Cannabinoid Hyperemesis Syndrome: A Case Report and Review of Pathophysiology

Abstract

A Caucasian male, aged 33 years, with a history of post-traumatic stress disorder, hypertension, and gastroesophageal reflux presented to a tertiary care center with a two-day history of severe nausea and intractable vomiting. The vomiting began with no identifiable precipitating factor, was bilious but nonbloody, and occurred as frequently as six times per hour. The patient reported abdominal pain and lightheadedness secondary to dehydration but denied any fever, coryza, change in bowel movements, or sick contacts.The patient had been experiencing similar episodes recurrently for the past 2 years, frequently associated with life stressors and requiring five previous hospitalizations. He had received an extensive work-up, including laboratory tests, kidney-ureter-bladder radiograph, computed tomography of the abdomen, abdominal ultrasound, gastric emptying study, and esophagogastroduodenoscopy. All tests returned negative for identifiable pathology, with the exception of electrolyte disturbances secondary to protracted emesis. As a result, the patient was diagnosed with cyclic vomiting syndrome.Notably, however, the patient had been an intermittent, recreational marijuana user for many years prior but had escalated to daily use over the past 2 years for symptom relief, citing the known antiemetic effects of cannabis. In addition, he described a compulsive pattern of bathing, stating that he often felt nauseated when having bowel movements and had discovered that transitioning directly from the toilet to a hot shower helped resolve his nausea. He described turning the shower temperature to a maximum, noting that it felt as though the hot water washed away his nausea. The patient often required several such showers per day and had been doing this for at least one year.His home medications included only citalopram and omeprazole. Family history was non-contributory. The patient drank two beers daily and had a history of Keywords: Cannabis; Cyclic vomiting; Hyperemesis; Marijuana Cannabis is the most widely used illicit drug in the United States, with lifetime prevalence of use estimated at 42% to 46%. The antiemetic properties of cannabis are well-known by the medical community and the general public; however, less well-recognized is the paradoxical potential for certain chronic users to develop hyperemesis. We describe in this case a patient with prior extensive work-up for nausea and vomiting and previous diagnosis of cyclic vomiting syndrome who presented with characteristic features of cannabinoid hyperemesis syndrome. We review the current literature for this condition and highlight potential mechanisms for its pathogenesis.

Cannabinoid hyperemesis syndrome

“…One suggested mechanism is that hot baths may increase body temperature enough to reverse the chronic hypothalamic cannabinoid receptor stimulation that may have caused nausea 1. Another mechanism states that, as splanchnic cannabinoid receptors mediate vasodilation in the gut, hot showers may divert blood to the periphery, resulting in ‘cutaneous steal syndrome’ 1 14…”

“…Additionally, it slows peristalsis and gastric emptying. Chronic, heavy cannabis use may cause cannabinoid receptors in the gut to override the effect of cannabinoid receptor stimulation in the brain, thereby leading to paradoxical hyperemesis 1 14…”

Cannabinoid Hyperemesis

“…When activated, both CB1 and CB2 as G-protein-coupled cannabinoid receptors inhibit adenylyl cyclase [18]. CB1 receptors, located mainly in the brain, appear to decrease the release of serotonin when activated [19, 20]. The transient receptor potential vanilloid 1 (TRPV1) receptor, located in the periphery along with certain areas of the CNS, may also play a role in CHS [21].…”

“…A summary of these studies appears in Table 2 [6, 7, 10, 19, 22, 54, 94, 97, 99, 101, 105, 111, 113, 114, 116, 117, 121, 126, 127, 132-173]. …”

“…The first is that cannabinoids contain psychoactive components which are hypothermic, and chronic users seek warmth to better regulate their core body temperature. Second, the body’s CB1 receptors are located in proximity to the body’s thermoregulation system in the hypothalamus, and warm water helps regulate body temperature [19, 101]. Third, it may be that warm water helps direct blood flow to the periphery and skin, away from the gut [102].…”