UMEM Educational Pearls

Title: Hyperemesis Cannabinoid Syndrome

Keywords: Hyperemesis, Cannabinoid (PubMed Search)

Posted: 10/18/2018 by Kathy Prybys, MD (Updated: 10/19/2018)
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Despite the well established antiemetic properties of marijuana, Cannabinoid Hyperemesis Syndrome (CHS) is a distinct under recognized syndrome characterized by severe cyclic vomiting and refractory abdominal pain. CHS can be divided into three phases with varying time lags: pre-emetic or prodromal, hyperemetic, and recovery phase. The hyperemetic phase consists of paroxsyms of overwhelming incapacitating nausea and vomiting.The underlying mechanism of the hyperemesis in CHS is not well understood but appears to be associated with cummulative and toxic effects of Δ₉-tetrahydrocannabinol (Δ₉-THC) in predisposed patients.

Diagnostic criteria include:

History of regular cannabis use at least weekly for any duration of time.
Compulsive hot water bathing multiple times per day for symptom relief which is mediated by the TRPV capsaicin receptors.
Resolution of symptoms with cannabis cessation.
Prior nonrevealing extensive diagnostic work up.

CHS Treatment:

Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.
Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.

Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea.

References

Cannabinoid hyperemesis: a case series of 98 patients. Simonetto DA, Oxentenko AS, et al,Mayo Clin Proc. 2012;87(2):114–9

Cannabinoid hyperemesis syndrome: potential mechanisms for the benfit of capsaicin and hot water hydrotherapy in treatment. Richards JR, Lapoint JM, et al. Clin Tox(phila) 2018 Jan :56(1): 15-24.

Cannabinoid Hyperemesis Syndrome: Public Health Implications and Novel Model Treatment Guidelines. West J Emerg Med. 2018 Mar:19(2):380-386.