POTD: Cannabinoid Hyperemesis Syndrome
Happy Sunday everyone. Hope you had your fill of Thanksgiving, turkey, football, relatives, and political disagreements over the dinner table. Today I want to delve into a topic that I feel like we encounter relatively regularly in the ED. Let me set the scene: You’re walking into the South Side 7 PM shift, through the ambulance bay doors, hot coffee in one hand and a large and refreshing bottle of San Pellegrino Mineral Water in the other. Stepping through the triage area you first hear- then see- our patient. A young person, actively retching to a volume audible from the waiting room, clutching a kidney basin for dear life. They usually are with a concerned loved one who is rubbing their shoulder for comfort. One quick look and you can size them up- this person looks ill and uncomfortable, but not sick. We’ve all been there. With a new feeling of empathy for this person’s exceptionally vocal nausea, you mosey on to the doctor’s station to await sign-out from your eager and exhausted colleagues. Another beautiful night on South Side- better have 3 In 1 on speed dial for some munchies.
The patient encountered is suffering from cannabinoid hyperemesis syndrome. Cannabis has been used as a medicine for centuries. As legislation in many states in the USA eases restrictions on its use (as of March 31, 2021, it is legal for adults 21 and older to possess up to three ounces of cannabis for personal use in New York), we are seeing more and more patients appearing in the ED presenting with the relatively rare side-effects from marijuana, including hyperemesis. Ironically, cannabinoids are used very commonly to treat nausea and vomiting, particularly in patients with chemotherapy-related symptoms, or patients with cyclic vomiting syndrome. Theoretically, this paradoxical illness is caused by highly potent THC that effects genetically predisposed individuals by differentially downregulating CBD receptors and causing autonomic dysfunction. There is speculation that there is a dose-dependency, and that a biphasic mechanism of action of THC may have anti-emetic effects at low doses, but pro-emetic at higher doses. Cannabinoid CB1 and CB2 are the main receptors for THC, one of the main active substances in marijuana. The theory is that the CB receptors in the medulla are responsible for anti-emetic properties, but the CB receptors in the GI tract are the source of dysregulation. There is another theory that the TRPV1 receptor (transient receptor potential vanilloid subtype 1), which is activated by marijuana, capsaicin, and heat, is altered by chronic marijuana use. It is speculated that the reason patients with CHS take repetitive hot showers is to upregulated the TRPV1 receptor.
Diagnosis
While no diagnostic criteria currently exist for definitive CHS diagnosis major characteristics patients typically display are:
History of regular cannabis use (100% Sensitivity)
Cyclic nausea and vomiting (100%)
Generalized, diffuse abdominal pain (85.1%)
Compulsive hot showers with symptom improvement (92.3%)
Symptoms resolve with marijuana use cessation (92.3%)
A higher prevalence in males (72.9%)
Often patients will experience three phases of Cannabinoid Hyperemesis Syndrome (3,8):
The Pre-emetic or Prodromal Phase:
Can last for months or years
Characterized by diffuse abdominal discomfort, feelings of agitation or stress, morning nausea, and fear of vomiting
May also include autonomic symptoms like flushing, sweating, and increased thirst
Often have increased use of marijuana to treat these symptoms
Hyper-emetic Phase:
24-48 hours
Multiple episodes of vomiting
Diffuse, severe abdominal pain
Recovery Phase:
Begins with total cessation of cannabis
Often patients require a bowel regimen, IV fluids, and electrolyte replacement
Resolution of symptoms may take up to one month
Common complications of CHS include electrolyte disturbances, dehydration or AKI, and muscle cramps or spasms. Life threatening complications that have been documented include pneumomediastinum from ruptured esophagus, and electrolyte derangement causing seizure or arrythmia. Patients with suspected CHS should be offered counseling, resources, and follow-up for marijuana cessation. Treatment in the symptomatic phase involves symptomatic treatment and pharmaceuticals. It is often necessary to take a multi-faceted approach by giving dopamine antagonists, antihistamines, serotonin antagonists, antipsychotics, and topical capsaicin. Capsaicin is thought to work by transiently activating TRPV1 (which remember, is speculated to be downregulated by chronic marijuana use, and is thought to be the reason for the relief from incessant hot showering). It is a cream that can be applied to the fatty areas of the backs of the arms and abdomen up to 3 times daily, and is available in concentrations from 0.025% to 0.15%.
Pearls
Cannabinoid Hyperemesis Syndrome is increasing in frequency in the United States.
CHS is characterized by nausea, vomiting, abdominal pain and chronic cannabis use.
Consider CHS diagnosis in patients with recurrent presentations and negative abdominal pain work-ups.
Avoid opiates for CHS treatment.
Consider capsaicin cream, benzodiazepines, antiemetics and antipsychotics for treatment of CHS
Hope this was informative, and that everyone had a great weekend. See you in the ED this week.
Mak Sarich MD
References: http://www.emdocs.net/more-than-a-hot-shower-treatment-for-cannabinoid-hyperemesis-syndrome-chs/