Investigating Cannabinoid Hyperemesis Syndrome

Not too long ago, I took care of an 18 year old young man. He was admitted under a diagnosis that I had never seen before, "Cannabinoid Hyperemesis Syndrome". I was fascinated and wanted to learn more about this syndrome. So we will learn together exactly what defines this syndrome, the causes, and what the treatments are.

Investigating Cannabinoid Hyperemesis Syndrome

Knocking on the door, I paused a second before opening it. Inside were two people, the young man who was the patient, and his mother. I introduced myself and began asking the usual questions for esophagogastroduodenoscopy/ colonoscopy patients. Did you finish your prep? Did you eat any solid food yesterday? He passed my test, so then after checking his armband, he hopped on the stretcher and off we went. As I pushed the stretcher to my department, he had a few questions of his own. How long will this take? Will I feel anything?

During our conversation both to the department and back to his room, I noticed some unusual words, and some not so unusual such as hot showers, how many drugs he had done and when, and pot smoking. Some of the conversation seemed cryptic between mother and son. I didn't participate in that part of the exchange, but listened.

Both exams showed normal results, and when I got report from my fellow GI nurse, she mentioned pot smoking, and in a whisper insinuated that there was more to the story than the mother knew. Once he was settled back in his room, I went to the nurses station to give report and that is when I found out about his diagnosis, Cannabinoid Hyperemesis Syndrome (CHS). The other nurse was just as interested as I, and she told me that it was basically when too much pot was smoked that they got severe abdominal cramps and vomiting,and then took long hot showers to relieve the cramping. That's when I decided I needed more information about this.

According to the article, "Cannabinoid Hyperemesis Syndrome", it is a rare situation that advances to repeated and very severe spells of vomiting. It is seen only in patients who use cannabis daily on a long term basis. The marijuana in these cases works paradoxical of what it usually does. Normally, it decreases nausea and vomiting, however in these cases, the opposite is true.

Marijuana is harvested from the dried leaves, seeds, and flowers of the Cannabis sativa plant. The chemicals in the plant bind to the brain and cause the "high" felt by the users. But not only does it bind to the brain, but also to the digestive tract. Long term users feel the effects of the drug because it affects the length of time it takes to empty the stomach as well as decreasing the pressure of the lower esophageal sphincter, leading to the emesis. Certain receptors in the brain stop responding to the drug which leads to hyperemesis.

Researchers are not sure why some patients get the syndrome while other do not. During these bouts of hyperemesis, patients can see blood from a tear in their esophagus called a Mallory Weiss tear. Whenever we see blood, it is scary and further investigation is needed to make sure there isn't something more serious wrong.

3 Stages of Cannabinoid Hyperemesis Syndrome (CHS)

Prodromal Phase

Early morning nausea and abdominal pain, most keep a normal eating habit during this phase, and use more marijuana to help the nausea. This phase can last from months to years.

Hyperemetic Phase

Ongoing nausea, repeated vomiting, abdominal pain, symptoms of dehydration, and decreased food intake, weight loss. Vomiting is intense and the patient is overwhelmed. They take multiple hot showers during the day and it eases the nausea. Most seek medical attention during this phase.

Recovery Phase

The symptoms go away only if the patient stops using the drug. Normal eating is resumed and this phase can last days to months. The symptoms usually return if the patient smokes marijuana again.

The symptoms of CHS are very similar to other issues, and because of it's relatively new diagnosis, it can often be misdiagnosed. The treatment for CHS is IV fluids for dehydration, antiemetic medications, pain medication, PPIs, and ironically frequent hot showers. To recover completely, the patient must stop the use of marijuana.

CHS Complications:

  1. Muscle spasm/weakness
  2. Brain swelling
  3. Seizures
  4. Kidney failure
  5. Heart rhythm abnormalities
  6. Shock

If you see patients with repeated admissions due to severe vomiting, consider CHS. Patients often do not admit they smoke pot to their doctor, however, it can save them possibly years of misdiagnosis and prevent further health problems. Have you had any patients with CHS?

Please share your story.

References

"Cannabinoid Hyperemesis Syndrome". N.d. Saint Lukes Health System. 17 May, 2018. Web.
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Brenda F. Johnson

About Brenda F. Johnson, MSN

Gastrointestinal Columnist
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My service sees CHS fairly frequently. You'd think people would figure out that smoking the pot is making their nausea worse instead of better (since that's the rationale they offer for why they're smoking so much pot), but, no ... And, boy howdy, they sure do not want to hear that laying off the pot is what they need to do to quit throwing up all the time.

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Specializes in Nurse Leader specializing in Labor & Delivery.

We see it a lot in prenatal women.

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Huh, interesting thanks for the knowledge!!!

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Specializes in allergy and asthma, urgent care.

Saw it in a patient that was not a heavy user. I did some research, and found it can also occur in light users who cannot clear the CBD molecules from their system (perhaps due to a genetic mutation), so it accumulates and causes the above mentioned symptoms. Treatment is an IV cocktail of Ativan, Zofran, and Haldol. Symptoms will return if the patient uses the drug again.

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I was first introduced to this as a nursing student in California. The doctor was familiar with the patient who had numerous hospitalizations for the same reason. I had never heard of this "downside" of cannabis before this patient, and I did read up on as much as I could (there was very little information available about it at the time.)

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Specializes in Emergency Department.

I first saw this about 3 years ago and one of the more interesting things is that the typical antiemetics only work for a little while. Since then, any time that I have a patient whose complaint includes nausea and vomiting, especially for several days, I ask about marijuana use. Even if I get a "no" answer to their use of marijuana, I do a quick teaching about marijuana and this syndrome, basically to the effect that sometimes marijuana use can have a paradoxical effect of causing nausea/vomiting which is what it usually stops and the only truly effective (and lasting) treatment for this is to stop using marijuana.

I'm not trying to keep a patient from using marijuana to stop the vomiting, rather to educate that marijuana use doesn't always relieve the problem and therefore to be careful about using it.

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I've seen quite a few cases in my ER. The way the doctor explains it best is that the patient is allergic to MJ. Not quite true but pt's understand allergy and to avoid repeated exposure. Haldol works *wonders* on this! More then the typical antiemesis medications at least.

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Specializes in ICU.

I've had several patients diagnosed with this syndrome.

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Specializes in Adult Internal Medicine.

See it quite often in my practice, the key to the diagnosis is hot showers because otherwise the vast majority of patients will insist that the marijuana actually helps their nausea (briefly) rather than being the cause of the problem. In adults, often this is mischaracterized as CVS.

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Specializes in Urgent Care, Oncology.

My brother-in-law suffers from this and refuses to quit smoking. He believes it is made up and that the marijuana is actually helping him. He was tested for autoimmune disorders and it came back that he is sensitive to gluten. However, he tells everyone that he has Celiac disease and that's what causes this.

The showers, let me tell you - that was the giveaway. He showers so much that he runs out of hot water and then goes over to my in-law's house and runs down their hot water heater. He moans and groans and screams out in pain. Two of the local ERs will see him when he's having an episode (obviously) but they won't give him any pain medication or antiemetics. He's a nurse's worst nightmare when he goes there with this.

He's been confronted on the issue and is unwilling to accept it. I remember finding one of the original articles that was written on it about two years ago and that's when I started putting the pieces of the puzzle together. He can't work "normal" jobs because he misses work when he has one of his vomiting spells. It has made things very tense in our family, to say the least.

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Specializes in Emergency Department.

Interesting topic & article, are your sources for this information available?

Quote
Marijuana is harvested from the dried leaves, seeds, and flowers of the Cannabis sativa plant. The chemicals in the plant bind to the brain and cause the "high" felt by the users. But not only does it bind to the brain, but also to the digestive tract. Long term users feel the effects of the drug because it affects the length of time it takes to empty the stomach as well as decreasing the pressure of the lower esophageal sphincter, leading to the emesis. Certain receptors in the brain stop responding to the drug which leads to hyperemesis.

The inflorescence ("flowers" or "buds") are the drug-containing portion of the cannabis sativa plant, while the leaves contain significantly less psychoactive chemicals and the seeds have no significant drug content. The chemicals are primarily cannabinoids, i.e. THC, and bind to human CB-1 and CB-2 G-protein coupled receptors, as does endogenous anandamide. These receptors help regulate nausea/appetite, pain, and inflammatory response. There are also many additional compounds in cannabis that are purported to provide a synergistic and/or additive effect to the cannabinoids.

Whether or not plant-based cannabinoid or synthetic cannabinoid mimetics are useful as medications is not yet the issue. The extensive anecdotal evidence as well as the rare clinical evidence warrants further study of these compounds and receptor systems. So many users (patients?) chronically consuming something we (clinically/scientifically) know very little about!

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