CANNABINOID HYPEREMESIS SYNDROME

While watching the CBS Evening News and feeling miserable about the deaths of Carrie Fisher and Debbie Reynolds, a health related story came on the air about a young man who presented multiple times to emergency departments with abdominal pain, vomiting and dehydration.  Turns out he fit the diagnosis of a contemporary syndrome of which we in California and other marijuana liberalized states are likely to encounter more frequently – cannabinoid hyperemesis syndrome (CHS).  Early reports were published by Allen et. al in 2004 and other reports followed with a recent report by Kim, et al, associating an increased incidence of CHS related emergency room visits in Colorado following its legalization of marijuana.

A light bulb lit up in my head realizing that I had a patient in care, with the diagnosis of cyclic vomiting, who might actually have CHS.  Read on.

The syndrome, described by Galli et al is characterized by cyclic episodes of nausea and vomiting, a learned behavior of frequent hot showers or baths – as this temporarily relieves the nausea – and relief with cessation of marijuana use.  Typically the use of marijuana is chronic with an average duration of use of 16.3 years but has been reported with much shorter use, less than three years.  Use is commonly several times daily.  Three phases have been described.  The prodromal, pre-emesis, phase with nausea, abdominal distress and fear of vomiting.  Not uncommonly, due to the otherwise beneficial anti- emetic effects of marijuana, use increases.  The hyperemetic phase follows with episodes of intense, incapacitating nausea, vomiting, retching and diffuse but mild abdominal pain.   Weight loss is common in this phase.   This can eventuate in multiple emergency department visits and extensive diagnostic evaluation.  The diagnosis of cyclic vomiting often follows. Of course CHS is but one of a number of possible diagnoses in this symptom setting and other diagnoses should be considered.  Oddly, a self-discovered temporary remedy of hot showers soon becomes compulsive.  The recovery phase, with the discontinuation of marijuana use, occurs over days to months and wellness, weight, and eating patterns return to baseline.  In the CBS story the interviewed patient also remarked on his return of motivational energy – (immediate flashback to Spicoli, “All I need are some tasty waves, a cool buzz, and I’m fine.” in Fast Times at Ridgemont High).   Relapse in cannabis use results in relapse.

Odd that an herb known for its antiemetic and appetite enhancing properties should cause vomiting and weight loss.  Well, herbs are complex and not single chemical pharmaceuticals.  There have been over 100 identified metabolites of THC.  Some, cannabidiol and cannabigerol, may be complicit in the syndrome.

So, I’m going to check up on that patient of mine to explore this possibility.

Jeff Spicoli:  “Awesome! Totally awesome!”

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