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cannabinoid/cannabis hyperemesis syndrome

Etiology: - drug adverse effect of marijuana Clinical manifestations: - episodic nausea/vomiting - abdominal pain - compulsive bathing - polydipsia - symptoms improve with - hot baths - cessation of marijuana use - phases of the syndrome [4] - prodromal phase: - nausea & abdominal pain, usually 30-90 minutes in duration - autonomic symptoms (sweating, hot or cold feeling, anxiety/panic) - emetic phase: - vomiting, abdominal pain - neurological symptoms - extreme thirst, polydypsia - recovery phase: - vomiting subsides, able to start or advance oral intake - resumption of regular activities - inter-episodic phase: - absent or minimal symptoms - 1/3 of patients have nausea or dyspepsia [4] Diagnostic criteria: - episodic vomiting >= 3 times a year - cannabis use (usually > 4 times weekly) for > 1 year prior to symptom onset - symptoms resolve after cannabis abstinence for >= 6 months or duration of >= 3 vomiting cycles* [4] * seems resolution of a syndrome not particularly useful as diagnostic criterion Laboratory: - comprehensive metabolic panel - serum amylase, serum lipase - pregnancy test [4] Special laboratory: - upper GI endoscopy as indicated [4] Radiology: - abdominal CT as indicated - neuroimaging if focal neurologic signs or symptoms [4] Differential diagnosis: - gastroparesis - pregnancy, - migraines - rumination syndrome - non-cannabis associated cyclic vomiting syndrome [4] Management: - marijuana cessation - prodromal phase (abortive medications) [4] - triptans, H1-antihistamines, or benzodiazepines. - emetic phase - antiemetics (benzodiazepines, promethazine, ondansetron, neuroleptics) - topical capsaicin cream applied to the upper abdomen - supportive therapies* - maintaining an empty stomach - resting in a quiet, dark room - inter-episodic phase - tricyclic antidepressants (mitriptyline, nortriptyline) - start 75-100 mg of amitriptyline - anticonvulsants - mitochondrial supplements (riboflavin, coenzyme Q10) - opioids should be avoided during all phases [4] Notes: - editorialist notes that this syndrome seems counterintuitive since Cannabis is used to treat nausea & vomiting [3]

Related

cannabinoid (spice, K2, AMB-FUBINACA)

General

drug adverse effect(s) of hyperemesis syndrome

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
  2. Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States. Dig Dis Sci. 2010 Nov;55(11):3113-9 PMID: 20130993
  3. Simonetto DA et al. Cannabinoid hyperemesis: A case series of 98 patients. Mayo Clin Proc 2012 Feb; 87:114 PMID: 22305024 - Mechoulam R. Cannabis - A valuable drug that deserves better treatment. Mayo Clin Proc 2012 Feb; 87:107 PMID: 22305022
  4. Rubio-Tapia A et al. AGA Clinical Practice Update on diagnosis and management of cannabinoid hyperemesis syndrome: Commentary. Gastroenterology 2024 May; 166:930. PMID: 38456869 https://www.gastrojournal.org/article/S0016-5085(24)00127-6/fulltext
  5. Frazier R, Li BUK, Venkatesan T. Diagnosis and Management of Cyclic Vomiting Syndrome: A Critical Review. Am J Gastroenterol. 2023 Jul 1;118(7):1157-1167 PMID: 36791365 Review. https://journals.lww.com/ajg/fulltext/2023/07000/diagnosis_and_management_of_cyclic_vomiting.16.aspx
  6. Borgundvaag B, Bellolio F, Miles I et al Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024 May;31(5):425-455. PMID: 38747203 https://onlinelibrary.wiley.com/doi/10.1111/acem.14911