Cannabinoid hyperemesis syndrome: a case report and review of pathophysiology

Cannabinoids in Medicine: A Multifaceted Exploration of Types, Therapeutic Applications, and Emerging Opportunities in Neurodegenerative Diseases and Cancer Therapy

In this review article, we embark on a thorough exploration of cannabinoids, compounds that have garnered considerable attention for their potential therapeutic applications. Initially, this article delves into the fundamental background of cannabinoids, emphasizing the role of endogenous cannabinoids in the human body and outlining their significance in studying neurodegenerative diseases and cancer. Building on this foundation, this article categorizes cannabinoids into three main types: phytocannabinoids (plant-derived cannabinoids), endocannabinoids (naturally occurring in the body), and synthetic cannabinoids (laboratory-produced cannabinoids). The intricate mechanisms through which these compounds interact with cannabinoid receptors and signaling pathways are elucidated. A comprehensive overview of cannabinoid pharmacology follows, highlighting their absorption, distribution, metabolism, and excretion, as well as their pharmacokinetic and pharmacodynamic properties. Special emphasis is placed on the role of cannabinoids in neurodegenerative diseases, showcasing their potential benefits in conditions such as Alzheimer's disease, Parkinson's disease, Huntington's disease, and multiple sclerosis. The potential antitumor properties of cannabinoids are also investigated, exploring their potential therapeutic applications in cancer treatment and the mechanisms underlying their anticancer effects. Clinical aspects are thoroughly discussed, from the viability of cannabinoids as therapeutic agents to current clinical trials, safety considerations, and the adverse effects observed. This review culminates in a discussion of promising future research avenues and the broader implications for cannabinoid-based therapies, concluding with a reflection on the immense potential of cannabinoids in modern medicine.

Recurrent Severe Burns Due to Cannabinoid Hyperemesis Syndrome

Cannabinoid hyperemesis syndrome (CHS) is one of the health outcomes of cannabis use that is showing an increase in the number of reported cases since it first emerged in the medical literature. It is a condition that is now frequently seen by many specialists, including consultation-liaison psychiatrists. CHS is a diagnosis of exclusion that is characterized by the presence of a prolonged history of daily cannabis use, cyclic episodes of nausea and vomiting, and frequent compulsive hot baths. It will be fairly argued that with the surge in the number of marijuana users and frequency of use since the legalization of marijuana in the United States, a proportionate rise in CHS cases is expected over time. In this case report, we present a unique case of a 36-year-old female diagnosed with CHS, and the compensatory behavior of compulsive hot baths led to repeated episodes of severe burns, sepsis, and intensive care unit (ICU) hospitalizations. To the authors' knowledge, this is the first published case of severe burns and sepsis as complications of cannabinoid hyperemesis syndrome.

A Case of Cannabinoid Hyperemesis Syndrome and Acute Kidney Injury: A Review of the Literature

Cannabis is a commonly used illicit drug worldwide with many noted adverse effects and medical properties. It has been previously used in medicine for the management of chemotherapy-induced nausea and vomiting. The chronic use of cannabis is well-known to be associated with psychological and cognitive adverse effects, however, cannabinoid hyperemesis syndrome is a less commonly recognized complication of chronic long-term use of cannabis, though it does not occur in the majority of chronic cannabis users. Here we present the case of a 42-year-old male who presented with classical clinical features of cannabinoid hyperemesis syndrome.

Urinary Cannabis Metabolite Concentrations in Cannabis Hyperemesis Syndrome

OBJECTIVE

Cannabis Hyperemesis Syndrome (CHS) is characterized by recurrent episodes of intractable emesis associated with heavy use of cannabis. Recognition of CHS can be problematic due to the lack of specific biomarkers, which can point the clinician to the diagnosis. We present, retrospectively, a series of adolescent/young adult patients who presented to a pediatric gastroenterology (GI) service with acute on chronic nausea and vomiting, subsequently found to have CHS with associated elevated urinary cannabis metabolite concentrations.

METHODS

We describe 15 patients referred to our pediatric GI division for intractable emesis with spot urinary cannabis metabolite carboxy-THC (THC-COOH) concentrations from January 1, 2018 through April 20, 2019. Urinary testing was performed using gas chromatography mass-spectrometry (GC-MS) in a manner consistent with Clinical Laboratory Improvement Amendments (CLIA) requirements at Mayo Clinic laboratory (Rochester, MN). The laboratory cutoffs were 3.0 ng/mL. Data was extracted via chart review and analyzed via online statistical application.

RESULTS

Fifteen patients (seven females, eight males) were studied with an average age of 17.7 years. All patients reported frequent cannabis use for at least 1 month and exhibited intractable, non-bilious emesis for at least 2 weeks. Twelve patients also reported weight loss. Two patients had underlying gastrointestinal disease (one with Crohn disease and one with irritable bowel syndrome). All patients had essentially normal GI workup including laboratory tests, imaging studies and endoscopies.Fourteen of 15 patients had urinary THC-COOH concentrations >100 ng/mL, with seven individuals exhibiting levels >500 ng/mL. One patient had a urinary TCH-COOH concentration level under 100 ng/mL had not used cannabis for 2 weeks. Most other patients had used cannabis within 2 days of providing a urine sample. The Binomial test for CHS patients with urinary THC-COOH levels over 100 ng/mL was significant with a P-value of <0.0005 (one tail test).

CONCLUSION

CHS is associated with an elevated urinary THC-COOH level usually exceeding 100 ng/mL, which is indicative of significant chronic cannabis exposure. In patients with a history consistent with CHS, urine THC-COOH testing may help guide the diagnostic evaluation of these patients and decrease the need for further workup.

The Impact of Marijuana on Antidepressant Treatment in Adolescents: Clinical and Pharmacologic Considerations

The neuropharmacology of marijuana, including its effects on selective serotonin reuptake inhibitor (SSRI)/antidepressant metabolism and the subsequent response and tolerability in youth, has received limited attention. We sought to (1) review clinically relevant pharmacokinetic (PK) and pharmacodynamic (PD) interactions between cannabinoids and selected SSRIs, (2) use PK models to examine the impact of cannabinoids on SSRI exposure (area under curve (AUC)) and maximum concentration (C_MAX) in adolescents, and (3) examine the frequency of adverse events reported when SSRIs and cannabinoids are used concomitantly. Cannabinoid metabolism, interactions with SSRIs, impact on relevant PK/PD pathways and known drug–drug interactions were reviewed. Then, the impact of tetrahydrocannabinol (THC) and cannabidiol (CBD) on exposure (AUC₂₄) and C_MAX for escitalopram and sertraline was modeled using pediatric PK data. Using data from the Food and Drug Administration Adverse Events Reporting System (FAERS), the relationship between CBD and CYP2C19-metabolized SSRIs and side effects was examined. Cannabis and CBD inhibit cytochrome activity, alter serotonergic transmission, and modulate SSRI response. In PK models, CBD and/or THC increases sertraline and es/citalopram concentrations in adolescents, and coadministration of CBD and CYP2C19-metabolized SSRIs increases the risk of cough, diarrhea, dizziness, and fatigue. Given the significant SSRI–cannabinoid interactions, clinicians should discuss THC and CBD use in youth prescribed SSRIs and be aware of the impact of initiating, stopping, or decreasing cannabinoid use as this may significantly affect es/citalopram and sertraline exposure.

Management of Pediatric Cannabinoid Hyperemesis Syndrome: A Review

With significant increases noted in adolescent marijuana use across the United States, perhaps as a result of legislative changes over the past half-decade, clinicians must be increasingly aware of the potential negative health effects. One such effect that warrants concern is cannabinoid hyperemesis syndrome (CHS) in the pediatric population. A systematic review of the literature was performed to determine the safety and efficacy of management strategies for CHS using PubMed, Scopus, the Cumulative Index of Nursing and Allied Health (CINAHL), Web of Science, and Cochrane Library databases. Search terms used in each database were "pediatric OR child OR children OR adolescent" AND "cannabinoid OR marijuana" AND "hyperemesis OR cyclic vomiting OR vomiting" NOT "seizure OR chemotherapy OR pregnancy OR cancer OR AIDS OR HIV." Fourteen pieces of literature that described either effective, ineffective, or supportive management strategies for pediatric CHS were included in this review. Benzodiazepines were the most reported efficacious agents, followed by topical capsaicin cream and haloperidol. A total of 9 of the 14 studies described intravenous fluid resuscitation and hot bathing rituals as supportive measures, and 7 cases reported traditional antiemetics were ineffective for CHS. The heterogenicity of reported data, combined with the limited number of encounters, make it difficult to ascertain whether a definitive treatment strategy exists. Clinicians should be cognizant of pharmacotherapy agents that are efficacious, and perhaps more importantly, avoid using traditional antiemetic therapies that do not provide benefit.

[Cannabinoid hyperemesis as a differential diagnosis of nausea and vomiting in the emergency department]

Cannabinoid hyperemesis syndrome (CHS) is caused by regular cannabis consumption and marked by cyclic episodes of severe emesis, often years after the beginning of cannabis consumption. Classical antiemetic treatment often shows no effect and fatal outcomes have sometimes also been reported. This article describe the case of a young man in whom the diagnosis was made after four presentations due to the typical anamnesis. At this point in time he had already undergone an abdominal computed tomography (CT) and gastroscopy, both with no pathological findings. The symptoms completely receded 6 months after presentation by maintaining cannabis abstinence.

Management of Cannabinoid Hyperemesis Syndrome: Focus on Capsaicin

Cannabinoid hyperemesis syndrome is a condition characterized by cyclic severe nausea, vomiting, and abdominal pain associated with frequent, long-term marijuana use. The condition resolves with cessation of cannabis but may be temporarily relieved by bathing in hot water. Topical capsaicin cream may also alleviate symptoms, perhaps through antiemetic effects produced by activation of TRPV1 receptors, similar to that of hot water bathing. This review summarizes the epidemiology, clinical presentation, diagnosis, pathophysiology, and management of cannabinoid hyperemesis syndrome, focusing on treatment with topical capsaicin.

Review of Medicinal Use of Cannabis Derivatives and the Societal Impact of Legalization

Background:

In recent past, there has been a rush to legalize marijuana along with a lot of support for its medicinal uses. This review intends to discuss the medicinal uses of marijuana and its adverse effects based on the current available evidence. Furthermore, it discusses the impact of legalization of marijuana.

Methodology:

This was a narrative review for which a thorough literature search was conducted on the Medline and PubMed databases. A detailed search of the Internet to find relevant information on webpages was also performed.

Results:

High-quality evidence for the majority of medical indications of marijuana remains investigational. Most of the available literature compares it against placebos. Postlegalization usage of marijuana has increased.

Conclusion:

It would be prudent to wait for studies which prove beyond doubt the advantages of marijuana over the existing drugs and also outweigh its side effects and addiction potential. Moreover, further legalization of marijuana should only be considered after evaluating its effects at places where it is already legally available.

Cannabinoid hyperemesis syndrome

Cannabinoid hyperemesis syndrome (CHS) is characterized by severe cyclical nausea, vomiting, and abdominal pain relieved by compulsive hot water bathing in the setting of chronic cannabinoid use. This article reviews the characteristics, proposed pathophysiology, treatment modalities, and role of nurses caring for patients with CHS.

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.

Cyclic vomiting syndrome: a case series and review of the literature

OBJECTIVE

Cyclic vomiting syndrome (CVS) is under-recognised. Treatment is difficult as the pathophysiology is incompletely understood. We report our experience of treating patients with amitriptyline, and review the literature to summarise symptoms and associated features, epidemiology, potential pathophysiological mechanisms, differential diagnoses and treatment.

DESIGN

Consecutive adult patients with CVS were identified during a 5-year period from January 2010 until December 2015. Medical records were reviewed retrospectively, and age and sex of the patient, symptoms, associated features and response to treatment with amitriptyline were recorded.

SETTING

A luminal gastroenterology clinic at a teaching hospital.

RESULTS

Seventeen patients were identified (mean age 29.8 years, 13 (76.5%) female). Five had a history of cannabis use. Duration of symptoms prior to diagnosis ranged from 5 months to 15 years. Fourteen patients commenced amitriptyline, and in eight (57.1%) symptoms either ceased entirely or improved. Review of the literature suggested the prevalence of CVS was 0.5%. Symptoms are stereotypical, with acute episodes of nausea and vomiting, interspersed by periods when the patient is symptom-free. Proposed pathophysiologies include neuroendocrine dysfunction, mutations in mitochondrial DNA and re-intoxication effects from cannabis stored in fat tissues. Treatment during the acute phase is supportive, with rehydration, sedation and antiemetics. Prophylaxis to prevent future attacks with antihistamines, antimigraine drugs, antiepileptics and tricyclic antidepressants may be beneficial. Complete cessation of cannabis smoking should be advised.

CONCLUSIONS

Diagnosis of CVS is often delayed in adults. Once identified, patients respond well to amitriptyline.

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.

Cannabinoid hyperemesis syndrome presentation to the emergency department: A two-year multicentre retrospective chart review in a major urban area

OBJECTIVE

Cannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the emergency department (ED) with cyclical nausea, vomiting, and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. The objective was to examine the epidemiology of CHS cases presenting to two major urban tertiary care centre EDs and one urgent care centre over a 2-year period.

METHODS

Using explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (ages 18 to 55 years) with a presenting complaint of vomiting and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. The inter-rater agreement was measured using a kappa statistic.

RESULTS

We identified 494 cases: mean age 31 (+/-11) years; 36% male; and 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>three times per week), 43% had repeat ED visits for similar complaints. Moreover, of these patients, 92% had bloodwork done in the ED, 92% received intravenous fluids, 89% received antiemetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the gastroenterology service. The inter-rater reliability for data abstraction was kappa=1.

CONCLUSIONS

This study suggests that CHS may be an overlooked diagnosis for nausea and vomiting, a factor that can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

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.

Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series

BACKGROUND

Cannabinoid hyperemesis syndrome (CHS) is characterized by symptoms of cyclic abdominal pain, nausea, and vomiting in the setting of prolonged cannabis use. The transient receptor potential vanilloid 1 (TRPV1) receptor may be involved in this syndrome. Topical capsaicin is a proposed treatment for CHS; it binds TRPV1 with high specificity, impairing substance P signaling in the area postrema and nucleus tractus solitarius via overstimulation of TRPV1. This may explain its apparent antiemetic effect in this syndrome.

PURPOSE

We describe a series of thirteen cases of suspected cannabis hyperemesis syndrome treated with capsaicin in the emergency departments of two academic medical centers.

METHODS

A query of the electronic health record at both centers identified thirteen patients with documented daily cannabis use and symptoms consistent with CHS who were administered topical capsaicin cream for symptom management.

RESULTS

All 13 patients experienced symptom relief after administration of capsaicin cream.

CONCLUSION

Topical capsaicin was associated with improvement in symptoms of CHS after other treatments failed.

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.

A Case Suspended in Time: The Educational Value of Case Reports

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.

Is haloperidol the wonder drug for cannabinoid hyperemesis syndrome?

Cannabinoid hyperemesis syndrome (CHS) is a rare clinical syndrome characterised by nausea, cyclic vomiting and severe abdominal pain in association with chronic cannabis use. It is often under-recognised or misdiagnosed, resulting in the unnecessary workup and frequent hospitalisations. Long-term treatment of CHS is abstinence from cannabis, but acute symptomatic management has been a struggle for many clinicians. The present report highlights the use of haloperidol as an agent that successfully and safely treats the unrelenting symptoms of CHS.

Cannabinoid hyperemesis syndrome and the onset of a manic episode

Cannabinoid hyperemesis syndrome is a rare, recently described, clinically diagnosed condition that is characterised by a chronic history of cannabis use, cyclic nausea and vomiting, symptomatic relief with hot water bathing, and resolution with cessation of use. We present a case of this syndrome concurrent in a patient with bipolar mania. We suggest that a 3-week period of vomiting in the context of this syndrome contributed to the precipitation of a manic episode by lowering mood stabiliser serum levels, and that this syndrome will have significant consequences for the patient's mental health.

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: an important differential diagnosis of persistent unexplained vomiting

INTRODUCTION

Chronic nausea and vomiting have a detrimental impact on quality of life. When standard diagnostic investigations fail to provide a definitive diagnosis, patients are often attributed as having a functional gastrointestinal disorder such as cyclic vomiting syndrome. Cannabinoid hyperemesis syndrome (CHS) is a relatively recently described entity presenting with symptoms similar to cyclic vomiting syndrome.

METHODS

We carried out a retrospective cohort study of all patients attending a tertiary neurogastroenterology and secondary care gastroenterology clinic from 2013 to 2015. Data were obtained by review of clinical notes, letters and electronic patient records.

RESULTS

We identified 10 cases of CHS (five men, mean age 27 years, range 19-51), who hitherto had been labelled with a variety of alternative diagnoses. All patients had symptoms that were episodic and refractory to medical therapy. Patients had experienced symptoms for a mean of 19.3±11.09 months before diagnosis. The median length of cannabinoid use was 42 months (interquartile range: 15-81.8). Eight patients (80%) had a history of compulsive hot water bathing (hydrophilia). The patients had a median follow-up of 9.5 months (range 1-20), during which symptoms recurred in three patients who returned to regular cannabis use.

CONCLUSION

CHS is an underappreciated cause of recurrent nausea and vomiting and is frequently misdiagnosed. Healthcare providers should have a low index of suspicion for diagnosing CHS and the clinical history in such patients should routinely include direct questioning on cannabis use. The prognosis is very good upon cessation of cannabis intake.

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.