Palliative MedicineTier 1Approach to a presentation

Vomiting

Red flags

Faeculent vomiting + absolute constipation + colicky pain - bowel obstruction
Forceful/projectile vomiting + morning headache + neurological signs - raised ICP
Haematemesis - upper GI bleed, needs its own urgent pathway
Inability to retain oral anti-seizure, cardiac, or anti-Parkinsonian medication - route change needed urgently (abrupt cessation risk)
Signs of aspiration in a frail/drowsy patient

Same mechanism framework as nausea (chemical/metabolic, gastric stasis, obstruction, vestibular, cortical) - vomiting is usually the endpoint of unrelieved nausea, so treat as one problem
Specific vomiting patterns:
- Early morning, effortless, with headache - raised ICP
- Large volume, relieves nausea temporarily, undigested food - gastric stasis/outlet obstruction
- Faeculent - established bowel obstruction
- Immediately post-prandial, small volume - anxiety/anticipatory, or oesophageal/gastric outlet lesion

Abdominal distension, visible peristalsis, bowel sounds, tenderness, palpable mass
Hydration status
Neurological exam if any suggestion of raised ICP

Guided by mechanism and by whether the result changes management (goals-of-care dependent)
Abdominal X-ray/CT for suspected obstruction - defines level and whether a surgical/stenting option exists
Calcium, renal function, LFTs
CT/MRI brain if raised ICP suspected and treatment would follow

If not obstructed - as per nausea, mechanism-based antiemetic

Malignant bowel obstruction - a distinct pathway

Surgery/stenting if a single obstructing lesion, reasonable prognosis, and fit for intervention - always consider first, do not assume inoperable
Medical management if not amenable to intervention:
- Dexamethasone - may relieve peritumoural oedema and resolve partial obstruction
- Hyoscine butylbromide - reduces colic and secretions
- Octreotide - reduces GI secretion volume where hyoscine insufficient
- Haloperidol or cyclizine for nausea (avoid metoclopramide if complete mechanical obstruction - prokinetic worsens colic)
- NG tube for decompression if vomiting remains distressing/high-volume despite medical therapy - a symptom-control measure, not routine
Stop non-essential oral intake pressure - small volumes for pleasure are acceptable even with obstruction if that is the patient's wish

Route of administration

Once vomiting is frequent, switch essential medications to subcutaneous/buccal/transdermal routes - a syringe driver is often the practical solution for multiple regular symptom medications

Assuming malignant bowel obstruction is always inoperable - re-discuss surgical/stenting options, don't default to medical management alone
Using metoclopramide (prokinetic) in complete mechanical obstruction - worsens colicky pain
Continuing oral medications for symptom control in a patient who cannot reliably absorb them - switch route early, don't wait for complete failure
Under-recognising raised ICP as a cause because nausea/vomiting is reflexively attributed to opioids or chemotherapy

1. Vomiting is nausea's endpoint - treat the same mechanism

2. Obstruction changes everything

"Faeculent vomiting and absolute constipation moves me straight to an obstruction pathway - and I still ask whether surgery or a stent is on the table."

3. Protect essential medications

"If oral intake is unreliable, I move seizure and cardiac medications to another route before there's a crisis."

4. Choose drugs that won't make it worse

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