Cannabinoid Hyperemesis Relieved by Compulsive Bathing

doi:10.4065/84.1.76

Mayo Clinic Proceedings

Volume 84, Issue 1, January 2009, Pages 76-78

https://doi.org/10.4065/84.1.76 Get rights and content

Cannabinoid hyperemesis is a clinical syndrome characterized by repeated vomiting and associated learned compulsive hot water bathing behavior due to long-term marijuana use. Research has indentified type 1 cannabinoid receptors in the intestinal nerve plexus that have an inhibitory effect on gastrointestinal motility. This inhibitory effect may lead to hyperemesis in marijuana users. The thermoregulatory role of endocannabinoids may be responsible for the patient's need to take hot showers. We report 2 cases of cannabinoid hyperemesis that demonstrate this unusual adverse effect of marijuana use.

Section snippets

Case 1

An obese 25-year-old woman who was a long-term cannabinoid user presented to the emergency department with nausea, vomiting, and abdominal pain that worsened for several days. During the previous 5 years, the patient had noted intermittent episodes of similar symptoms, each lasting about a week and often requiring hospitalization for dehydration. Her symptoms were refractory to all types of antiemetic medications and only responded to prolonged hot showers, some lasting 6 hours or more. Her

DISCUSSION

Cannabinoid hyperemesis, an often unrecognized adverse effect of marijuana use, is characterized by repeated vomiting without an obvious organic cause and learned compulsive bathing behavior. The symptoms resolve in 24 to 48 hours with conservative management and cessation of marijuana use. Both patients about whom we report here exhibited these outcomes.

The mechanism of cannabinoid hyperemesis is unknown. Marijuana, whether taken as a pill or smoked, has been used to treat chemotherapy-induced

CONCLUSION

The toxicity and adverse consequences of long-term marijuana use are still under investigation. Marijuana may either cause or control nausea and vomiting, but the mechanism is unknown. Given the prevalence of illicit marijuana use and the increased popularity of marijuana use for medicinal purposes, these paradoxical effects require further investigation. This case report aims to raise awareness of the potential adverse effects of marijuana use and the importance of obtaining a thorough patient

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Cyclic vomiting syndrome (CVS) is a disorder of gut–brain interaction (DGBI) and represents 3%–14% of cases of unexplained chronic nausea and vomiting. The condition was first characterized in children but is now known to affect all age-groups. The diagnosis is frequently delayed and is often misdiagnosed which causes significant health-related and personal burdens. CVS is often associated with other conditions, especially migraine headaches with which it likely shares common pathophysiology in many instances. Other autonomic, gastrointestinal, and behavioral symptoms occur in concert with emesis. There are four phases in CVS—prodromal, acute emetic, recovery, and inter-episodic—which vary in duration from patient to patient. Common triggers for CVS flares include stress and menstrual periods. The diagnosis of CVS is made clinically using criteria generated by consensus working groups from the Rome Foundation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
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Cannabinoid hyperemesis syndrome (CHS) presents after prolonged use of cannabis with stereotypical episodes of emesis similar to cyclic vomiting syndrome (CVS). The best accepted treatment of CHS is abstinence from cannabis intake; recurrent CHS is reported after restarting its use. Initial management to abort CHS episodes involves supportive measures, including intravenous fluids. The current belief that antiemetic therapies employed for CVS have little utility in CHS is based on limited study. Measures specifically reported to relieve acute CHS attacks include hot showers, cutaneous application of capsaicin, and intravenous administration of benzodiazepines and the dopamine antagonist haloperidol. The benefits of agents accepted for CVS prophylaxis have not been defined for CHS. Special considerations are given for pediatric CHS and for pregnant women with CHS.
Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis
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Citation Excerpt :
A number of other agents, such as haloperidol and benzodiazepines, have shown to provide some benefit for CHS, as well [11]. Interestingly, hot showers or baths have also been noted to relieve symptoms of CHS by potentially counteracting transient receptor potential vanilloid 1 (TRPV1) desensitization and the hypothermic effect of cannabis on cannabinoid type 1 (CB1) receptors in the hypothalamus [12]. An alternative treatment modality to these agents includes topical capsaicin.
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.
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.
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.
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.
Pediatric Cannabinoid Hyperemesis: A Single Institution 10-Year Case Series
2021, Journal of Adolescent Health
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.
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.
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.
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.
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Gastroparesis presents with upper gastrointestinal symptoms of nausea, vomiting, bloating, abdominal discomfort, early satiety, and postprandial fullness. While the established definition of gastroparesis rests on gastric emptying delay without mechanical obstruction, patients may not always have delayed gastric emptying as the disease is chronic but can also wax and wane. A lack of widely used standards for assessing delayed gastric emptying may account for these findings. Gastroparesis has varying symptoms, stemming from differences in its underlying etiology. These exist not only from the main three etiologies of gastroparesis—idiopathic, diabetic, and postsurgical—but also from differences amongst its less well-known and less common etiologies. Additionally, patients with disorders of brain-gut interaction such as functional dyspepsia may report symptoms similar to gastroparesis that stem from syndromes entirely separate from gastroparesis itself. This chapter explores the full spectrum of these diseases and disorders from which patients report symptoms of gastroparesis.

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CASE REPORTCannabinoid Hyperemesis Relieved by Compulsive Bathing

Section snippets

Case 1

DISCUSSION

CONCLUSION

Brain Res

Prevalence of marijuana use disorders in the United States: 1991-1992 and 2001-2002

JAMA

Cannabis use disorders in the USA: prevalence, correlates and co-morbidity

Psychol Med

Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse

Gut

Cannabis. Micromedex Healthcare Series

Drug information L to Z: Tetrahydrocannabinol and cannabidiol

Nausea, vomiting, and indigestion

Metoclopramide: pharmacology and clinical application

Ann Intern Med

CASE REPORT
Cannabinoid Hyperemesis Relieved by Compulsive Bathing