Hospital Medicine - Journal of Hospital Medicine


Society of Hospital Medicine: 2013 RIV Abstract Issue, Volume 8,
May 2013 Abstract Supplement

Society of Hospital Medicine: 2013 Abstracts
National Harbor,Maryland May 16-19, 2013.


A UNIQUE CAUSE OF INTRACTABLE NAUSEA AND VOMITING: CANNABINOID HYPEREMESIS SYNDROME

Ivonne Pena 1 , Vince Faridani 2

1 Virginia Tech -— Carilion Clinic School of Medicine, Roanoke, VA
2 Virginia Tech—- Carilion Clinic School of Medicine, Roanoke, VA

Case Presentation:

Cannabis has gained worldwide recognition of its medicinal value hailed as “the aspirin of the 21st century.” It is common knowledge that cannabis has an antiemetic entity; proven to act as a partial 5HT1A agonist. However, less commonly discussed are the negative consequences of its use in high doses. The following case demonstrates a classic presentation of cannabinoid hyperemesis syndrome (CHS) that was undiagnosed for many years.

Discussion:

A 31-year-old woman with a history of gastroparesis, PTSD, and vomiting refractory to medical management presented to ED for the seventh time in less than a year with nausea and vomiting. She reported 4 days of vomiting with diffuse abdominal pain and an unintentional 5-poundweight loss in 1 month. Denies personal or family history of migraines. She reported daily cannabis use for the past 15 years associated with frequent hot showers lately 6 times daily. She was reluctant to disclose quantity for fear of authorities being notified. Physical exam revealed a cachectic, anxious-appearing woman with diffuse abdominal pain, no rebound or guarding. During her admission, she had frequent outbursts and became agitated multiple times, which induced vomiting. Also, she was found by nursing staff in the shower for hours. The day after admission her abdominal pain resolved, and patient was eager for discharge. She had 15 urine drug screens in past 5 years positive for cannabis. Prior workup of her hyperemesis included 27 abdominal x-rays, 9 abdominal CT scans, 9 abdominal ultrasounds, 2 gastric-emptying studies, and 2 endoscopies in the past 17 years. Pertinent findings included an abnormal gastric-emptying study showing 27% emptying and an EGD significant for lower esophageal erosions. She also had 17 admissions and 8 ED visits in the past 4 years alone. Her prior diagnoses included gastroparesis, gastritis, gastroenteritis, achalasia, and cyclic vomiting syndrome

Conclusions:

The clinical presentation of cannabis hyperemesis is classically identified as excessive cannabis use coupled with compulsive showering. Compulsive showering is a learned behavior, and although the mechanism is unclear, hot showers are the only effective mechanism to eradicate nausea and vomiting. Largely unknown to the general population, the antiemetic property of cannabis is true only at low doses. In high doses, cannabis can be proemetic with a 5HT1A antagonist effect. The principle active metabolite in cannabis is ?9-tetrahydrocannabinol (THC), which is stored in fat cells at high concentrations. Release of these metabolites is stimulated by high-stress states, which leads to the hyperemesis stage of cannabinoid hyperemesis syndrome (CHS). CHS is an underrecognized clinical diagnosis, and patients are often misdiagnosed with cyclic vomiting syndrome. This case demonstrates the importance of expanding hospitalist differentials when encountering patients with refractory intractable nausea and vomiting.

Author Disclosure: Ivonne Pena, none; Vince Faridani, none.

To cite this abstract, please use the following information:
Pena Ivonne,Faridani Vince; A UNIQUE CAUSE OF INTRACTABLE NAUSEA AND VOMITING: CANNABINOID HYPEREMESIS SYNDROME [abstract]. Journal of Hospital Medicine 8 Suppl 1 :872

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