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:
- Muscle spasm/weakness
- Brain swelling
- Seizures
- Kidney failure
- Heart rhythm abnormalities
- 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?
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