Cannabinoid hyperemesis syndrome

A rare syndrome associated with long-term chronic cannabis use that is characterised by recurrent nausea and vomiting associated with abdominal pain has been reported. These symptoms have been reported to be alleviated temporarily by taking a hot shower or bath or more permanently by abstaining from cannabis use. Several case reports have been published across the world in the last five years and are listed in Table 1.

The first published cases of cannabinoid hyperemesis were reported by Allen and colleagues in 2004. This article spurred some interest in clinicians and several other case reports were published (see Table 1). However, the article also spurred some debate. Byrne and colleagues (2006) posited that alternative explanations (of symptoms) need to be sought and that the syndrome should not be accepted as being caused by cannabis without additional reports and other evidence . Although several case reports have been published, there remains to be any accepted explanation of symptoms.

Sontineni and colleagues (2009) have offered guidelines for the clinical diagnosis of cannabinoid hyperemesis. They suggest the essential features of: 1) history of regular cannabis use for years; 2) major clinical features of syndrome; 3) severe nausea and vomiting; 4) vomiting that recurs in a cyclic pattern over months; and 5) resolution of symptoms after stopping cannabis use. In addition diagnosis has supportive features of: 1) compulsive hot baths with symptom relief; 2) colicky abdominal pain; and 3) no evidence of gall bladder or pancreatic inflammation.

Various theories attempting to explain symptoms have been published. These theories fall into two themes; 1) dose dependent build up of cannabinoids and related effects of cannabinoid toxicity, and 2) the functionality of cannabinoid receptors in the brain and particularly in the hypothalamus (which regulates body temperature and the digestive system). Chang and Windish (2009) offer a summary of corroborating evidence for these theories; however, the authors note that the mechanisms by which cannabis causes or controls nausea and the adverse consequences of long-term cannabis toxicity remain unknown. The authors also conclude that organic disease should not be ruled out as a possible cause.

The largest case series to date was recently provided by Simonetto and colleagues (2012). Patient records from 2005 to 2010 from the Mayo Clinic, Minnesota, were screened for the presence of cannabinoid hyperemesis. Following screening, 98 patients met the criteria proposed by Sontineni and colleagues (2009). In addition, the authors provided follow-up data from 10 patients who were advised to stop using cannabis to relieve symptoms. Of these patients, 7 stopped using cannabis and 6 of these individuals reported relief of symptoms. This study expanded on Sontineni and colleagues diagnosis pattern with the major feature of weekly cannabis use and supportive (common but non-essential) features of 1) age younger than 50 years, 2) weight loss greater than 5 kilograms, 3) morning predominance of symptoms, 4) normal bowel habits, and 5) negative laboratory, radiographic and endoscopic test results. It was noted that the majority of patients developed symptoms within 1 to 5 years from onset of cannabis use (ranging from 4 months to 27 years).

Despite numerous case study reports, Byrne and colleagues (2006) call for further evidence and research is still pertinent with little knowledge regarding the causal mechanisms of the syndrome.

References

1. Alfonso, M.V., Ojesa, F. & Moreno-Osset, E. (2006). Cannabinoid hyperemesis. Gastroenterolog a y hepatolog a 29, 434-435.
2. Allen, J.H., De Moore, G.M., Heddle, R., & Twartz, J.C. (2004). Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse. Gut 53, 1566-1570.
3. Bagdure, S., Smalligan, R.D., Sharifi, H., & Khandheria, B. (2012). Waning effect of compulsive bathing in cannabinoid hyperemesis. The American Journal on Addictions 21, 184-185.
4. Boeckxstaens, G.E. (2005). Cannabinoid hyperemesis with the unusual symptom of compulsive bathing. Nederlands Tijdschrift Voor Geneeskunde 149, 1468.
5. Budhraja, V., Narang, T. & Azeez, S. (2008). Cannabinoid hyperemesis syndrome: Cyclic vomiting, chronic cannabis use, and compulsive bathing. Practical Gastroenterology September, 79-80.
6. Byrne, A., Hallinan, R. & Wodak, A. (2006). Cannabis hyperemesis causation questioned. Gut 55, 132.
7. Chang, Y.H. & Windish, D.M. (2009). Cannabinoid hyperemesis relieved by compulsive bathing. Mayo Clinic Proceedings 84, 76-78.
8. Chepyala, P. & Olden, K.W. (2008). Cyclic vomiting and compulsive bathing with chronic cannabis abuse. Clinical Gastroenterology and Hepatology 6, 710-712.
9. de Moore, G.M., Baker, J. & Bui, T. (1996) Psychogenic vomiting complicated by marijuana abuse and spontaneous pneumomediastinum. Australia and New Zealand Journal of Psychiatry 30, 290 294.
10. Donnino, M.W., Cocchi, M.N., Miller, J., & Fisher, J. (2011). Cannabinoid hyperemesis: A case series. The Journal of Emergency Medicine 40, e63-e66.
11. Fleig, S. & Brunkhorst, R. (2011). Hyperemesis and a high water bill. Zeitschrift Gastroenterologie 49, 1479-1481.
12. Lieb, M., Palm, U., Nicolaus, M., Reibke, R., & Baghai, T.C. (2011). Cannabinoid-induced hyperemesis. Psychiatrische Praxis 38, 147-149.
13. Martineau-Beaulieu, D. & Baillargeon, J.D. (2009). A lipase induced in error… Canadian Journal of General Internal Medicine 4, 7-9.
14. Miller, J.B., Walsh, M., Patel, P.A., Rogan, M., Arnold, C., Maloney, M., & Donnino, M. (2010). Pediatric cannabinoid hyperemesis: Two cases. Pediatric Emergency Care 26, 919-920.
15. Ochoa-Mangado, E.M., Jim nez G.M., Salvador V.E., & Madoz-G rpide, A. (2009). Cyclical hyperemesis secondary to cannabis abuse. GastroenterologIa y Hepatologia 32, 406-409.
16. Patterson, D.A., Smith, E., Monahan, M., Medvecz, A., Hagerty, B., Krijger, L., Chauhan, A., & Walsh, M. (2010). Cannabinoid hyperemesis and compulsive bathing: A case series and paradoxical pathophysiological explanation. Journal of the American Board of Family Medicine 23, 790-793.
17. Price, S.L., Fisher, C., Kumar, R., & Hilgerson, A. (2011). Cannabinoid hyperemesis syndrome as the underlying cause of intractable nausea and vomiting. Journal of the American Osteopathic Association 111, 166-169.
18. Roche, E. & Foster, P.N. (2005). Cannabinoid hyperemesis: Not just a problem in Adelaide Hills. Unpublished manuscript.
19. Roelofs, J., Vorel, S.K., Vorel-Havelkova, E., & Brombacher, P.J. (2005). Cannabinoid hyperemesis with the unusual symptom of compulsive bathing. Nederlands tijdschrift voor geneeskunde 149, 2376.
20. Sannarangappa, V. & Tan, C. (2009). Cannabinoid hyperemesis. Internal Medicine Journal 39, 777-778.
21. Schmid, S.M., Lapaire, O., Huang, D.J., J rgens, F.E., & G th, U. (2011). Cannabinoid hyperemesis syndrome: An underreported entity causing nausea and vomiting of pregnancy. Archives of Gynecology and Obstetrics 284, 1095-1097.
22. Simonetto, D.A., Oxentenko, A.S., Herman, M.L., & Szostek, J.H. (2012). Cannabinoid hyperemesis: A case series of 98 patients. Mayo Clinic Proceedings 87, 114-119.
23. Singh, E. & Coyle, W. (2008). Cannabinoid hyperemesis. The American Journal of Gastroenterology 103, 1048-1049.
24. Sontineni, S.P., Chaudhary, S., Sontineni, V., & Lanspa, S.J. (2009). Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse. World Journal of Gastroenterology 15, 1264.
25. Soriano-Co, M., Batke, M. & Cappell, M.S. (2010). 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. Digestive Diseases and Science 55, 3113-3119.
26. Stuijvenberg, M.P., Ramaekers, G.M. & Bijpost, Y. (2011). Cannabinoid hyperemesis syndrome.Nederlands Tijdschrift Voor Geneeskunde 155, 2880.
27. Wallace, D., Martin, A.L. & Park, B. (2007). Cannabinoid hyperemesis: Marijuana puts patients in hot water. Australasian Psychiatry 15, 156-158.
28. Watts, M. (2009). Cannabinoid hyperemesis presenting to a New Zealand hospital. The New Zealand Medical Journal 122, 116.
29. Wild, K. & Wilson, H. (2012). Cannabinoid hyperemesis. Emerging Medicine 29, 67-69.
30. Wolfhagen, F.H. (2005). Cannabinoid hyperemesis with the unusual symptom of compulsive bathing [Comment and Case Report]. Nederlands Tijdschrift Voor Geneeskunde 149, 1468-1471.

Written by Dr Peter Gates.