Cannabinoid hyperemesis syndrome: an underreported entity causing nausea and vomiting of pregnancy

Addressing cannabis consumption among patients with hyperemesis gravidarum

Severe nausea and vomiting of pregnancy and hyperemesis gravidarum affect up to 3% of all pregnant people, causing substantial maternal and neonatal morbidity, suffering, and financial cost. Evidence supports the association of cannabis consumption with symptoms of severe nausea and vomiting of pregnancy or hyperemesis gravidarum as the general public has come to believe that cannabis is a natural, safe antiemetic. Cannabis consumption in pregnancy is discouraged strongly by the Surgeon General of the United States and the American College of Obstetricians and Gynecologists because of evidence of potential harms. Symptoms of intractable, severe nausea and vomiting of pregnancy or hyperemesis gravidarum associated with cannabis consumption may be unrecognized cannabinoid hyperemesis syndrome, and this syndrome may be more common than previously thought. Cannabis consumption is especially detrimental when causing or exacerbating debilitating symptoms such as the intense, persistent, recurrent, or cyclic vomiting and associated dehydration and other sequelae of cannabinoid hyperemesis syndrome. Open discussion of cannabis consumption during pregnancy is very challenging for patients and maternity care providers in our current environment of variable legal status across states and variable degrees of personal and societal acceptance. Evidence-based medical knowledge, guidance, tools, and skills are needed to differentially diagnose and treat cannabinoid hyperemesis syndrome in pregnancy. Researchers, clinicians, and medical specialty organizations must work together to strengthen the evidence base and develop or refine the necessary guidelines and tools for maternity care provider skill development, and to increase public and patient awareness of cannabinoid hyperemesis syndrome, specifically during pregnancy.

Cannabinoid hyperemesis syndrome in the pregnant patient: clinical case and literature review

BACKGROUND

Cannabis use is on the rise. Several cases of cannabinoid hyperemesis syndrome, secondary to chronic cannabis intoxication, have been described worldwide, but few cases have described this entity in pregnant women.

CASE PRESENTATION

We describe a 29-year-old pregnant patient that had consumed cannabis and experienced uncontrolled vomiting. The use of hot baths, the rapid improvement in symptoms, and results of complementary examinations suggested a diagnosis of cannabinoid hyperemesis syndrome. The patient could return home, and she continued her pregnancy and childbirth without peculiarities.

CONCLUSION

Cannabinoid hyperemesis syndrome should be considered in the differential diagnosis of vomiting in pregnancy. Consumption of cannabis must be systematically included in the anamnesis. However, it seems to be somewhat unacceptable socially or medically. Consumption must be stopped to manage symptoms.

Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome

Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.

Cannabinoid Hyperemesis

Cannabinoid hyperemesis syndrome (CHS) is a paradoxical condition in which a long-term cannabis user suffers an episode of intractable vomiting that may last days separated by longer asymptomatic periods of weeks or months. Cannabinoids are often utilized for their antiemetic properties, so CHS can be a puzzling condition, and the diagnosis of CHS may be disputed by patients. Unlike other cyclic vomiting syndromes, CHS can be relieved by hot showers or topical capsaicin. Abstinence from cannabinoids causes CHS to resolve, sometimes in a matter of days or hours. Marijuana users as well as many clinicians are not aware of CHS, and patients may undergo unnecessary tests, scans, and other procedures to get an accurate diagnosis. Symptoms may be severe enough to require hospitalization. With liberalization of marijuana laws and favorable public opinion about the healing properties of cannabis, CHS may be more frequently observed in clinical practice.

Emergency Department Burden of Nausea and Vomiting Associated With Cannabis Use Disorder: US Trends From 2006 to 2013

BACKGROUND AND AIMS

Chronic cannabis use is associated with nausea and vomiting that may lead to emergency department (ED) visits, multiple diagnostic tests, and procedures. The aim of this study was to analyze recent trends in ED visits for vomiting associated with cannabis use disorder between 2006 and 2013.

METHODS

Data were obtained from the National Emergency Department Sample records in which vomiting (ICD-9-CM codes 787.01, 787.03, and 536.2) was a primary diagnosis in combination with cannabis abuse or dependence (304.3, 304.30, 304.31, 304.32, 304.33, 305.2, 305.20, 305.21, 305.22, and 305.23) and were seen in the ED between 2006 and 2013. The National Emergency Department Sample collects data from more than 25 million visits in over 950 EDs and is weighted to provide national estimates.

RESULTS

The rate of ED visits for vomiting with cannabis use disorder from 2006 compared with 2013 increased from 2.3 to 13.3 per 100,000 ED visits, while the mean inflation-adjusted costs increased 68.5% from $2758.43 to $4647.62, respectively. Men between the ages of 20 and 29 were the most common group to present to the ED for vomiting with cannabis use disorder. The Midwest and West had the higher rates of ED visits for vomiting with cannabis use disorder compared with the Northeast and South.

CONCLUSIONS

ED visits for vomiting associated with cannabis use disorder is common and is associated with significant medical costs. Further research on the role of cannabis use in nausea and vomiting is warranted.

Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series

Cannabinoid hyperemesis syndrome (CHS) is an underrecognized diagnosis among adolescents. In the adult literature, it is characterized as nausea, vomiting, and abdominal pain in patients with chronic marijuana use. CHS is often refractory to the standard treatment of nausea and vomiting. Unconventional antiemetics, such as haloperidol, have been successful in alleviating symptoms; however, even 1 dose of haloperidol can lead to grave adverse effects, such as dystonia, extrapyramidal reactions, and neuroleptic malignant syndrome. The use of topical capsaicin cream to treat CHS has been well described in the adult literature. This treatment is cost-effective and is associated with few serious side effects. Here, we describe 2 adolescent patients with nausea, vomiting, and abdominal pain in the setting of chronic cannabis use whose symptoms were not relieved by standard antiemetic therapies, but who responded well to topical capsaicin administration in our pediatric emergency department. We also discuss the pathophysiology behind capsaicin's efficacy. These are the first reported cases in which capsaicin was successfully used to treat CHS in pediatric patients.

A case of cannabinoid hyperemesis syndrome with Heliobacter pylori and preeclampsia during pregnancy

BACKGROUND

The condition termed cannabinoid hyperemesis syndrome (CHS) was characterized a decade ago by Allen et al. and includes cyclic episodes of nausea and vomiting and the learned behavior of hot bathing in individuals with chronic cannabis abuse. During pregnancy, the differential diagnosis of this syndrome is challenging, since it can be masked by typical symptoms of early pregnancy or by hyperemesis gravidarum, a complication of early pregnancy associated with excessive nausea and vomiting.

CASE DESCRIPTION

The authors herein describe the case of a 21-year-old primigravida patient diagnosed with hyperemesis gravidarum at 6 weeks of gestation and with preeclampsia at 35 weeks. At 30 weeks of gestation, a drug screen was performed that was positive for cannabis; therefore, a diagnosis of CHS was made. After labor induction, the patient delivered an infant who developed normally and had a negative drug test of the umbilical cord blood. Esophagogastroduodenoscopy was performed 9 days post delivery, with biopsies taken of the duodenal, gastric, and esophageal tissues. Moderate chronic gastritis with lymphoid aggregates and slight acute inflammation were noticed, whereas no malignancy, dysplasia, or goblet cell metaplasia was detected. A number of Helicobacter-like organisms were identified by H. pylori immunostaining.

CONCLUSION

Presented here is the first case reporting an association of chronic cannabis use with H. pylori colonization and preeclampsia in pregnancy, which brings to light the possible involvement of a cannabinoid-related pathway in the link between pregnancy-specific complications and bacterial colonization.

Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review

Cannabinoid hyperemesis syndrome (CHS) has become more prevalent with increasing cannabis use. CHS is often resistant to standard antiemetics. The objective of this study is to review the current evidence for pharmacologic treatment of CHS. Medline, PsycINFO, DARE, OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to February 2017. Articles were selected and reviewed independently. Evidence was graded using Oxford Center for Evidence-Based Medicine guidelines. The search resulted in 1262 articles with 63 of them eligible for inclusion (205 human subjects). There were 4 prospective level-2, 3 retrospective level-3 studies, 12 level-4 case series, and 44 level-5 case reports. Among level-2 studies (64 subjects), tricyclic antidepressants (TCAs) and lorazepam were discussed as effective long- and short-term treatments, respectively, in two studies. Ondansetron, promethazine, diphenhydramine, and opioids were also mentioned, but the authors did not comment on their efficacy. Among level-3 studies (43 subjects), one reported effective treatment with antiepileptics zonisamide and levetiracetam, but not TCAs. Another reported favorable response to morphine, ondansetron, and lorazepam but did not specify the actual number of patients receiving specific treatment. Among the level-4 case series (54 subjects), benzodiazepines, haloperidol, and capsaicin were reported as helpful. For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. High-quality evidence for pharmacologic treatment of CHS is limited. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.

Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use. Our objective is to summarize the available evidence on CHS diagnosis, pathophysiology, and treatment. We performed a systematic review using MEDLINE, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library from January 2000 through September 24, 2015. Articles eligible for inclusion were evaluated using the Grading and Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were abstracted from the articles and case reports and were combined in a cumulative synthesis. The frequency of identified diagnostic characteristics was calculated from the cumulative synthesis and evidence for pathophysiologic hypothesis as well as treatment options were evaluated using the GRADE criteria. The systematic search returned 2178 articles. After duplicates were removed, 1253 abstracts were reviewed and 183 were included. Fourteen diagnostic characteristics were identified, and the frequency of major characteristics was as follows: history of regular cannabis for any duration of time (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%). The pathophysiology of CHS remains unclear with a dearth of research dedicated to investigating its underlying mechanism. Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting. Cannabis cessation appears to be the best treatment. CHS is a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution with cessation of cannabis. The pathophysiology underlying CHS is unclear. Cannabis cessation appears to be the best treatment.

Cannabinoid hyperemesis syndrome

The antiemetic properties of marijuana are well known, but there is increasing evidence of its paradoxical hyperemetic effects on the gastrointestinal tract and central nervous system, known as 'cannabinoid hyperemesis syndrome' (CHS). We report a case of CHS encountered in our outpatient clinic. We also completed a review of the literature using PubMed in patients over 18 years of age with CHS. Understanding the diagnostic criteria and risk factors associated with CHS may reduce the ordering of unnecessary and expensive investigations, and pursuing inappropriate medical and surgical treatments. Ultimately, abstaining from cannabis use leads to resolution of symptoms in the majority of patients.

Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy

BACKGROUND

Cannabinoid hyperemesis syndrome is a condition present among chronic cannabis users resulting in abdominal pain, intractable nausea and vomiting, and compulsive bathing behaviors. Given the recent legalization of marijuana in certain areas of the United States, the incidence of this condition may increase among pregnant women.

CASE

We report the case of a pregnant 28-year-old woman with multiple admissions for episodic nausea and vomiting resulting in Mallory-Weiss esophageal tears, dehydration, and abdominal pain who was noted to be showering compulsively during her hospitalizations. After an extensive workup for the etiology of her intractable nausea and pain, she was diagnosed with cannabinoid hyperemesis syndrome, which is treated simply with abstinence from marijuana use.

CONCLUSION

Cannabinoid hyperemesis syndrome should be considered in pregnant women with intractable nausea relieved by frequent hot bathing. By considering this diagnosis, extensive diagnostic testing can be avoided and the correct therapy, abstaining from cannabis use, can be recommended.

Cannabinoid Hyperemesis Syndrome: A Case Report and Literature Review

PURPOSE

As society has seen an increase in rates of cannabis abuse, largely related to an increase in legalization of the substance, a new clinical condition deemed cannabinoid hyperemesis syndrome has been recognized. This syndrome of idiopathic etiology is stimulated from chronic marijuana usage and produces cyclic episodes of nausea, vomiting, and epigastric pain often alleviated with compulsive hot water bathing.

PATIENT AND METHODS

A 42-year-old woman with a medical history of hypertension and myasthenia gravis was admitted to the authors' institution with a mandibular fracture.

RESULTS

Her laboratory work showed her to be extremely hypokalemic and with slight metabolic alkalosis. This was attributed to her reports of chronic vomiting, multiple times daily, over several weeks' duration. After her medical workup, cannabinoid hyperemesis syndrome was diagnosed and treated by fluid resuscitation, antiemetic medications, and marijuana cessation. After correction of her clinical symptoms and laboratory work, she was able to undergo open reduction and internal fixation of her mandibular fracture.

CONCLUSIONS

The dental community is well aware of the positive antiemetic and appetite-stimulating effects of marijuana, but they might be unaware of some of the paradoxical effects it can produce as shown in this newly documented clinical condition. As society is seeing an increase in the legalization of marijuana for medical and recreational usage in the United States, the dental community should be aware of this condition and its implications.

Cannabinoid hyperemesis syndrome

BACKGROUND

The purpose of this review is to describe cannabinoid hyperemesis syndrome (CHS), which is thought to be induced by long-term cannabis use, and provide clinical pharmacists with information to manage the hyperemetic phase of CHS.

METHOD

Published literature was searched and reviewed using PubMed.

RESULTS

CHS is characterized by intractable nausea and vomiting without an obvious organic cause and associated learned compulsive hot water bathing behavior. Patients often seek care in the emergency department (ED) for symptomatic relief.

CONCLUSION

CHS is potentially underrecognized and underdiagnosed in the ED, and it should be considered in the differential diagnosis in long-term cannabis use patients with CHS symptoms to avoid unnecessary extensive diagnostic workup including invasive radiologic imaging. Pharmacists have an important role in CHS recognition, education, and symptom management.

Mitochondrial disorder caused Charles Darwin's cyclic vomiting syndrome

BACKGROUND

Charles Darwin (CD), "father of modern biology," suffered from multisystem illness from early adulthood. The most disabling manifestation was cyclic vomiting syndrome (CVS). This study aims at finding the possible cause of CVS in CD.

METHODS

A literature search using the PubMed database was carried out, and CD's complaints, as reported in his personal writings and those of his relatives, friends, colleagues, biographers, were compared with various manifestations of mitochondrial disorders (MIDs), known to cause CVS, described in the literature.

RESULTS

Organ tissues involved in CD's disease were brain, nerves, muscles, vestibular apparatus, heart, gut, and skin. Cerebral manifestations included episodic headache, visual disturbance, episodic memory loss, periodic paralysis, hysterical crying, panic attacks, and episodes of depression. Manifestations of polyneuropathy included numbness, paresthesias, increased sweating, temperature sensitivity, and arterial hypotension. Muscular manifestations included periods of exhaustion, easy fatigability, myalgia, and muscle twitching. Cardiac manifestations included episodes of palpitations and chest pain. Gastrointestinal manifestations were CVS, dental problems, abnormal seasickness, eructation, belching, and flatulence. Dermatological manifestations included painful lips, dermatitis, eczema, and facial edema. Treatments with beneficial effects to his complaints were rest, relaxation, heat, and hydrotherapy.

CONCLUSION

CVS in CD was most likely due to a multisystem, nonsyndromic MID. This diagnosis is based upon the multisystem nature of his disease, the fact that CVS is most frequently the manifestation of a MID, the family history, the variable phenotypic expression between affected family members, the fact that symptoms were triggered by stress, and that only few symptoms could not be explained by a MID.