CASE PRESENTATION A 45-year-old man presented to the ED with a 5-day history of persistent nausea and vomiting that began abruptly. The symptoms had been constant since onset, resulting in very little oral intake. [ncbi.nlm.nih.gov]

The results of this initiative are presented here (Figure). [westjem.com]

The present case is that of a 29-year-old, 15-week pregnant woman who presented with symptoms suggestive of Cannabis induced panic disorder and Cannabis Hyperemesis Syndrome. [scitechnol.com]

This constellation of symptoms is not typically present in CHS, and patients do not abstain from cannabis [2, 3]. [hindawi.com]

However, subjects with acute cannabinoid intoxication are present more and more frequently in emergency departments (EDs) or clinics. [iem-student.org]

• Hypothermia

  Acting via hypothalamic CB1 receptors, THC induces dose-dependent hypothermia that is reversible upon administration of CB1 antagonists.9,10 Interestingly, the SSRI fluoxetine has been shown to modulate this action by attenuating hypothermia when fluoxetine [ncbi.nlm.nih.gov]

  In animal studies, cannabinoids have been shown to dysregulate the hypothalamus which correlates with hypothermia [14]. [hindawi.com]

  […] main hypotheses have been formulated to explain the relieve of symptoms by taking hot showers: Cannabinoids are believed to act on central CB1 receptors located in the preoptic area near the thermoregulatory centre located in the hypothalamus and cause hypothermia [auctoresonline.org]

  Delta9-tetrahydrocannabinol (Delta9-THC) prevents cerebral infarction via hypothalamic-independent hypothermia. Life Sci. 2007;80:1466-1471. [PubMed] 18. Sim-Selley LJ. [wjgnet.com]

• Epilepsy

  Epidiolex is a formulation of CBD that was approved by the FDA in 2018 for those with rare forms of epilepsy. [jphmpdirect.com]

  Low Dose Cannabinoid Consumption Causes DNA Damage Monday, October 29, 2018 569 Abstract Cannabidiol (CBD) and cannabidivarin (CBDV) are natural cannabinoids which are consumed in increasing amounts worldwide in cannabis extracts, as they prevent epilepsy [dalgarnoinstitute.org.au]

• Vomiting

  Cannabinoid Hyperemesis Syndrome (CHS) is characterized by severe vomiting and associated with heavy, long-term marijuana use. It is well-known among those who use marijuana that the drug can help relieve symptoms of nausea and vomiting. [therecoveryvillage.com]

  Are cyclic vomiting syndrome and cannabinoid hyperemesis syndrome the same thing? There is definite overlap between cyclic vomiting syndrome and CHS. [uwhealth.org]

  Per the Nelson Textbook of Pediatrics, cyclic vomiting syndrome is defined by having sudden onset episodes of vomiting, having at least four bouts of vomiting per hour, and often having 12 to 15 episodes of vomiting per day. [statpearls.com]

  Cyclical vomiting syndrome (CVS) causes similar symptoms. [weedmaps.com]

  Yet some chronic cannabis users may develop Cannabinoid Hyperemesis Syndrome (also sometimes called “Cannabis Hyperemesis Syndrome,” a condition that causes persistent vomiting, seemingly endless vomiting episodes, and severe abdominal pain. [remedycolumbia.com]

• Nausea

  This may explain its beneficial effect of reducing nausea and vomiting in our patient. [hindawi.com]

  Because cannabis is usually known to help keep nausea and vomiting at bay, these users may consume more cannabis once symptoms of CHS present. [weedmaps.com]

  However, many patients up their cannabis use, thinking the cannabis will cure their nausea and vomiting. It’s obviously paradoxical that cannabis (which many patients use to get rid of nausea and vomiting) could cause it others. [remedycolumbia.com]

  Patients often demonstrate the learned behavior of frequent hot bathing, which produces temporary cessation of nausea, vomiting, and abdominal pain. [eurekaselect.com]

• Abdominal Pain

  Physicians should have a high index of suspicion for this rare condition in patients with unexplained chronic abdominal pain and vomiting. This report provides useful information on a rare disease as the cause of chronic abdominal pain and vomiting. [wjgnet.com]

  He also reported abdominal pain associated with the nausea. The patient characterized his pain as “dull and achy” diffuse pain that was partially relieved with emesis. [ncbi.nlm.nih.gov]

  […] by episodes of morning sickness and abdominal pain. [analesdepediatria.org]

  Narcotic use should be avoided for management of abdominal pain. Patients should be counseled against marijuana use. [the-hospitalist.org]

  Opioids for abdominal pain should be used with caution due to the possibility of potentiating emesis as a side effect. [sites.kowsarpub.com]

• Recurrent Vomiting

  […] syndrome (CHS) is recurrent nausea, vomiting, and cramping abdominal pain due to cannabis use.[3] These symptoms may improve temporarily by taking a hot shower or bath.[1] Complications may include kidney failure, electrolyte problems, and skin burns [en.wikipedia.org]

• Epigastric Pain

  Main Article Content Abstract A 38-year-old male presented to the emergency department with severe acute-on-chronic abdominal pain. For the previous 20 years, he had experienced daily sharp epigastric pain with generalization to the entire abdomen. [cjgim.ca]

  Criteria essential for diagnosis include chronic marijuana use and then major features include cyclic N/V, epigastric pain, weekly use of marijuana, resolution of symptoms with cannabis cessation. [acep.org]

  The patient presented to the Gastroenterology Clinic due to cyclical epigastric pain associated with postprandial stomach heaviness, nausea and vomiting. [reed.es]

  Hyperemetic phase The hyperemetic phase is characterized by 24 to 48 hours of intense vomiting, epigastric or diffuse abdominal pain, sweating, and flushing. Vomiting occurs as frequently as four or more times per hour. [myamericannurse.com]

  Chronic cannabis use with hyperemesis, epigastric pain and conditioned showering behavior. Journal of Gastroenterology and Hepatology Research. 2012;1(6):107–110. [Google Scholar] 15. Nicolson SE, Denysenko L, Mulcare JL, Vito JP, Chabon B. [ncbi.nlm.nih.gov]

• Tachycardia

  In the literature, the arrhythmic effects are described together with cases of sinus tachycardia, sinus bradycardia, atrioventricular blockages, and cardiac arrest. [iem-student.org]

  Vital signs were significant for tachycardia and mild orthostatic hypotension. His abdomen was diffusely tender, soft, and nondistended. Urine toxicology is positive for delta-9-tetrahydrocannabinol (THC) only. [mdedge.com]

• Delusion

  Strong evidence now shows that smoking potent forms of the Class B drug increases the chance of psychosis, paranoid delusions and schizophrenia. [dalgarnoinstitute.org.au]

• Excitement

  It can be an exciting hobby for those with a predilection for math and statistics, in addition to those who want to earn some money from their sports expertise. [medium.com]

  As for why it afflicts some heavy users but not others, Verbora thinks it may come down to individual genetic differences in response to cannabis — much as the same joint can make one person excitable and another sedated. [globalnews.ca]

  The inflammation resulting from exposure to capsaicin is believed to be the result of the body's reaction to nerve excitement. [en.wikipedia.org]

• Peripheral Neuropathy

  neuropathies) and as an antispasmodic in multiple sclerosis, it is important to recognize this phenomenon’s risk factors and presentation in both emergency and primary care.[1][3][4] Etiology The physiology of vomiting is related to multiple organ systems [statpearls.com]

  […] may be applied in cream form for the temporary relief of minor aches and pains of muscles and joints associated with arthritis, backache, strains and sprains, often in compounds with other rubefacients.[11] It is also used to reduce the symptoms of peripheral [en.wikipedia.org]

Prior workup included abdominal radiographs, abdominal ultrasonography, abdominal CT, and gastric biopsy; all are normal. He has mild gastritis and esophagitis on esophagogastroduodenoscopy and mildly delayed gastric emptying. [mdedge.com]

Physicians should be aware of this unique cluster of symptoms to avoid misdiagnosis even after a protracted, invasive and costly workup. [wjgnet.com]

An initial workup showed a mild elevation of serum creatinine to 1.36 mg/dL (baseline is 1.10 mg/dL). [ncbi.nlm.nih.gov]

As a result, patients may undergo extensive negative workups for various other conditions, such as CVS, pancreatitis, and gastroparesis, which may mimic some symptoms of CHS. [uspharmacist.com]

Earlier recognition of this syndrome can help reduce unnecessary workups, doctor visits, and hospital admissions. The prognosis is very good with resolution of symptoms in most patients upon cessation of cannabis use. [sites.kowsarpub.com]

CHS patients frequently present to the emergency department and may require treatment for intractable emesis, dehydration, and electrolyte abnormalities. [ucdavis.pure.elsevier.com]

Conclusion An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. [westjem.com]

In an expert consensus treatment guideline, topical capsaicin 0.075% applied three times daily to the back of the arms or abdomen is recommended as a reasonable first-line treatment [17]. [clinmedjournals.org]

[Topical capsaicin cream in the treatment for cannabinoid hyperemesis syndrome]. Med Clin (Barc). 2016;147(11):517-518. Graham J, Barberio M, Wang Capsaicin cream for treatment of cannabinoid hyperemesis syndrome in adolescents: a case series. [epmonthly.com]

Research on the treatment of CHS is limited. [emdocs.net]

Long-term follow-up and prognosis of CHS have not been reported previously. [wjgnet.com]

Prognosis The prognosis is generally good as long as the diagnosis is made early and the patient commits to cannabinoid cessation. [statpearls.com]

She was subsequently lost to follow-up; thus we were unable to determine her long-term prognosis. 3. Discussion The pathophysiology behind cannabis-induced hyperemesis is not completely understood. [hindawi.com]

The prognosis is very good with resolution of symptoms in most patients upon cessation of cannabis use. More studies are needed for better understanding of the etiology, prevalence, and risk factors for developing this syndrome. References 1. [sites.kowsarpub.com]

[…] metoclopramide).[19] Acetaminophen has shown some benefit in case reports for alleviating headaches associated with CHS.[11] Opioids can provide some relief of abdominal pain, but their use is discouraged due to the risk of worsening nausea and vomiting.[10] Prognosis [en.wikipedia.org]

Once out of hospital, follow‐up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. [onlinelibrary.wiley.com]

It demands a finely detailed history to further tease out an etiology as well as directed treatments. [statpearls.com]

Etiology and Pathophysiology The pathophysiology remains unknown, but there have been multiple proposed mechanisms. Cannabinoids such as cannabidiol (CBD) at high doses may be proemetic, whereas low doses are antiemetic (3). [unboundmedicine.com]

To rule out other organic etiologies, the patient underwent abdominal computed tomography, which was unremarkable. Upper gastrointestinal endoscopy with gastric biopsies revealed no pathology. [cjgim.ca]

COMPLICATIONS OF CHS: Although CHS does not have a life threatening etiology, there are specific complications that can arise from the syndrome which include cutaneous burns from compulsive showering, AKI, electrolyte abnormalities, and dramatic weight [acep.org]

Knowledge of the epidemiology, pathophysiology, and natural course of Cannabinoid Hyperemesis Syndrome is limited and requires further investigation. [eurekaselect.com]

Epidemiology Incidence Cannabis use has been increasing with the legalization of medical and recreational use. In 2017, 30.5 million Americans reported current cannabis use (1). [unboundmedicine.com]

The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable [onlinelibrary.wiley.com]

However, it is likely that CHS is under-recognized and under-reported.2,4,5 CHS symptoms may be misattributed to cyclic vomiting syndrome,3 because 50% of patients diagnosed with cyclic vomiting syndrome report daily Cannabis use.6 There is no epidemiological [mdedge.com]

Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment. Clin Auton Res. 2018 Apr;28(2):203–9. Alaniz VI, Liss J, Metz TD, Stickrath E. Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy. [iem-student.org]

Objective: This aim of this review is to investigate the pathophysiology of CHS and evaluate the published literature on pharmacologic treatment in the emergency department. [ucdavis.pure.elsevier.com]

More clinical and pre-clinical research is needed to fully understand the underlying pathophysiology of this disorder and the negative consequences of prolonged high-dose cannabis use. [liebertpub.com]

Etiology and Pathophysiology The pathophysiology remains unknown, but there have been multiple proposed mechanisms. Cannabinoids such as cannabidiol (CBD) at high doses may be proemetic, whereas low doses are antiemetic (3). [unboundmedicine.com]

Pathophysiology The pathophysiology of CHS is not clearly understood, but research is underway. Many theories have been proposed to explain its occurrence. For example, THC is highly lipophilic. [journals.lww.com]

Knowledge of the epidemiology, pathophysiology, and natural course of Cannabinoid Hyperemesis Syndrome is limited and requires further investigation. [eurekaselect.com]

Can Cannabinoid Hyperemesis Syndrome Be Prevented? Unfortunately, CHS cannot even be predicted, let alone prevented. Most people who use cannabis heavily never develop the syndrome, so prevention is not necessary for most people. [therecoveryvillage.com]

Prevention You can prevent CHS by not using cannabis. References Adverse effects of cannabinoids. EBSCO DynaMed website. Available at: https://www.dynamed.com/drug-review/adverse-effects-of-cannabinoids. Updated October 28, 2018. [lahey.org]

Prevention You can prevent CHS by not using cannabis. [winchesterhospital.org]

Prevention You can prevent CHS by not using cannabis. References Cannabinoid hyperemesis syndrome. Cedars-Sinai website. Available at: https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cannabinoid-hyperemesis-syndrome.html. [wkhs.com]