (10mg-TDS)
• Corticosteroids- Dexamethasone
• Life style modifications:
  • Eating small, frequent meals
  • Choose healthful foods
  • Eat food at room temperature

Hiccup

Causes:

• Gastric distension (Rapid swallowing of food, air, alcohol)
• Intracranial tumor/ infection/ hemorrhage
• Uremia, hepatic coma, acute prostrating fever, hypocapnia, hysterical, 
• Mediastinal mass, pleurisy
• Foreign body in ear
• Diaphragmatic irritation (pericarditis, subphrenic abscess, peritonitis, pancreatitis, cholecystitis, liver abscess/tumor, splenic infarct, post-operative gastric distension)
• Sudden change in temperature

Treatment:

• Syp. Mucaine gel 10ml- PO- TDS
• Tab. Metoclopramide (Perinorm)- 10mg- TDS
• Tab. Baclofen- 10mg- TDS
• Tab. Chlorpromazine(Relitil)- 25mg BD

Constipation

Causes:

• Opioid analgesics
• Other drugs: Vincristine, antacids, antidepressants, calcium channel blockers, etc
• Bowel obstruction
• Spinal cord compression
• Hypercalcemia
• Hypokalemia
• Diabetes mellitus
• Hypothyroidism
• Fissue in ano
• Prolapsed hemorrhoids
• Uremia

Preventive measures:

• Increase oral fluids
• Increase dietary fiber
• Exercise (if appropriate)
• Prophylactic medications- Senna +/- docusate- 2 tablets HS

Evaluation:

• History and physical examination
• X Ray erect abdomen and USG abdomen- To rule out intestinal obstruction
• Thyroid function tests
• Colonoscopy

Treatment:

• Treatment of cause if found
• Avoid using bulk forming agents, in absence of motility agents, especially in debilitated patient
• T. Bisacodyl- l-5mg- 2-3tab HS- to ensure 1 non-forced bowel movement every 1-2days
• Lactulose 20ml- HS- Titrate the dose to maximal therapeutic dose
• If persistent constipation- Add- polyethylene glycol- 1cap mixed in 1 glass water HS
• Consider use of prokinetics- Tab. Metoclopramide- 10-20mg- TDS
• Occasionally large volume enemas/ lubricant stimulants may be used
• If impacted stool- Manual disimpaction after giving analgesics
• If bowel obstruction: Immediate surgical consultation

Diarrhea

Causes:

• Infections
• Malabsorption syndrome
• Gut GVHD
• GI bleed
• Medications: Antibiotics, purgatives, NSAIDs, magnesium containing antacids
• Radiation to abdomen or pelvis
• Overflow incontinence
• Cl. defficile infection

Investigations:

• Stool routine and culture
• Stool for Cl. defficile toxin

Treatment:

• Correct dehydration and electrolyte imbalances
• Racecadotril (antisecretory agent)
• Antibiotics- Ofloxacin + Ornidazole
• Bland diet. Avoid foods containing Lactose and which form gas.
• Avoid antimotility drugs (Loperamide 2-4mg- TDS/ Tab. Lomotil- Diphenoxylate+Atropine-2.5-5mg-TDS) in hematology patients (except bortezomib induced diarrhea)
• If Cl. defficile infection: Metronidazole- 500mg- PO- QID/ Vancomycin 125-500mg- PO- QID

Pancreatitis

Causes in hematology patients:

• Drugs: L-Asparaginase, steroids, 6-MP, H2 Blocker, furosemide, metronidazole
• Infections: Mumps, Measles, E. Coli, CMV, Hepatitis virus
• Following multiorgan failure
• Secondary to hypercalcemia
• Infiltration by blasts

Treatment:

• Aggressive pain management
• IV fluids
• Withdraw offending drug
• Bowel rest
• Gastric drainage via NG tube
• TPN
• Broad spectrum antibiotics, antifungals
• Pantoprazole
• Aprotinin- 2-5lac units stat, then 1lac unit- OD
• Inj. Octreotide- 125-250microgm stat, then SC.5-10microgm/kg/day BD, for 3-5 days
• Treatment of hypocalcemia
• Early ERCP is suspected to have biliary obstruction
• SOS- surgical debridement of necrotic tissue

Mucositis

Causes

• Drugs- Commonly seen with bleomycin, cytarabine, doxorubicin, melphalan, methotrexate, etoposide, 5 Fluorouracil
• Radiation
• Poor fitting oral prosthesis
• Periodontal disease
• Poor oral hygiene

Clinical features:

• Oral mucositis: Grading:
  • 0-None
  • 1-Erythema only
  • 2-Mild painful erythema/ Ulcer
  • 3-Increasing pain, which interferes with eating, requires constant analgesia
  • 4-Severe pain, needs opioids and TPN for nutritional support
• Gastroenteritis-nausea, vomiting, diarrhea, abdominal pain (Breaches in mucosal lining can lead to sepsis). Improvement occurs at the time of hematopoietic reconstitution 

Prophylaxis:

• Mouth rinses with sodium chloride/ sodium bicarbonate/ chlorhexidine/ calcium phosphate
• Cryotherapy (Ice cubes) for patients receiving high dose melphalan conditioning
• Amifostine- For protecting salivary glands in patients receiving radiotherapy
• Keratinocyte growth factor 1 (Palifermin)- 60microgm/kg/day for 3 days prior to conditioning and 3 days after transplant
• Acyclovir prophylaxis
• Use soft tooth brush

Treatment:

• Local ointments
  • GelClair- Bioadherant gel that adheres to oral surface
  • Local anesthetics- Lidocaine
  • Magnesium based antacids
  • Others: diphenhydramine, corticosteroids, antacids, sodium hyaluronate gel and mucoadhesive protectants
• Mouth wash- 5 times a day- Mixture of Xylocaine and Panthenol and cover lesion with astringents
• Do not use chlorhexidine on open wounds
• Antifungal- Nystatin ointment
• Narcotic for severe pain
• Parenteral nutrition support
• Novel agents-keratinocyte growth factor

Typhlitis

Clinical features:

• Right lower quadrant pain
• Fever
• Watery/ bloody diarrhea

Treatment:

• Conservative
• Bowel rest
• TPN
• Broad spectrum antibiotics, Amphotericin B
• Antipyretics
• Surgical indications
  • Appendicitis
  • Peritonitis
  • Bowel perforation
  • Liver abscess
  • Intractable GI bleed