Cannabinoid Hyperemesis Syndrome in Pediatrics: An Emerging Problem

Distinguishing Clinical Features of Cannabinoid Hyperemesis Syndrome and Cyclic Vomiting Syndrome: A Retrospective Cohort Study

OBJECTIVE

To identify clinical characteristics that distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS), 2 conditions marked by episodes of nausea, vomiting, and abdominal pain.

STUDY DESIGN

We performed a retrospective chart review of patients admitted to a large children's health care system from 2015 through 2022. Patients with CHS and CVS were identified by the electronic medical record using International Classification of Diseases, Ninth and Tenth Revision codes.

RESULTS

Of 201 patients screened, 125 were included. Patients with CHS were older than those with CVS (mean [SD] 18.06 [1.41] vs 14.50 [2.91] years, P < .001). There were no significant differences in sex, race, ethnicity, or hospital length of stay between groups. Patients with CHS were more likely to have a positive urine drug screen (86% vs 2.9%, P < .001), lower mean (SD) serum potassium (3.62 [0.77] vs 3.88 [0.49], P < .001), and greater mean (SD) serum creatinine (0.83 (0.41) vs 0.63 (0.17), P < .001). The average (SD) systolic blood pressure was significantly greater in patients with CHS (systolic blood pressure 124.46 [10.66] vs 118.55 [10.99], P = .032) compared with children of comparable age range with CVS. Imaging was obtained in 36% of all patients, and only 2.4% had abnormalities.

CONCLUSIONS

Clinical features including older age, greater systolic blood pressure, positive urine drug screen, and select electrolyte findings might distinguish CHS from CVS. Abdominal imaging in both conditions is of low yield. These findings may allow for early recognition and appropriate therapy in CHS patients.

Paediatric cannabinoid hyperemesis

PURPOSE OF REVIEW

The prevalence of adolescent cannabinoid hyperemesis syndrome (CHS) continues to grow, as clinicians increasingly recognize the presenting features of cyclical nausea, emesis, abdominal pain and relief of symptoms with hot showers, in the setting of chronic cannabinoid use.

RECENT FINDINGS

Our understanding of the contributory mechanisms continues to grow, but high-quality evidence of effective treatment in adolescents remains lacking. Current best evidence in the treatment of acute paediatric CHS suggests intravenous rehydration and electrolyte correction, followed by 0.05 mg/kg haloperidol with or without a benzodiazepine. The only long-term treatment remains complete cessation of cannabinoid use.

SUMMARY

This article reviews our growing knowledge of adolescent CHS and provides practical guidance for diagnosis, treatment and understanding the underlying mechanisms of the condition.

A Case of Red Retching?

This piece features a 14-year-old young man who presented with epigastric pain and bright red emesis. His father brought both a photo and sample of the vomitus, which guided initial management in one direction, and then on closer inspection, diverted his diagnostic trajectory. Through a traditional case report and accompanied image and prose, we explore how we process and reinterpret visual data to help guide our management of hematemesis.

Cannabinoid Hyperemesis Syndrome: Lighting Up an Emergency Department Near You

Cannabis legalization may increase the rates of emergency department presentations and hospitalizations from Cannabinoid Hyperemesis Syndrome (CHS). This syndrome was first described nearly 20 years ago and has become increasingly common. Yet, for a variety of reasons, CHS is still an underrecognized cause of recurrent abdominal pain, nausea, and vomiting. All physicians must be prepared to diagnose, manage, and counsel patients on this condition, regardless of their state's current or future cannabis legislation.

Cannabinoid hyperemesis syndrome: A 6-year audit of adult presentations to an urban district hospital

OBJECTIVE

To describe the local experience of adult patients presenting with cannabinoid hyperemesis syndrome (CHS) to an urban ED in the outer northern suburbs of Melbourne.

METHODS

Retrospective chart review of adult patients presenting to the ED with a documented history of CHS or equivalent terminology from January 2015 to January 2021. Age, sex, cannabis use, clinical features, pathology results, imaging and symptomatic management were examined as well as outcomes regarding disposition, representation, morbidity and mortality.

RESULTS

One hundred and forty-two adult presentations were included. Sixty-seven were unique presentations and 29 were patients who represented during the study period. Most represented within 3 months (37.8%) and most represented at least twice. Males were overrepresented (68.7%). Patients were young (median age 31 years, interquartile range 23-35 years) and all had a history of regular cannabis use (usually daily). Cyclical nausea and/or vomiting was the most common clinical feature compared to others in previously reported diagnostic criteria. Patients typically had elevated white cell counts with associated neutrophilia (75.8%) and mild hypokalaemia (57.9%). Lipase was not elevated, and C-reactive protein was typically less than 50 mmol/L (98.2%). Imaging was not commonly performed but largely normal. Treatment was supportive with anti-emetic use, intravenous fluids and analgesia. There were no deaths or admissions to intensive care.

CONCLUSIONS

Cyclical nausea and vomiting was the most common feature observed in this cohort compared to other clinical features reported in prior studies. Serum lipase was normal and C-reactive protein only mildly elevated. Prospective studies are required to further assess these findings.

Functional Nausea Is Real and Makes You Sick

Functional nausea is a condition that severely impairs the quality of life of affected individuals. Only recently, it has been added to the pediatric list of disorders of gut-brain interaction. In most cases, only minimal testing is needed to diagnose functional nausea. Hypnotherapy has been shown to be a very effective treatment and there are several other medical and non-medical interventions which have the potential to benefit sub-groups of patients with chronic nausea.