Cannabis Hyperemesis Syndrome: An Emerging Cause of Intractable Nausea & Vomiting

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1 Cannabis Hyperemesis Syndrome: An Emerging Cause of Intractable Nausea & Vomiting Morganna Freeman-Keller, DO ACP Associate Member University of Florida Internal Medicine Residency Program

2 Public Health Facts In 2009, there were 4.6 million drug-related ED visits nationwide - almost one million involving an illicit substance, with nearly 400,000 related to marijuana use 1.

3 Patient Summary A 36 year old male with a history of uncontrolled HTN, polysubstance abuse and medical noncompliance presented to our hospital with intractable abdominal pain, nausea and vomiting.

4 History of Present Illness He reported recurrent, severe vomiting with colicky abdominal pain but denied fever, chills, unusual food, or sick contacts. Social history was positive for cocaine and opiate use, as well as smoking marijuana up to four grams a day.

5 Physical Findings & Diagnostics He was noted to be hypertensive and reported missing BP medications because of vomiting. Physical exam showed mild abdominal tenderness but was otherwise unremarkable. CT of the abdomen showed no acute findings. Admission lab workup showed no leukocytosis, electrolyte derangement, elevation in transaminases, or lactic acidosis.

6 A Chronic Problem? Similar presentations in April and September 2011 Each time diagnosed with gastroenteritis and poorly controlled HTN due to not being able to keep down oral BP meds Recovered with IV fluids and was discharged home within 1-2 days

7 A Little Chart Snooping Multiple admissions since 2004 for the same complaints Numerous GI workups (8 CT scans of the abdomen, EGD, and gastric emptying study) failed to identify a cause of his symptoms Each time diagnosed with gastroenteritis UDS was repeatedly positive for cannabinoids.

8 Dude, is it somehow related?

9 Cannabis Hyperemesis Syndrome First described by a 2004 Australian case study 2 of 19 patients with cyclical vomiting, all with heavy marijuana use prior to the onset of illness Clinical features: Persistent nausea & vomiting Colicky abdominal pain Compulsive bathing or showering

10 The Role of THC Source: Drugs Today, 2006 Source: gut.bmj.com Delta-9-tetrahydrocannabinol, also known as THC, acts on CB1 receptors in the brain and gut Toxic accumulation of THC leads to CNS receptor downregulation and is a potent inhibitor of gut motility 3.

11 In Hot Water Curious clinical feature of frequent hot baths or showers Hypothalamus is rich in CB1 receptors and high THC levels appear to cause temperature dysregulation 4 Patients experience relief from frequent bathing; sources have noted the hotter the water, the better

12 Public Health Impact Recent literature 5 suggests it is poorly recognized and reported in clinic and emergency department settings, thus is an often-missed diagnosis resulting in repeated hospitalizations and unnecessary diagnostic testing.

13 A recent WHO survey 6 found the US is the world s leading per capita marijuana consumer, with approximately 15 million users Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys, 2008

14 Source: monitoringthefuture.org Youth Trends

15 Advancements in plant cultivation have resulted in higher THC-containing marijuana Source: University of Mississippi Potency Monitoring Project, whitehouse.gov

16 Correlation of THC and Hospitalizations Results from 2010 National Survey on Drug Use and Health, samsa.gov

17 Patient Outcome Repeated attempts to follow up on the patient were thwarted due to frequent showers Suspecting hyperemesis relating to marijuana abuse, he was treated with IV hydration and antispasmodic agents He recovered uneventfully and was counseled on the need to quit smoking marijuana if he hoped to improve his symptoms.

18 Emerging Data 7 papers listed in PubMed in the last 6 months, 2 dozen since initial case series Case reports in Pediatrics, GI, ObGyn, Emergency Medicine Treatment recommendations primarily supportive

19 Goal of Treatment: Abstinence

20 Key Points for Physicians Cannabis toxicity should be considered in patients seen for recurrent severe vomiting and abdominal pain which has no obvious structural or chemical etiology The rising prevalence of this syndrome is directly related to increasing use of marijuana products coupled with higher THC potency of domestic plants Early recognition of this syndrome will reduce unnecessary diagnostic testing and optimize patient care

21 References Data from Drug Abuse Warning Network (DAWN), 2. JH Allen, GM de Moore. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut 2004, November; 53(11): Darmani NA. Cannabinoid-Induced Hyperemesis: A Conundrum From Clinical Recognition to Basic Science Mechanisms. Pharmaceuticals Luther V, Yap L. A Hot Bath to Cure What Ails You. Acute Med. 2012;11(1): Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys, 2008