The Best in FOAM Education

Understanding Cannabinoid Hyperemesis Syndrome

February 10, 2020

A twenty-two year old male with a past medical history of diabetic ketoacidosis presents to the ED with a chief complaint of nausea and vomiting. Patient has had recurrent daily nausea “for a while” accompanied by colicky diffuse abdominal pain. He is unable to tolerate PO and has had multiple instances of emesis in the emergency department.  

 

On initial evaluation the patient is resting on the stretcher, but is moaning in pain. When you attempt to examine the abdomen, he begs you to not touch it. 

  

Vital Signs:

BP: 125/ 73  HR: 80   RR: 15   SPO2: 99% on RA 

 

Physical Exam:

  • General: alert, young male resting on the stretcher. Moaning in pain when you start to ask him questions

  • Skin: No rashes, abrasions or lesions. Well perfused  

  • CV: Regular rate and rhythm, no murmur, normal peripheral perfusion, no lower extremity edema 

  • Pulmonary: Clear lungs to auscultation bilaterally  

  • GI: Soft abdomen, diffusely tender to palpation. No localization on exam 

  • Neuro: A&O x3 

 

Initial blood glucose = 125 

  

Rest of workup: Labs were largely unremarkable, normal electrolytes, normal glucose, normal lipase. Upon chart review, patient had a normal CT abdomen and pelvis with contrast 1 week ago when he presented with similar symptoms.  

 

Further questioning: patient has been actively smoking marijuana multiple times per day. Has never tried to quit.  

  • IVF 

  • Morphine for pain control 

  • Zofran for nausea 

 

Patient was treated symptomatically for nausea, vomiting and abdominal pain. Placed on ED observation for symptomatic treatment; discharged  

 

Take Away #1

Cannabinoid Hyperemesis Syndrome:  

Nausea, vomiting, and abdominal pain are rarely seen in chronic marijuana users (>2 years) with daily use. Symptoms improved with warm showers. Symptoms resolve with cessation of marijuana use. Associated with cyclic vomiting syndrome.  

 

Pathophysiology: Unclear, but though to be associated with downregulation of cannabinoid receptors (CB1) with chronic use, inducing hypothalamic pituitary axis activation resulting in hyperemesis.  

 

Take Away #2 

History – it is important to ask a social history on every patient. After asking about daily marijuana use, we then inquired further and found that warm showers improve his nausea.   

 

Take Away #3 

Best treatments for cannabinoid hyperemesis syndrome:  

  • Marijuana cessation. Studies showed  improvement within 2-3 days of abstinence  

  • Topical capsaicin shows some improvement 

 

Dopamine antagonists: 

  • Metoclopramide, prochlorperazine, promethazine (act on dopamine receptors of chemoreceptor trigger zone) 

  • Droperidol: 1-2.5 mg IV 

  • Haloperidol

 

Other Interventions:  

  • Zofran 

  • Benzodiazepines

​Alison Rosser, MD is a current first year resident at Stony Brook Emergency Medicine.

  

References:

 

Edited by Bassam Zahid, MD

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