CYCLICAL VOMITING ENSHROUDED IN A CLOUD
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1 CYCLICAL VOMITING ENSHROUDED IN A CLOUD
2 HPI Ø39 year old man ØEpigastric pain X 3 days Recurrent for the past 2 years (@least 2x/month) Dull then sharp, 8/10 Non radiating,constant ØAssociated with nausea and vomiting
3 ROS Ø appetite but no weight loss ØNo change in bowel movements ØNo fever, chills or night sweats ØNo chest pain, palpitations or respiratory symptoms
4 PMH Ø Recurrent abdominal pain ØRecurrent vomiting Ø Knee surgery and vasectomy ØMeds Vitamin C
5 FSH Ø Heart disease (mother) ØSH Smokes a few cigarettes daily; smokes marijuana
6 Physical Examination ØVS: BP149/80, HR 77, RR 18, O2 sat 98%,T 98 F ØChest: Clear to auscultation ØHeart: S1 S2 normal No murmurs ØAbdomen: Epigastric tenderness No guarding or rebound normal bowel sounds ØExtremities: no Pedal edema ØCNS - no focal deficits
7
8 LABS ØCBC; WBC 15.5 Hb 14 Hct 43 Plt 273 ØBMP: Na 142 K 4.4 Cl 105 CO2 23 BUN 17 Creatinine 0.8 ØHepatic: AST 42 ALT 38 AlkP 72 Bili 0.65 Alb 5.0 ØAmylase and Lipase normal ØUA Normal
9 OTHER WORKUP ØEKG-normal ØCT scan of abdomen and pelvis normal
10 ????
11 Gastritis/GERD Peptic Ulcer disease Biliary Colic/stone Cyclical vomiting syndrome Inferior wall MI LL Pneumonia Porphyria or Lead Poisoning Pancreatitis Gastric malignancy Splenic abscess/infarction Intestinal obstruction Differentials
12 Ruling In/Out Gastritis/GERD Peptic Ulcer disease Biliary Colic/stone Cyclical vomiting syndrome Inferior wall MI LL Pneumonia Porphyria or Lead Poisoning Pancreatitis Gastric malignancy Splenic abscess/infarction Intestinal obstruction
13 Ruling In/Out Gastritis/GERD Peptic Ulcer disease Biliary Colic/stone Cyclical vomiting syndrome Inferior wall MI LL Pneumonia Porphyria or Lead Poisoning Pancreatitis Gastric malignancy Splenic abscess/infarction Intestinal obstruction
14 Ruling In/Out Gastritis/GERD Peptic Ulcer disease Biliary Colic/stone Cyclical vomiting syndrome Inferior wall MI LL Pneumonia Porphyria or Lead Poisoning Pancreatitis Gastric malignancy Splenic abscess/infarction Intestinal obstruction
15 Ruling In/Out Gastritis/GERD Peptic Ulcer disease Biliary Colic/stone Cyclical vomiting syndrome Inferior wall MI LL Pneumonia Porphyria or Lead Poisoning Pancreatitis Gastric malignancy Splenic abscess/infarction Intestinal obstruction
16 HOSPITAL COURSE ØNexium, Ultram, Zofran ØGI consulted EGD ØNausea alleviated by warm showers ØPrior to D/C Medical records were obtained from two other hospitals Recurrent admissions (abdominal pain) EGDs (normal).most recently a month prior CTs/HIDA - normal Porphyria screen negative
17
18 Cannabinoid Hyperemesis Syndrome
19 History of Marijuana Cannabis plant 483 known compounds Incl. THC 84 cannabinoids 2737 BC Chinese emperor Shen Nung Rheumatism Gout Malaria, and absent-mindedness Middle East Hashish
20 Marijuana In America Introduced in the 16 th Century - Spanish Listed in the Pharmacopeia ( ) Controlled substance Act 1970 Marijuana Heroin and LSD Schedule I Gateway drug theory Compassionate Use Act 1996 Medical Marijuana 31 states with Medical Marijuana laws in place
21 Marijuana in America
22 CB1 and CB2 receptors
23 CNS Heart Endothelial Liver Hematopoietic GIT Testes Lung Kidney CB1 and CB2 receptors
24 Marijuana in Medicine Preclinical/animal studies Antitumor activity (Colon, HCC and Breast) Clinical Trials (human) Rx of cancer none Side effects of cancer and cancer therapy Stimulating appetite Pain relief Anxiety and sleep Intraocular pressure seizures FDA approved Dronabinol Nabilone Epidiolex Cannabis not FDA approved
25 Cannabinoid Hyperemesis Syndrome Cannabinoid hyperemesis syndrome is a recently described condition that was first penned in the literature in Numerous cases have since been described, all with the unifying features of cyclical vomiting in the absence of organic etiology in chronic cannabis users. Other important features are abdominal pain and improvement of symptoms with cessation of cannabis use.
26 Cannabinoid Hyperemesis Syndrome The use of marijuana-derived compounds as antiemetics is well documented. It is now known that the cannabinoids can also exert opposing effects on the emesis response. A disruption in the balance between pro- and antiemetic effects may explain the paradoxical vomiting seen in cannabinoid hyperemesis syndrome. Alteration in the hypothalamic regulation of body temperature may explain the compulsive hot showering seen in many patients.
27 Cannabinoid Hyperemesis Syndrome While the exact underlying pathophysiology is unclear, various mechanisms have been proposed which are thought to involve the CB1 receptor. Cyclic vomiting syndrome remains the primary differential consideration. Both conditions are characterized by similar symptoms. Long term follow up is necessary to clearly separate the two, as complete resolution of symptoms after cannabis cessation is a feature that is unique to CHS.
28 Management Treatment is supportive as well as educational. During the hyperemetic phase, supportive treatment involves management of abdominal pain, fluid replacement, and prevention of vomiting. Various classes of anti-emetics, such as D2 and H1 receptor antagonists, have been tried with minimal or no effect. Patients commonly experience temporary relief from compulsive hot showers or baths and permanent relief from cessation of cannabis use
29 Conclusion As the prohibition on marijuana use is progressively lifted, we will continue to see an increase in its usage. This will no doubt result in an increase in the number of cases of CHS. Clinicians should be aware of this condition and have a high level of suspicion in patients who present with hyperemesis and history of concurrent cannabis use.
30 References 1. J.H. Allen, G.M. de Moore, R. Heddle et al. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse; Gut, 53 (2004), pp Sontineni S.P., Chaudhary S., Sontineni V., Lanspa S.J. Cannabinoid hyperemesis syndrome: clinical diagnosis of an under recognized manifestation of chronic cannabis abuse. World J Gastroenterol. 2009; 15(10): Jonathan A. Galli, Ronald Andari Sawaya, Frank K. Friedenberg Cannabinoid Hyperemesis Syndrome Curr Drug Abuse Rev December; 4(4): D.A. Patterson, E. Smith, M. Monahan et al. Cannabinoid hyperemesis and compulsive bathing: a case series and paradoxical pathophysiological explanation; J Am Board Fam Med, 23 (2010), pp Y.H. Chang, D.M. Windish. Cannabinoid hyperemesis relieved by compulsive bathing; Mayo Clin Proc, 84 (l) (2009), pp
31 References 6. D.A. Simonnetto, A.S. Oxentenko, M.L. Herman et al. Cannabinoid hyperemesis: a case series of 98 patients; Mayo Clin Proc, 87 (2) (2012), pp Galli,JA; Sawaya,RA; Friedenberg,FK Cannabinoid Hyperemesis Syndrome. Current Drug Abuse Reviews. Dec (4): E.A. Wallace, S.E. Andrews, C.L. Garmany, M.J. Jelley. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm; South Med J, 104 (9) (2011), pp Hickey JL, Witsil JC, Mycyk MB. Haloperidol for treatment of cannabinoid hyperemesis syndrome. Am J Emerg Med Jun; 31(6): Blumentrath,CG; Dohrmann,B; Ewald,N. Cannabinoid Hyperemesis and the Cyclic Vomiting Syndrome in adults: recognition, diagnosis, acute and long-term treatment.germed Sci. 2017; 15: Doc 06
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