Cannabinoid hyperemesis syndrome

CASE REPORT

Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse

Siva P Sontineni, Sanjay Chaudhary, Vijaya Sontineni, Stephen J Lanspa
Online Submissions: wjg.wjgnet.com World J Gastroenterol 2009 March 14; 15(10): 1264-1266
wjgwjgnet.com World Journal of Gastroenterology ISSN 1007-9327
doi:10.3748/wjg.15.1264 © 2009 The WJG Press and Baishideng. All rights reserved.
Siva P Sontineni, Sanjay Chaudhary, Vijaya Sontineni,
Stephen J Lanspa, Department of Medicine, Creighton
University, Suite 5850, 601 N 30th Street, Omaha, NE 68131,
United States
Author contributions: Sontineni SP provided the patient’s data,
organized, conceptualized and contributed to the manuscript
writing and final approval; Chaudhary S collected the patient
data, reviewed the literature and contributed to the manuscript
writing; Sontineni V reviewed the literature and compiled the
references; Lanspa SJ supervised, provided critical review
and obtained financial support from the division; All authors
approved the final manuscript.
Correspondence to: Siva P Sontineni, MD, Department
of Internal Medicine, 601 N 30th St Suite 5850, Creighton
University Medical Centre, Omaha, NE 68131,
United States. ssontinenigmail.com
Telephone: +1-402-4158319 Fax: +1-402-2804220
Received: October 25, 2008 Revised: February 8, 2009
Accepted: February 15, 2009
Published online: March 14, 2009

Abstract

Cannabis is a common drug of abuse that is associated with various long-term and short-term adverse effects.
The nature of its association with vomiting after chronic abuse is obscure and is underrecognised by
clinicians. In some patients this vomiting can take on a pattern similar to cyclic vomiting syndrome with
a peculiar compulsive hot bathing pattern, which relieves intense feelings of nausea and accompanying
symptoms. In this case report, we describe a twentytwo year-old-male with a history of chronic cannabis
abuse presenting with recurrent vomiting, intense nausea and abdominal pain. In addition, the patient
reported that the hot baths improved his symptoms during these episodes. Abstinence from cannabis led
to resolution of the vomiting symptoms and abdominal pain. We conclude that in the setting of chronic
cannabis abuse, patients presenting with chronic severe nausea and vomiting that can sometimes be
accompanied by abdominal pain and compulsive hot bathing behaviour, in the absence of other obvious
causes, a diagnosis of cannabinoid hyperemesis syndrome should be considered.
© 2009 The WJG Press and Baishideng. All rights reserved.

INTRODUCTION
Cannabis has been used recreationally for millennia and is the third most commonly used drug after tobacco
and alcohol[1,2]. Research into the neurobiology of the compound has led to the discovery of an endogenous
cannabinoid system. The therapeutic potential of cannabinoids has been recognized and these compounds are
utilized as anti-emetics[3-5]. Recently, a distinct syndrome in chronic cannabis abusers characterized by recurrent
vomiting associated with abdominal pain and a tendency to take hot showers has been increasingly recognised.
This clinical manifestation is paradoxical to the previously identified therapeutic role of cannabinoids as antiemetics.
We describe the case of a young male seeking repeated emergency room care with recurrent nausea
and vomiting.

CASE REPORT
A 22-year male presented with recurrent episodes of nausea, refractory vomiting, and colicky epigastric pain
for one week. The symptoms were characterized by treatment-resistant nausea in the morning, continuous
vomiting, and colicky epigastric abdominal pain. Each episode lasted 2 to 3 h and increased with food intake.
He often had two or more episodes a day during the symptomatic period. He had been treated for the severe
nausea and vomiting in the emergency room on two occasions in the preceding two months. He also reported
having learned to help himself by taking a hot bath each time the symptoms appeared, which dramaticallyimproved his symptoms. This habit had become a compulsion for him for symptom relief with each episode
of hyperemesis. On physical examination his mucous membranes were dry, his pulse rate was 102/min and
blood pressure was 140/100 with positive orthostasis. The remainder of the physical examination was unremarkable.
His complete blood count and comprehensive metabolic panel were unremarkable. In addition, serum
amylase and lipase levels were within the normal range. His urine drug screen was positive for tetrahydrocannabinol
(THC). Abdominal X-ray series and ultrasonography were within normal limits.
Oesophagogastroduodenoscopy revealed Grade 2 distal oesophagitis and hiatal hernia. On further interviewing,
he admitted to consistent marijuana abuse for the past 6 years, often smoking cannabis every hour or
two on a daily basis. The patient and his mother did not recall any significant past illnesses or recurrent vomiting
when he was a child. He was treated with intravenous fluids with steady improvement in symptoms, and metoclopramide,
pantoprazole and morphine for the abdominal pain. It was explained that marijuana was the cause
of his symptoms and he was advised not to resume marijuana abuse. On subsequent follow-up, he had abstained from cannabis and remained symptom-free.

DISCUSSION
Cannabis is one of the most commonly abused drugs worldwide. Over the past decade, marijuana has
remained the most commonly used illicit substance with close to 50% of high school seniors admitting use at
some time[1]. It is estimated that each year 2.6 million individuals in the USA become new users and most are
younger than 19 years of age[6].
The long-term and short-term toxicity of cannabis abuse is associated with pathological and behavioural
effects. However, cannabis has also been suggested to have therapeutic properties with anticonvulsive,
analgesic, antianxiety and anti-emetic activities. Cannabis has also been used to treat anorexia in patients with
acquired immunodeficiency syndrome[3-5]. The actions of cannabis are mediated by specific cannabinoid
receptors. The first of the cannabinoid receptors-CB-1- was identified in 1990 and this finding revolutionized the
study of cannabinoid biology. Since then, a multitude of roles for the endogenous cannabinoid system has been
proposed. A large number of endogenous cannabinoid neurotransmitters or endocannabinoids have been
identified, and the CB-1 and CB-2 cannabinoid receptors have been characterized[7]. The CB-1 receptors exert
a neuromodulatory role in the central nervous system and enteric plexus[8]. Cannabinoid type 2 receptors
have an immunomodulatory effect and are located on tissues such as microglia[5]. The presence of other
receptors, transporters, and enzymes responsible for the synthesis or metabolism of endocannabinoids are
being recognised at an extraordinary pace. Cannabinoids have a wide variety of effects on the body systems and
physiologic states (Table 1) due to their actions on the receptors as well as direct toxic effects.
The anti-emetic effect of cannabinoids is largely mediated by CB-1 receptors in the brain and the
intestinal tract, although some of their effect may also be receptor-independent. However, in this report,
we were presented with the paradoxical effect of hyperemesis in a susceptible chronic cannabis abuser.
Such a paradoxical response has previously only been demonstrated following acute toxicity to an intravenous
injection of crude marijuana extract[9]. Proposed mechanisms of cannabinoid hyperemesis include
toxicity due to marijuana’s long half-life, fat solubility, delayed gastric emptying, and thermoregulatory and
autonomic disequilibrium via the limbic system[10].
Cannabinoids are known to impair peristalsis in a dosedependent manner[11,12], which can theoretically override
the centrally mediated anti-emetic effects, thus leading to hyperemesis. It is not known why the hyperemesis
syndrome surfaces after several years of cannabis abuse. The effects of cannabinoids on the functions of the
thermoregulatory and autonomic mechanisms of the brain can lead to behavioural changes[10]. Such effects
might be the underlying mechanism for the compulsive hot bathing behaviour. There is also a supposition that
the syndrome could represent a type of cyclic vomiting.
Cyclic vomiting syndrome (CVS) in adults is now very well recognized, and it has been proposed that marijuana
contributes to CVS[13]. However, unlike the other forms of CVS, patients with cannabinoid hyperemesis are not
likely to have a history of migraine or other psychosocial stressors and the peculiar behaviour of hot showers is
Cognitive and mental health
Impaired memory
Impaired attention, organization and integration of complex information
Association with schizophrenia
Increased risk for depression
Pulmonary
Carcinogenic effect
Obstructive lung disease
Increased propensity toward infections
Acute and chronic bronchitis
Behavioural
Weapon possession and physical fighting
Unwanted and unprotected sexual encounters
Unwanted pregnancies
School dropout
Amotivational syndrome
Impairment of driving skill and coordination
Endocrine
Decreased testosterone, sperm motility and production, disruption of
ovulatory cycle
Pregnancy
Low birth weight
Problems with attention, memory and higher cognitive function
Cardiovascular
Stroke
Dose-dependent increase in HR
Orthostasis
Decreased exercise tolerance
Precipitation of angina or myocardial infarction unique to this syndrome.

Allen et al[10] first noted this condition in a group of nineteen patients from Australia with chronic
cannabis abuse and cyclical vomiting illness. An earlier case report by de Moore et al[17] described a chronic
cannabis abuser with psychogenic vomiting, which was complicated by spontaneous pneumomediastinum.
Subsequent reports have identified similar clinical presentations[7-9,18]. Given the high prevalence of chronic
cannabis abuse worldwide and the paucity of reports in the literature, clinicians need to be more attentive to the
clinical features of this underrecognised condition.

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bathing with chronic cannabis abuse. Clin Gastroenterol
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pneumomediastinum. Aust N Z J Psychiatry 1996; 30: 290-294
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S- Editor Li LF L- Editor Kerr C E- Editor Yin DH
Essential for diagnosis:
History of regular cannabis use for years
Major clinical features of syndrome
Severe nausea and vomiting
Vomiting that recurs in a cyclic pattern over months
Resolution of symptoms after stopping cannabis use
Supportive features
Compulsive hot baths with symptom relief
Colicky abdominal pain
No evidence of gall bladder or pancreatic inflammation
Table 2 Clinical diagnosis of cannabinoid hyperemesis

Source: 1266 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol March 14, 2009 Volume 15 Number 10
www.wjgnet.com

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