Aetiology

Vastgesteld: 16-06-2014
Regiehouder: IKNL

There are several causes of nausea and/or vomiting, which may occur simultaneously and have reciprocal enhancing effects. Multiple causative factors are evident in 25% of cases. A clear cause cannot be found in 25-33% of cases.

Known causes include the following:

Delayed gastric emptying (35 - 44%)
- gastroparesis as a result of abnormal gastric motor function:
  - tumour invasion (gastric carcinoma, metastasis from elsewhere)
  - after partial or total gastrectomy
  - as part of the anorexia-cachexia syndrome
  - paraneoplastic autonomic neuropathy
  - medication (including opioids, anticholinergic agents, vinca alkaloids, cisplatin, calcium blockers)
  - comorbidity (e.g. diabetes mellitus, renal failure, amyloidosis, scleroderma)
- decreased gastric capacity caused by gastric carcinoma or compression due to hepatomegaly, extragastric tumours or ascites
- pyloric or duodenal obstruction, e.g. as a result of a pancreatic carcinoma
- gastritis or ulcer
  - peptic
  - drug-related: aspirin, NSAIDs, dexamethasone, mucolytic agents, antibiotics, iron preparations
  - radiotherapy of the spine or stomach in which the stomach lies within the radiation field
Other abdominal causes (24-32%)
- constipation
- infiltration or traction of the mesenterium or peritoneum caused by carcinomatous peritonitis (with or without ascites)
- ileus (due to obstruction, pseudo-obstruction, adhesions, faecal impaction, acute bacterial peritonitis or sepsis)
- liver metastases (caused by hepatomegaly and/or metabolic abnormalities or icterus)
- congested liver associated with heart failure
- reflux
- dumping syndrome after gastric resection
- gastroenteritis, pancreatitis, cholecystitis, cholangitis, hepatitis, cystitis
- gall stones, kidney stones
- recent surgery
- cough or hiccups leading to reflectory vomiting
Chemical/metabolic causes (30-33%)
- medications:
  - opioids (especially shortly after starting or after a dose increase)
    These agents may cause nausea and/or vomiting via different mechanisms: activation of the chemoreceptor trigger zone, delayed gastric emptying (see point 1) and vestibular (see point 5)
  - chemotherapeutic agents
    Nausea and/or vomiting can be acute (within 24 hours after administration) or delayed (more than 24 hours after administration); it is likely that different mechanisms play a role .
  - The incidence of nausea and vomiting is highly dependent on the dose and type of chemotherapeutic agents used. A distinction is made between highly emetogenic chemotherapy (>90% chance of vomiting without anti-emetics), moderately emetogenic chemotherapy (30-60%) and low or not emetogenic chemotherapy (<30%).
    Other factors that may increase the chance of nausea and/or vomiting occurring after chemotherapy are: female gender, young age, sensitivity to nausea (e.g. during pregnancy or in the case of motion sickness or sea sickness), fear/stress and prior poor experiences with chemotherapy
  - tyrosine kinase inhibitors (including sunitinib, sorafenib, imatinib, erlotinib)
  - other medications (including anti-epileptic agents, theophylline, digoxin, SSRIs, anaesthetics)
- electrolyte disorders (hypercalcaemia and hyponatraemia)
- acute or chronic renal insufficiency
- liver failure
- dysregulated diabetes mellitus
- bacterial toxins and sepsis
Cerebral/psychogenic causes (7%)
- brain metastases or primary brain tumour with increased intracranial pressure
- leptomeningeal metastases
- meningitis (infectious, chemical)
- stroke
- total cranial irradiation
- influences relating to smell and taste
- severe pain
- anxiety and stress
- anticipatory nausea and vomiting: through classical conditioning, stimuli associated with the original stimulus by means of time or place (e.g. chemotherapy) can induce nausea or vomiting
Vestibulary causes (very rare in the palliative phase):
- pharmacological (opioids, aspirin)
- labyrinth disorders: motion sickness, Ménière's disease, neuritis vestibularis or labyrinthitis
- tumour of the inner or middle ear/base of skull