A 57-year-old woman receiving chemotherapy for stage IV Hodgkin lymphoma has severe nausea, vomiting, and general malaise. Her last bowel movement was yesterday, and she has had crampy abdominal pain on and off since the vomiting began. The patient's second cycle of chemotherapy ended 3 days ago. Her temperature is 36.7 C (98 F), blood pressure is 109/68 mm Hg, pulse is 88/min, and respirations are 18/min. Pulse oximetry reading is 95% on room air. BMI is 18 kg/m². Physical examination shows dry mucous membranes and enlarged cervical lymph nodes. The chest is clear to auscultation. Mild epigastric tenderness is present on abdominal palpation, but there is no guarding or rebound. Laboratory studies are as follows: Intravenous fluids are started. Which of the following is the best next step in the management of this patient?

Question

Quizplus · Accepted Answer

This patient's laboratory values are relatively unremarkable aside from mild anemia and thrombocytopenia, two common findings in patients with lymphoproliferative disorders on chemotherapy. Her symptoms of vomiting and malaise are likely side effects of chemotherapy. In the setting of normal lipase levels, an abdominal examination without rebound or guarding, and a bowel movement yesterday, other diagnoses such as pancreatitis, perforation, or bowel obstruction are less likely. The presence of dry mucous membranes suggests mild volume depletion due to vomiting; therefore, intravenous fluid administration is a good first step in this patient's management. The subsequent step would be to treat her nausea and vomiting. Serotonin (5HT) receptor antagonists (eg, ondansetron) that target the 5HT3 receptor are considered first-line treatment for chemotherapy-induced nausea. They have a low side-effect profile and are highly efficacious. These medications can be used to manage acute emesis but are also useful as prophylaxis, sometimes in combination with corticosteroids. (Choice A) The primary anticholinergic agent used to treat vomiting is scopolamine, but this is usually given in the form of a patch to help reduce motion sickness. This drug is not as effective as 5HT3 antagonists for chemotherapy-induced symptoms. (Choice B) Patients on chemotherapy, especially in the setting of a lymphoproliferative disorder, are at a higher risk for infection. However, this patient is afebrile and not neutropenic (with absolute neutrophil count >1500 cells/mm³), making ongoing infection unlikely. (Choice C) Dopamine antagonists such as metoclopramide and prochlorperazine are useful second- or third-line agents for refractory vomiting. However, in the setting of recent chemotherapy, 5HT3 antagonists have a better side-effect profile and are more efficacious. (Choice D) Motilin receptors promote gastrointestinal motility. Erythromycin is primarily used as an antibiotic, but it also functions as a motilin receptor agonist and can help treat nausea secondary to gastroparesis. (Choice E) Gastrointestinal-specific opioid antagonists such as methylnaltrexone can be used in patients to reverse opioid-induced constipation. Although severe constipation can cause nausea and vomiting, it is less likely to be a factor in this patient who had a bowel movement yesterday. Educational objective: Serotonin (5HT) antagonists that block 5HT3 receptors are the drugs of choice for treating and preventing chemotherapy-induced nausea and vomiting.

A 57-Year-Old Woman Receiving Chemotherapy for Stage IV Hodgkin Lymphoma