Nausea and vomiting secondary to hydronephrosis in palliative patients.

Anne Waithira Mwangi  RN/M/RH

Palliative Care Unit, Department Of  Medicine, Kenyatta National Hospital, Nairobi, Kenya.

Correspondence:  Anne Waithira Mwangi, Palliative care unit, Department Of Medicine, Kenyatta National Hospital, P.O. Box 2029-00202,  Nairobi, Kenya. Email: anne_waithirah@yahoo.com

SUMMARY

Nausea and vomiting are common symptoms that can cause enormous misery for cancer patients.  Nausea and vomiting as it occurs in patients with cancer of the cervix is discussed to illustrate the importance of the need for improving palliative care in Africa as well as the need to improve early diagnosis and early management of cancer.

INTRODUCTION

Nausea is an unpleasant feeling of the need to vomit. Vomiting is the forceful expulsion of gastric contents through the mouth. ¹ In a systemic review of patients with incurable cancer it was found that nausea occurred in 17 % of patients ( 6 studies, 2219 patients) and vomiting in 13% of patients (3 studies, 799 patients) in their last weeks of life. ² In another review comparing symptom prevalence in different advanced conditions,  nausea was present in 6-68% of patients with cancer  (19 studies,  9,140 patients) ² . Nausea and vomiting cause patients and their families’ deep distress and is profoundly debilitating when prolonged; this can undermine the quality of life of patients and contribute to weakness, anorexia and nutritional problems.

The causes of vomiting are multiple and can be categorised into 4 groups as illustrated in Table 1: cancer disease, effects of treatment, consequences of debility and consequences of concurrent conditions.  Evaluation, explanation, management and monitoring are very important for good symptom control.

OVERVIEW OF OUR EXPERIENCE AT KENYATTA NATIONAL HOSPITAL

Kenyatta National Hospital (KNH) is Kenya’s tertiary referral hospital. It is also the only public hospital with a cancer treatment center and with a radiotherapy machine. In 2007, according to KNH medical records department, 3616 patients with cancer were seen at the hospital, these were in all age groups. The commonest cause of morbidity was Cancer of the breast followed by cancer of the cervix (Ca cervix). Most Ca cervix patients present to hospital when the disease is advanced usually with TNM stage III disease which implies that the disease has extended to the surrounding organs e.g. ureters or the kidney causing hydronephrosis. This affects the functions of the kidney and patients may present with nausea, vomiting, confusion and severe pain. Evidence based management for treatment-induced emesis is available but management of nausea arising from the disease itself,  is less well researched. ³

Hydronephrosis is distension of the kidney with urine, caused by a backward pressure on the kidney when the flow of urine is obstructed. This can be relieved by nephrostomy tube insertion. In this situation, the challenges in Kenya, which may also apply to the rest of Africa, are many and include: (1) long waiting periods as very few personnel are trained in interventional radiology - in our hospital, only one radiologist is trained and the waiting period for the procedure is between 2-3 weeks; (2) lack of finances as the procedure is expensive and patients have to pay for medical care themselves; (3) patients are predisposed to repeated infections after nephrostomy which are themselves expensive to treat; (4) secondary kidney failure; (5) trauma of the adjacent areas during nephrostomy; (6) inadequate pain control before nephrostomy because of accumulation of opioids as their elimination by the kidneys is often compromised; (7) delayed active or palliative cancer treatment while waiting for the hydronephrosis to be sorted out; and (8) slipping out of  inserted nephrostomy tubes.

CONCLUSION

While efforts should obviously be made to improve capacity for managing hydronephrosis to relieve nausea and vomiting and other features of renal failure in palliative patients, efforts to encourage early presentation, diagnosis and management of conditions like Ca cervix should be intensified. Women should be encouraged to have annual pap smears for early detection and treatment which is what we are advocating for in formal and informal meetings. All countries should have a cancer policy so that treatment becomes affordable. The national body in our country is advocating for it among the policy makers. Palliative care education should be included in curriculums so that personnel can be aggressive in improving the quality of life in patients with life threatening illnesses.

FOOTNOTES

Conflicts of interest: The author declares no competing conflicts of interest.

REFERENCES

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3. Mannix K. Palliation of nausea and vomiting in malignancy. Clinical Medicine 2006;6(2):144-147.