Cannabinoid hyperemesis relieved by compulsive bathing

Severe and rapidly changing hypophosphatemia in cannabinoid hyperemesis syndrome: a case report

The increasing prevalence of cannabis worldwide requires awareness of a potential, less recognized, paradoxical entity, the cannabinoid hyperemesis syndrome (CHS). This includes cyclic episodes of nausea, vomiting, and compulsive hot water bathing for alleviation in individuals with chronic cannabis use. An 18-year-old male with daily and prolonged cannabis use has excessive nausea and vomiting, is diagnosed with CHS, and is further complicated by severe and rapidly fluctuating hypophosphatemia. He was successfully managed with intravenous (IV) antiemetic (metoclopramide) and IV normal saline in the emergency department. Hypophosphatemia was treated with IV phosphorous. Although hypophosphatemia in CHS is a rare encounter, the authors share their experience to promote broader recognition and insight into successful management.

Cannabis Hyperemesis Syndrome in a Recently Abstinent Chronic User: Assessment and Intervention

BACKGROUND

Cannabis Hyperemesis Syndrome (CHS) is a condition characterized by episodic bursts of vomiting and abdominal pain linked to cannabis use. The clinical picture mimics an acute abdomen and is often misdiagnosed, especially when the patient avoids reporting their cannabis use for legal reasons.

CASE REPORT

We report on the case of a 33-year-old man that was brought to the emergency room with a history of 3 days of non-bloody, non-projectile, and non-bilious brownish vomit, coupled with severe epigastric and left hypochondriac pain, and a slight fever. He was a daily cannabis user for several years and had stopped using a week or so before the onset of the symptoms, as he was traveling to a country with more restrictive cannabis laws. His condition deteriorated rapidly, followed by emergency room attendance, thorough diagnostic work-up, and unsuccessful interventions, including intravenous treatment with the anti-emetic Ondansetron. The patient was referred to a psychiatrist after a suspected psychogenic etiology by the medical team. The history was suggestive of CHS and also included anxious, depressed mood with 'brain fog'. The abdominal pain was the most severe complaint. A combination of tramadol, promethazine, and mirtazapine given on an outpatient basis led to full recovery within 10 days.

CONCLUSION

CHS can occur soon after the interruption of chronic cannabis use and overlap with withdrawal symptom. A combination of anti-histaminergic, opioid-based medication, and antidepressant mirtazapine seemed an effective treatment of CHS, which resulted in a relatively quick recovery.

Cyclic Vomiting Syndrome and Cannabis Hyperemesis Syndrome: The State of the Science

This article provides a narrative review of the state of the science for both cyclic vomiting syndrome and cannabis hyperemesis syndrome along with a discussion of the relationship between these 2 conditions. The scope of this review includes the historical context of these conditions as well as the prevalence, diagnostic criteria, pathogenesis, and treatment strategies for both conditions. A synopsis of the endocannabinoid system provides a basis for the hypothesis that a lack of cannabidiol in modern high-potency Δ 9 -tetrahydrocannabinol cannabis may be contributory to cannabis hyperemesis syndrome and possibly other cannabis use disorders. In concluding assessment, though the publications addressing both adult cyclic vomiting syndrome and cannabis hyperemesis syndrome are steadily increasing overall, the state of the science supporting the treatments, prognosis, etiology, and confounding factors (including cannabis use) is of moderate quality. Much of the literature portrays these conditions separately and as such sometimes fails to account for the confounding of adult cyclic vomiting syndrome with cannabis hyperemesis syndrome. The diagnostic and therapeutic approaches are, at present, based generally on case series publications and expert opinion, with a very limited number of randomized controlled trials and a complete absence of Level 1 evidence within the cyclic vomiting literature overall as well as for cannabis hyperemesis syndrome specifically.

Pediatric Cannabinoid Hyperemesis: A Single Institution 10-Year Case Series

PURPOSE

Cannabis hyperemesis (CH) is an under-recognized condition in patients with chronic or cyclic vomiting and who regularly use cannabis. Once thought to be rare, it is now increasingly recognized in both adults and children. We report a case series of adolescent patients with CH who presented at a single institution over 10 years.

METHODS

Patients were included if they had a diagnosis code of cannabis-related or cyclic vomiting, experienced the onset of regular vomiting after starting to regularly use cannabis, and if no other diagnosis was found to better explain the presentation. Thirty-four patients aged 13-20 years (median 17 years) met the inclusion criteria.

RESULTS

The presenting clinical features were broadly similar to adult CH: cyclic nausea and emesis after at least 3 months of regular cannabis use, abdominal pain, change in bowel habit, and symptomatic relief from hot showers or baths. No antiemetic was found to be of particular benefit. Follow-up was recorded in under half of the patients; documentation of drug history was also frequently incomplete. Clinicians should consider CH when assessing any adolescent with cyclic or chronic vomiting.

CONCLUSIONS

A detailed drug history, preferably taken in the absence of parents or other involved adults and corroborated by urine drug screening, is helpful in substantiating the diagnosis. Further prospective studies are needed to confirm the incidence, prevalence, presenting features, and the effectiveness of treatments, including drug counseling and cessation. Based on our findings, we propose pragmatic criteria to aid in the diagnosis of pediatric CH.

Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis

INTRODUCTION

Cannabinoid hyperemesis syndrome (CHS) is a condition that is being recognized and treated more frequently in emergency departments (EDs) across the United States. Currently, ED providers rely on antiemetics, antipsychotics and benzodiazepines to alleviate the symptoms. Topical capsaicin, a transient receptor potential vanilloid 1 (TRPV1) agonist, has been proposed in recent years as a low-cost and effective alternative to the traditional antiemetic regimen when treating CHS. The aim of this systematic review and meta-analysis is to demonstrate the reliability and the gaps of what is known about this treatment modality.

METHODS

Articles were extracted from PubMed, SCOPUS, and Google Scholar databases. Publication dates ranged from the inception of the databases to October 2020. Initial searches found 328 studies. After careful review and screening by two investigators, 7 studies met the inclusion criteria and were included for our meta-analysis. Variables that were evaluated included the prevalence of hospital admissions for patients treated with capsaicin, time to relief of symptoms after capsaicin administration, and ED length of stay (LOS). I-square and Q-statistic values were used to assess heterogeneity.

RESULTS

Among the 7 studies, there was a total of 106 patients. Two studies reported time to resolution of symptoms following capsaicin administration and ED LOS. Means for these outcomes were 325 (95% CI 234-787) and 379 (95% CI 10-747) minutes respectively. I-square was 44%, and Q-statistic was 11 with 6 degrees of freedom, with a p-value of 0.1.

DISCUSSION

With acceptable time to resolution of symptoms after topical administration and ED LOS, capsaicin appears to be an effective treatment option for symptomatic relief of CHS. Further randomized controlled trials should be conducted to examine if it is the more efficacious and efficient treatment for CHS across various care settings.

Cannabidiol and Sports Performance: a Narrative Review of Relevant Evidence and Recommendations for Future Research

Cannabidiol (CBD) is a non-intoxicating cannabinoid derived from Cannabis sativa. CBD initially drew scientific interest due to its anticonvulsant properties but increasing evidence of other therapeutic effects has attracted the attention of additional clinical and non-clinical populations, including athletes. Unlike the intoxicating cannabinoid, Δ9-tetrahydrocannabinol (Δ9-THC), CBD is no longer prohibited by the World Anti-Doping Agency and appears to be safe and well-tolerated in humans. It has also become readily available in many countries with the introduction of over-the-counter "nutraceutical" products. The aim of this narrative review was to explore various physiological and psychological effects of CBD that may be relevant to the sport and/or exercise context and to identify key areas for future research. As direct studies of CBD and sports performance are is currently lacking, evidence for this narrative review was sourced from preclinical studies and a limited number of clinical trials in non-athlete populations. Preclinical studies have observed robust anti-inflammatory, neuroprotective and analgesic effects of CBD in animal models. Preliminary preclinical evidence also suggests that CBD may protect against gastrointestinal damage associated with inflammation and promote healing of traumatic skeletal injuries. However, further research is required to confirm these observations. Early stage clinical studies suggest that CBD may be anxiolytic in "stress-inducing" situations and in individuals with anxiety disorders. While some case reports indicate that CBD improves sleep, robust evidence is currently lacking. Cognitive function and thermoregulation appear to be unaffected by CBD while effects on food intake, metabolic function, cardiovascular function, and infection require further study. CBD may exert a number of physiological, biochemical, and psychological effects with the potential to benefit athletes. However, well controlled, studies in athlete populations are required before definitive conclusions can be reached regarding the utility of CBD in supporting athletic performance.

Role of the stress response and the endocannabinoid system in Δ9-tetrahydrocannabinol (THC)-induced nausea

RATIONALE

Dysregulation of the endocannabinoid (eCB) system by high doses of Δ⁹-tetrahydrocannabinol (THC) is hypothesized to generate a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis contributing to cannabinoid hyperemesis syndrome (CHS).

OBJECTIVES AND METHODS

Using the conditioned gaping model of nausea, we aimed to determine if pre-treatments that interfere with stress, or an anti-emetic drug, interfere with THC-induced nausea in male rats. The corticotropin-releasing hormone (CRH) antagonist, antalarmin, was given to inhibit the HPA axis during conditioning. Since eCBs inhibit stress, MJN110 (which elevates 2-arachidonylglycerol (2-AG)) and URB597 (which elevates anandamide (AEA)) were also tested. Propranolol (β-adrenergic antagonist) and WAY-100635 (5-HT_1A antagonist) attenuate HPA activation by cannabinoids and, therefore, were assessed. In humans, CHS symptoms are not alleviated by anti-emetic drugs, such as ondansetron (5-HT₃ antagonist); however, benzodiazepines are effective. Therefore, ondansetron and chlordiazepoxide were tested. To determine if HPA activation by THC is dose-dependent, corticosterone (CORT) was analyzed from serum of rats treated with 0.0, 0.5, or 10 mg/kg THC.

RESULTS

Antalarmin (10 and 20 mg/kg), MJN110 (10 mg/kg), URB597 (0.3 mg/kg), propranolol (2.5 and 5 mg/kg), WAY-100635 (0.5 mg/kg), and chlordiazepoxide (5 mg/kg) interfered with THC-induced conditioned gaping, but the anti-emetic ondansetron (0.1 and 0.01 mg/kg) did not. THC produced significantly higher CORT levels at 10 mg/kg than at 0.0 and 0.5 mg/kg THC.

CONCLUSIONS

Treatments that interfere with the stress response also inhibit THC-induced conditioned gaping, but a typical anti-emetic drug does not, supporting the hypothesis that THC-induced nausea, and CHS, is a result of a dysregulated stress response.

Cannabinoid Hyperemesis Syndrome: A Review of Potential Mechanisms

Introduction: Cannabinoids have long been known for their ability to treat nausea and vomiting. Recent reports, however, have highlighted the paradoxical proemetic effects of cannabinoids. Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclical episodes of nausea and vomiting, accompanied by abdominal pain following prolonged, high-dose cannabis use, which is alleviated by hot baths and showers. Little is known about the cause of this syndrome. Discussion: Cannabinoids produce a biphasic effect on nausea and vomiting, with low doses having an antiemetic effect and high doses producing emesis. Presentation and treatment of CHS are similar to cyclical vomiting syndrome as well as chemotherapy-related anticipatory nausea and vomiting, suggesting that these phenomena may share mechanisms. The prevalence of CHS is not known because of the symptomatic overlap with other disorders and the lack of knowledge of the syndrome by the public and physicians. Treatment with typical antiemetic drugs is ineffective for CHS, but anxiolytic and sedative drugs, along with hot showers, seem to be consistently effective at reducing symptoms. The only known way to permanently end CHS, however, is abstinence from cannabinoids. Case studies and limited pre-clinical data on CHS indicate that prolonged high doses of the main psychotropic compound in cannabis, Δ9-tetrahydrocannabinol (THC), result in changes to the endocannabinoid system by acting on the cannabinoid 1 (CB1) receptor. These endocannabinoid system changes can dysregulate stress and anxiety responses, thermoregulation, the transient receptor potential vanilloid system, and several neurotransmitters systems, and are thus potential candidates for mediating the pathophysiology of CHS. Conclusions: Excessive cannabinoid administration disrupts the normal functioning of the endocannabinoid system, which may cause CHS. More clinical and pre-clinical research is needed to fully understand the underlying pathophysiology of this disorder and the negative consequences of prolonged high-dose cannabis use.

Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome

Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.

Cannabinoid Hyperemesis

Cannabinoid hyperemesis syndrome (CHS) is a paradoxical condition in which a long-term cannabis user suffers an episode of intractable vomiting that may last days separated by longer asymptomatic periods of weeks or months. Cannabinoids are often utilized for their antiemetic properties, so CHS can be a puzzling condition, and the diagnosis of CHS may be disputed by patients. Unlike other cyclic vomiting syndromes, CHS can be relieved by hot showers or topical capsaicin. Abstinence from cannabinoids causes CHS to resolve, sometimes in a matter of days or hours. Marijuana users as well as many clinicians are not aware of CHS, and patients may undergo unnecessary tests, scans, and other procedures to get an accurate diagnosis. Symptoms may be severe enough to require hospitalization. With liberalization of marijuana laws and favorable public opinion about the healing properties of cannabis, CHS may be more frequently observed in clinical practice.

Emergency Department Burden of Nausea and Vomiting Associated With Cannabis Use Disorder: US Trends From 2006 to 2013

BACKGROUND AND AIMS

Chronic cannabis use is associated with nausea and vomiting that may lead to emergency department (ED) visits, multiple diagnostic tests, and procedures. The aim of this study was to analyze recent trends in ED visits for vomiting associated with cannabis use disorder between 2006 and 2013.

METHODS

Data were obtained from the National Emergency Department Sample records in which vomiting (ICD-9-CM codes 787.01, 787.03, and 536.2) was a primary diagnosis in combination with cannabis abuse or dependence (304.3, 304.30, 304.31, 304.32, 304.33, 305.2, 305.20, 305.21, 305.22, and 305.23) and were seen in the ED between 2006 and 2013. The National Emergency Department Sample collects data from more than 25 million visits in over 950 EDs and is weighted to provide national estimates.

RESULTS

The rate of ED visits for vomiting with cannabis use disorder from 2006 compared with 2013 increased from 2.3 to 13.3 per 100,000 ED visits, while the mean inflation-adjusted costs increased 68.5% from $2758.43 to $4647.62, respectively. Men between the ages of 20 and 29 were the most common group to present to the ED for vomiting with cannabis use disorder. The Midwest and West had the higher rates of ED visits for vomiting with cannabis use disorder compared with the Northeast and South.

CONCLUSIONS

ED visits for vomiting associated with cannabis use disorder is common and is associated with significant medical costs. Further research on the role of cannabis use in nausea and vomiting is warranted.

Emergency Department Treatment of Cannabinoid Hyperemesis Syndrome: A Review

BACKGROUND

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with chronic cannabis use. As cannabis consumption steadily increases each year, CHS is becoming a commonplace and costly occurrence in hospitals nationwide. Currently, there are no best treatment strategies agreed upon universally.

AREAS OF UNCERTAINTY

Thus far, most data about CHS have come from case reports and case series. Consequently, the pathophysiology of the syndrome is unclear, and its occurrence in some cannabis users, but not others, is not understood.

DATA SOURCES

A literature search was conducted through PubMed, Embase, and Google Scholar from inception until 2017. Publications only in English describing the epidemiology, pathophysiology, diagnostic criteria, and treatments of CHS were incorporated after thorough evaluation. National government surveys were also referred to for current information about the CHS patient population.

RESULTS

CHS should be considered in the differential diagnosis of any patient presenting with persistent nausea and vomiting. In particular, the diagnosis is suggested if the patient demonstrates regular and chronic cannabis use, intractable nausea and vomiting, cyclical vomiting, relief of symptoms with hot baths, and resolution of symptoms after cannabis cessation. There are currently many possible explanations regarding the mechanisms behind CHS. A variety of treatment options have also been examined, including hot water baths, haloperidol, capsaicin, and benzodiazepines.

CONCLUSIONS

CHS is becoming an increasingly prevalent and complicated problem for health care providers and patients. Further research must be done to address the diagnostic and therapeutic challenges of this syndrome.

A patient with a curious case of cyclical vomiting

Cannabis-related ED visits are on the rise due to wider legalization and availability of marijuana, and habitual daily use is increasingly common. Cannabis abuse has long been associated with various short-term and long-term adverse reactions. One such reaction is cannabinoid hyperemesis syndrome: cyclical vomiting, nausea, and abdominal pain that only resolves with a warm bath or shower. Healthcare providers must understand the signs and symptoms of cannabinoid hyperemesis syndrome so the problem can be recognized early and patients avoid unnecessary testing.

Cannabinoid Hyperemesis Syndrome and the Consulting Psychiatrist: A Case Study of Diagnosis and Treatment for an Emerging Disorder in Psychiatric Practice

The increasing prevalence of cannabis use in the United States requires awareness of cannabis-related disorders and familiarity with treatment options. We present a case of cannabinoid hyperemesis syndrome that required psychiatric consultation for diagnostic clarification and effective treatment with intravenous haloperidol. Literature from emergency medicine, toxicology, and gastroenterology is reviewed, including proposed diagnostic criteria for cannabinoid hyperemesis syndrome and reported off-label treatment options, with a specific focus on clinical questions facing the practicing psychiatrist regarding this emerging disorder.

Cyclic vomiting syndrome: a case series and review of the literature

OBJECTIVE

Cyclic vomiting syndrome (CVS) is under-recognised. Treatment is difficult as the pathophysiology is incompletely understood. We report our experience of treating patients with amitriptyline, and review the literature to summarise symptoms and associated features, epidemiology, potential pathophysiological mechanisms, differential diagnoses and treatment.

DESIGN

Consecutive adult patients with CVS were identified during a 5-year period from January 2010 until December 2015. Medical records were reviewed retrospectively, and age and sex of the patient, symptoms, associated features and response to treatment with amitriptyline were recorded.

SETTING

A luminal gastroenterology clinic at a teaching hospital.

RESULTS

Seventeen patients were identified (mean age 29.8 years, 13 (76.5%) female). Five had a history of cannabis use. Duration of symptoms prior to diagnosis ranged from 5 months to 15 years. Fourteen patients commenced amitriptyline, and in eight (57.1%) symptoms either ceased entirely or improved. Review of the literature suggested the prevalence of CVS was 0.5%. Symptoms are stereotypical, with acute episodes of nausea and vomiting, interspersed by periods when the patient is symptom-free. Proposed pathophysiologies include neuroendocrine dysfunction, mutations in mitochondrial DNA and re-intoxication effects from cannabis stored in fat tissues. Treatment during the acute phase is supportive, with rehydration, sedation and antiemetics. Prophylaxis to prevent future attacks with antihistamines, antimigraine drugs, antiepileptics and tricyclic antidepressants may be beneficial. Complete cessation of cannabis smoking should be advised.

CONCLUSIONS

Diagnosis of CVS is often delayed in adults. Once identified, patients respond well to amitriptyline.

Running Out of Options: Rhabdomyolysis Associated with Cannabis Hyperemesis Syndrome

Cannabis hyperemesis syndrome (CHS) is a condition in which some patients with long-term, frequent use of cannabis paradoxically develop recurrent episodes of nausea and vomiting. The pathophysiology underlying this condition is poorly understood, as is the explanation for its common association with patients' discovery that hot-water bathing alleviates symptoms. We describe the case of a 24-year-old male with daily marijuana use and a history of CHS who was found to have rhabdomyolysis induced by a period of 15 h of continuous jogging after he discovered that this activity helped to alleviate his symptoms. To our knowledge, this is the first reported case of exercise-alleviated CHS symptoms, and we propose that this case provides support to the theory of redistribution of enteric blood flow as the mechanism behind the learned hot-water bathing behavior seen so commonly in CHS.

Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series

Cannabinoid hyperemesis syndrome (CHS) is an underrecognized diagnosis among adolescents. In the adult literature, it is characterized as nausea, vomiting, and abdominal pain in patients with chronic marijuana use. CHS is often refractory to the standard treatment of nausea and vomiting. Unconventional antiemetics, such as haloperidol, have been successful in alleviating symptoms; however, even 1 dose of haloperidol can lead to grave adverse effects, such as dystonia, extrapyramidal reactions, and neuroleptic malignant syndrome. The use of topical capsaicin cream to treat CHS has been well described in the adult literature. This treatment is cost-effective and is associated with few serious side effects. Here, we describe 2 adolescent patients with nausea, vomiting, and abdominal pain in the setting of chronic cannabis use whose symptoms were not relieved by standard antiemetic therapies, but who responded well to topical capsaicin administration in our pediatric emergency department. We also discuss the pathophysiology behind capsaicin's efficacy. These are the first reported cases in which capsaicin was successfully used to treat CHS in pediatric patients.

Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review

Cannabinoid hyperemesis syndrome (CHS) has become more prevalent with increasing cannabis use. CHS is often resistant to standard antiemetics. The objective of this study is to review the current evidence for pharmacologic treatment of CHS. Medline, PsycINFO, DARE, OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to February 2017. Articles were selected and reviewed independently. Evidence was graded using Oxford Center for Evidence-Based Medicine guidelines. The search resulted in 1262 articles with 63 of them eligible for inclusion (205 human subjects). There were 4 prospective level-2, 3 retrospective level-3 studies, 12 level-4 case series, and 44 level-5 case reports. Among level-2 studies (64 subjects), tricyclic antidepressants (TCAs) and lorazepam were discussed as effective long- and short-term treatments, respectively, in two studies. Ondansetron, promethazine, diphenhydramine, and opioids were also mentioned, but the authors did not comment on their efficacy. Among level-3 studies (43 subjects), one reported effective treatment with antiepileptics zonisamide and levetiracetam, but not TCAs. Another reported favorable response to morphine, ondansetron, and lorazepam but did not specify the actual number of patients receiving specific treatment. Among the level-4 case series (54 subjects), benzodiazepines, haloperidol, and capsaicin were reported as helpful. For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. High-quality evidence for pharmacologic treatment of CHS is limited. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.

Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use. Our objective is to summarize the available evidence on CHS diagnosis, pathophysiology, and treatment. We performed a systematic review using MEDLINE, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library from January 2000 through September 24, 2015. Articles eligible for inclusion were evaluated using the Grading and Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were abstracted from the articles and case reports and were combined in a cumulative synthesis. The frequency of identified diagnostic characteristics was calculated from the cumulative synthesis and evidence for pathophysiologic hypothesis as well as treatment options were evaluated using the GRADE criteria. The systematic search returned 2178 articles. After duplicates were removed, 1253 abstracts were reviewed and 183 were included. Fourteen diagnostic characteristics were identified, and the frequency of major characteristics was as follows: history of regular cannabis for any duration of time (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%). The pathophysiology of CHS remains unclear with a dearth of research dedicated to investigating its underlying mechanism. Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting. Cannabis cessation appears to be the best treatment. CHS is a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution with cessation of cannabis. The pathophysiology underlying CHS is unclear. Cannabis cessation appears to be the best treatment.

Cannabinoid Hyperemesis Syndrome: An Emerging Drug-Induced Disease

Cannabinoid hyperemesis is a relatively rare but significant adverse effect of chronic marijuana use characterized by severe, cyclic nausea, vomiting, and abdominal pain and marked by compulsive hot-water bathing for temporary symptom relief. A 37-year-old African American male with no significant medical history other than the habitual abuse of marijuana was admitted for intractable nausea, vomiting, and abdominal pain. With the exception of abdominal skin hyperpigmentation and scarring secondary to the direct application of heat through a heating pad, physical examination of the abdomen was unremarkable. Laboratory studies revealed a mild leukocytosis and acute renal dysfunction. All diagnostic examinations were found to be unremarkable or noncontributory to the patient's presenting state. Consistent with previous admissions, the patient's urine toxicology screening was found to be positive for marijuana. After several days of aggressive IV fluid hydration and as needed antiemetics and pain management, all laboratory studies and vital signs returned to baseline and the patient was subsequently discharged. Symptoms of cannabinoid hyperemesis resolve with cannabis cessation and recur when cannabis use is reinitiated, supporting an association between chronic use and cyclic vomiting. A Naranjo algorithm score of 5 revealed a probable incidence of cyclic vomiting associated with chronic cannabis abuse in our patient. Marijuana use, both legal and illegal, is becoming more prevalent in the United States. Given the nationwide increase in marijuana use for recreational and medical reasons, pharmacists and other health care providers should be aware of this interesting drug-induced phenomenon.

The Role of the Endocannabinoid System in the Brain-Gut Axis

The actions of cannabis are mediated by receptors that are part of an endogenous cannabinoid system. The endocannabinoid system (ECS) consists of the naturally occurring ligands N-arachidonoylethanolamine (anandamide) and 2-arachidonoylglycerol (2-AG), their biosynthetic and degradative enzymes, and the cannabinoid (CB) receptors CB1 and CB2. The ECS is a widely distributed transmitter system that controls gut functions peripherally and centrally. It is an important physiologic regulator of gastrointestinal motility. Polymorphisms in the gene encoding CB1 (CNR1) have been associated with some forms of irritable bowel syndrome. The ECS is involved in the control of nausea and vomiting and visceral sensation. The homeostatic role of the ECS also extends to the control of intestinal inflammation. We review the mechanisms by which the ECS links stress and visceral pain. CB1 in sensory ganglia controls visceral sensation, and transcription of CNR1 is modified through epigenetic processes under conditions of chronic stress. These processes might link stress with abdominal pain. The ECS is also involved centrally in the manifestation of stress, and endocannabinoid signaling reduces the activity of hypothalamic-pituitary-adrenal pathways via actions in specific brain regions, notably the prefrontal cortex, amygdala, and hypothalamus. Agents that modulate the ECS are in early stages of development for treatment of gastrointestinal diseases. Increasing our understanding of the ECS will greatly advance our knowledge of interactions between the brain and gut and could lead to new treatments for gastrointestinal disorders.

Cannabinoid hyperemesis syndrome masquerading as an eating disorder

The case of a 22 year old woman with cannabinoid hyperemesis syndrome (CHS) presenting as an eating disorder is described. The importance of recognizing chronic cannabis use as a cause of episodic vomiting is emphasized, given that CHS can be confused with self-induced purging and cyclic vomiting. This case was further complicated by the well-defined history of anorexia nervosa (binge-purge type), major depressive disorder, obsessive-compulsive disorder, migraine headache, and the initial denial of cannabis use. However, collateral history and a positive drug screen confirmed the diagnosis. The signs, symptoms and pathophysiological mechanisms of CHS are reviewed in light of clinical presentations that mimic eating disorder phenomenology complicated by addiction. Given the trend for increasing legalization of recreational marijuana as well as medical marijuana, CHS is an important and potentially complicating disorder that eating disorder clinicians need to be aware of. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:826-829).

Cyclic Vomiting Syndrome: A Functional Disorder

Cyclic vomiting syndrome (CVS) is a functional disorder characterized by stereotypical episodes of intense vomiting separated by weeks to months. Although it can occur at any age, the most common age at presentation is 3-7 years. There is no gender predominance. The precise pathophysiology of CVS is not known but a strong association with migraine headaches, in the patient as well as the mother indicates that it may represent a mitochondriopathy. Studies have also suggested the role of an underlying autonomic neuropathy involving the sympathetic nervous system in its pathogenesis. CVS has known triggers in many individuals and avoiding these triggers can help prevent the onset of the episodes. It typically presents in four phases: a prodrome, vomiting phase, recovery phase and an asymptomatic phase until the next episode. Complications such as dehydration and hematemesis from Mallory Wise tear of the esophageal mucosa may occur in more severe cases. Blood and urine tests and abdominal imaging may be indicated depending upon the severity of symptoms. Brain magnetic resonance imaging and upper gastrointestinal endoscopy may also be indicated in certain circumstances. Management of an episode after it has started ('abortive treatment') includes keeping the patient in a dark and quiet room, intravenous hydration, ondansetron, sumatriptan, clonidine, and benzodiazepines. Prophylactic treatment includes cyproheptadine, propranolol and amitriptyline. No mortality has been reported as a direct result of CVS and many children outgrow it over time. A subset may develop other functional disorders like irritable bowel syndrome and migraine headaches.

Cannabinoid hyperemesis syndrome: an important differential diagnosis of persistent unexplained vomiting

INTRODUCTION

Chronic nausea and vomiting have a detrimental impact on quality of life. When standard diagnostic investigations fail to provide a definitive diagnosis, patients are often attributed as having a functional gastrointestinal disorder such as cyclic vomiting syndrome. Cannabinoid hyperemesis syndrome (CHS) is a relatively recently described entity presenting with symptoms similar to cyclic vomiting syndrome.

METHODS

We carried out a retrospective cohort study of all patients attending a tertiary neurogastroenterology and secondary care gastroenterology clinic from 2013 to 2015. Data were obtained by review of clinical notes, letters and electronic patient records.

RESULTS

We identified 10 cases of CHS (five men, mean age 27 years, range 19-51), who hitherto had been labelled with a variety of alternative diagnoses. All patients had symptoms that were episodic and refractory to medical therapy. Patients had experienced symptoms for a mean of 19.3±11.09 months before diagnosis. The median length of cannabinoid use was 42 months (interquartile range: 15-81.8). Eight patients (80%) had a history of compulsive hot water bathing (hydrophilia). The patients had a median follow-up of 9.5 months (range 1-20), during which symptoms recurred in three patients who returned to regular cannabis use.

CONCLUSION

CHS is an underappreciated cause of recurrent nausea and vomiting and is frequently misdiagnosed. Healthcare providers should have a low index of suspicion for diagnosing CHS and the clinical history in such patients should routinely include direct questioning on cannabis use. The prognosis is very good upon cessation of cannabis intake.

Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy

BACKGROUND

Cannabinoid hyperemesis syndrome is a condition present among chronic cannabis users resulting in abdominal pain, intractable nausea and vomiting, and compulsive bathing behaviors. Given the recent legalization of marijuana in certain areas of the United States, the incidence of this condition may increase among pregnant women.

CASE

We report the case of a pregnant 28-year-old woman with multiple admissions for episodic nausea and vomiting resulting in Mallory-Weiss esophageal tears, dehydration, and abdominal pain who was noted to be showering compulsively during her hospitalizations. After an extensive workup for the etiology of her intractable nausea and pain, she was diagnosed with cannabinoid hyperemesis syndrome, which is treated simply with abstinence from marijuana use.

CONCLUSION

Cannabinoid hyperemesis syndrome should be considered in pregnant women with intractable nausea relieved by frequent hot bathing. By considering this diagnosis, extensive diagnostic testing can be avoided and the correct therapy, abstaining from cannabis use, can be recommended.

Cannabinoid Hyperemesis Syndrome: A Case Report and Literature Review

PURPOSE

As society has seen an increase in rates of cannabis abuse, largely related to an increase in legalization of the substance, a new clinical condition deemed cannabinoid hyperemesis syndrome has been recognized. This syndrome of idiopathic etiology is stimulated from chronic marijuana usage and produces cyclic episodes of nausea, vomiting, and epigastric pain often alleviated with compulsive hot water bathing.

PATIENT AND METHODS

A 42-year-old woman with a medical history of hypertension and myasthenia gravis was admitted to the authors' institution with a mandibular fracture.

RESULTS

Her laboratory work showed her to be extremely hypokalemic and with slight metabolic alkalosis. This was attributed to her reports of chronic vomiting, multiple times daily, over several weeks' duration. After her medical workup, cannabinoid hyperemesis syndrome was diagnosed and treated by fluid resuscitation, antiemetic medications, and marijuana cessation. After correction of her clinical symptoms and laboratory work, she was able to undergo open reduction and internal fixation of her mandibular fracture.

CONCLUSIONS

The dental community is well aware of the positive antiemetic and appetite-stimulating effects of marijuana, but they might be unaware of some of the paradoxical effects it can produce as shown in this newly documented clinical condition. As society is seeing an increase in the legalization of marijuana for medical and recreational usage in the United States, the dental community should be aware of this condition and its implications.

A rare case of cannabis hyperemesis syndrome relieved by hot water bathing

We present here a case of cannabinoid hyperemesis syndrome (CHS), which is an under-recognised disorder presenting in chronic abusers of cannabis typically as cyclical vomiting relieved by frequent hot baths. Increased awareness of CHS allows for earlier recognition by emergency departments, leading to prompter treatment and the prevention of future recurrence through cannabis cessation.

Cannabinoid hyperemesis syndrome

BACKGROUND

The purpose of this review is to describe cannabinoid hyperemesis syndrome (CHS), which is thought to be induced by long-term cannabis use, and provide clinical pharmacists with information to manage the hyperemetic phase of CHS.

METHOD

Published literature was searched and reviewed using PubMed.

RESULTS

CHS is characterized by intractable nausea and vomiting without an obvious organic cause and associated learned compulsive hot water bathing behavior. Patients often seek care in the emergency department (ED) for symptomatic relief.

CONCLUSION

CHS is potentially underrecognized and underdiagnosed in the ED, and it should be considered in the differential diagnosis in long-term cannabis use patients with CHS symptoms to avoid unnecessary extensive diagnostic workup including invasive radiologic imaging. Pharmacists have an important role in CHS recognition, education, and symptom management.

A case of cannabinoid hyperemesis syndrome caused by synthetic cannabinoids

BACKGROUND

Cannabinoid hyperemesis syndrome (CHS) was initially described in 2004 and remains an under-recognized clinical entity that occurs in chronic heavy marijuana smokers.

CASE REPORT

We describe the first report of CHS in an abuser of synthetic cannabinoids. CHS is thought to be caused by over-stimulation of the cannabinoid 1 receptor. The synthetic cannabinoids found in K2, Spice, and other commonly abused designer cannabinoids, including those used by our patient (JWH-018, JWH-073, JWH-122, AM-2201, and AM-694), are potent agonists of the cannabinoid 1 receptor.

CONCLUSION

Our report suggests that frequent habitual smoking of synthetic cannabinoids can cause cannabinoid hyperemesis syndrome.

Association of marijuana use and cyclic vomiting syndrome

Cannabis use has become one of the most commonly abused drugs in the world. 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. Reports describe marijuana use as high as 40–50% in male Cyclic Vomiting Syndrome patients. It is this interest in cannabis in the World, coupled with recognition of a cyclic vomiting illness associated with its chronic use that beckons a review of the most current articles, as well as a contribution from our own experiences in this area. The similarities we have demonstrated for both cannibinoid hyperemesis syndrome and cyclic vomiting make the case that cannibinoid hyperemesis syndrome is a subset of patients who have the diagnoses of cyclic vomiting syndrome and the role of marijuana should always be considered in the diagnosis of CVS, particularly in males.