Cannabinoid hyperemesis syndrome

Background

  • Cannabis is the most widely used drug in the US and the world
  • Cannabinoid hyperemesis syndrome, first described by Allen et al. in 2004 consists of nausea, vomiting, and abdominal pain in a patient with no other organic cause who frequently uses marijuana and has relief of symptoms with hot showers[1]
  • Pathophysiology not yet well understood[2]

Clinical Features[3]

Essential Features

  • Long term cannabis use (typically > 2 years)

Major Features

  • Severe cyclical nausea, vomiting
  • Weekly use of marijuana
  • Relief of symptoms with hot showers or baths
  • Abdominal pain: epigastric or periumbilical
  • Resolution of symptoms with cannabis cessation

Supportive Features

  • Age < 50y
  • Weight loss > 5kg
  • Symptoms greater in morning
  • Normal bowel habits
  • Negative labs, imaging and endoscopy

Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Evaluation

  • Generally considered a diagnosis of exclusion after evaluating for other causes of nausea and vomiting

Management

  • Cessation of marijuana use, as hyperemetic phase lasts only 24-48 hrs unless pt relapses
  • Symptomatic treatment (Antiemetics, anxiolytics, and hydration)
    • Haloperidol 5 mg IV/IM and diphenhydramine 50 mg IV[4]
    • Hot shower (>109°F), though short-lived[5]
    • Capsaicin cream 0.025-0.075% across abdomen/arms/back, with symptoms diminishing within 30 min[6]

Disposition

  • Discharge once tolerating PO

See Also

External Links

References

  1. Allen, J H; De Moore, GM; Heddle, R; Twartz, JC (2004). "Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse". Gut 53 (11): 1566–70. doi:10.1136/gut.2003.036350. PMC 1774264
  2. Byrne, A; Hallinan, R; Wodak, A (2006). "'Cannabis hyperemesis' causation questioned". Gut 55 (1): 132; author reply 132. PMC 1856368
  3. Simonetto, Douglas A.; Oxentenko, Amy S.; Herman, Margot L.; Szostek, Jason H. (2012). "Cannabinoid Hyperemesis: A Case Series of 98 Patients". Mayo Clinic Proceedings 87 (2): 114–9. doi:10.1016/j.mayocp.2011.10.005. PMID 22305024
  4. Hickey JL et al. Haloperidol for treatment of cannabinoid hyperemesis syndrome. Am J Emerg Med. 2013 Jun;31(6):1003.e5-6.
  5. Galli JA et al. Cannabinoid Hyperemesis Syndrome. Curr Drug Abuse Rev. 2011 Dec; 4(4): 241–249.
  6. Leon G. Toxicology Rounds: The Anti-Munchies: Cannabinoid Hyperemesis Syndrome. Emergency Medicine News: November 2011 - Volume 33 - Issue 11 - p 14.