The anti-munchies: cannabinoid hyperemesis syndrome

August 25, 2011, 11:14 pm

★★★½☆

Cannabinoid Hyperemesis Syndrome: Literature Review and Proposed Diagnosis and Treatment Algorithm. Wallace EA et al. Southern Med J 2011 Sep;104:659-664.

Abstract

Last month we reviewed a diagnosis TPR had not heard of before: narcotic bowel syndrome. This paper describes another diagnosis new to us: cannabinoid hyperemesis syndrome (CHS). Although cannabis has well-known anti-emetic properties, frequent chronic use can produce paradoxical nausea and vomiting.  This may have something to do with alterations of the cannabinoid type I (CB1) receptors.

Hallmark of CHS are:

  • chronic use of marijuana (usually daily for more than a year)
  • recurrent episodes of severe nausea and vomiting
  • abdominal pain
  • relief of symptoms from a hot bath or shower, leading to compulsive bathing

It is not known why exposure to hot water in a bath or shower relieves symptoms of CHS, but the extremes to which patients may go to seek relief this away can be astounding. Baths or showers can last for several hours and be repeated multiple times in a day. In one case described in the medical literature (there have been a total of 31 so far), the patient was said to have spent 300 or 365 days a year in the bath. (I would like to see his water heating bill.) Patients usually have been seen multiple times in emergency rooms and other healthcare facilities, and often have undergone extensive workup for recurrent symptoms.

Treatment involves rehydration and cessation of exposure to cannabinoids.  The authors hypothesize that with medical marijuana becoming more freely available, we may be seeing more cases of CHS.

[Addendum August 27, 2011: On further reflection, I decided that this article deserved an upgrade from TPR‘s original rating of 3 skulls.]

10 Comments:

  1. Domhnall Says:

    Although there are only a small number of cases in the literature, in my experience in Australia in several centres, this is a fairly common aetiology for recurrent presenting abdominal pain. The showering is indeed a hallmark, and several of the twenty or so cases I have managed have presented to ED WHEN THEIR HOT WATER RUNS OUT AT HOME! Not uncommon to arrive at their cubicle to assess them, and they are not there, because they have gone straight to the shower! So, ask insistently about marijuana use in your frequent flyers with abdominal pain, especially if they have fairly dramatic dry retching behaviour which seems to settle when they fall asleep, and recurs on waking, and if they spend much of their ED time in or asking for a shower!

  2. Leon Says:

    Domhnall:

    Thanks for sharing your experience! I’m not surprised that the 31 cases of cannabinoid hyperemesis syndrome reported in the literature seriously underestimate the problem. I doubt many physicians have heard of the diagnosis (I hadn’t) and would guess that it is often missed.

  3. Domhnall Says:

    You aren’t oging to believe this, but I arrived on shift 20 minutes ago to the characteristic dramatic retch mentioned, a compulsive showering story, and lo and behold, years of THC use! Denial of any possibility that THC may be the cause is a common feature too!!!

  4. Leon Says:

    Domhnall:

    Amazing! Some of the articles about cannabinoid hyperemesis syndrome suggest possible approaches to addressing marijuana use with patient in whom CHS is on the differential. Either first explaining the possible connection between cannabinoids and chronic vomiting, and they asking if he/she is a user; or asking “Have you ever tried marijuana to deal with this problem?” It seems to me the first way would work better.

  5. Heather Says:

    My husband has been hospitalized numerous times from this syndrome and been diagnosed with it after I saw an article from mayo clinic and showed it to his gastro doctor. Anyways, he is so addicted to it that after he quicks for a few days he feels better and then smokes again and start to feel sick and literally lays in the shower almost 24 hrs a day. One time he had 2nd degree burns and when the hot water ran out he begged me to heat up water and pour it on his back. He has been demoted from work for missing to much time & I’m afraid it won’t be long till he loses his job. He’s been to out-patient therapy and it hasn’t worked and see’s a therapist/Doctor. I understand addiction as I’ve had my problems with alcohol, but I really don’t know what else to do. He has no control over it no matter how sick or the repercussions of losing his career.

    Any thought?

  6. Leon Says:

    Heather:

    It seems that the only cure for cannabinoid hyperemesis syndrome is to avoid cannabis exposure entirely. I would recommend consulting a good detox clinic or addiction specialist in your area, especially one who has experience with patients suffering from CHS. Although such programs are certainly no 100% successful, I would think they’d give the best chance of beating this condition.

  7. Tammy Says:

    I am a compulsive marijuana smoker, I have been recently diagnosed with (CHS), I was totally shocked because I thought the weed was helping me with my appetite however it was not. I spent months and months trying to find out why I was vomiting, unable to eat, constant abdominal pain, frequent ER visits, I was truly miserable. I can’t believe this condition is real, however all my symptoms lead to this disorder and when was going through these spells, I’d constantly take a hot bath or shower!!! I am working hard to refrain from any marijuana use considering I have smoked it everyday for the last 15 years.

  8. Leon Says:

    Tammy:

    CHS is a difficult diagnosis, especially since the concept that cannabis can cause nausea and vomiting is counter-intuitive. My guess would be that, even now, many physicians are not aware of it. It’s great that you found one who was and made the diagnosis. Good luck in the future.

  9. Tim Says:

    After many years of cannabis use . I’ve come to the conclusion that cannabis is the real cause of my cyclical case of nausea. I was diagnosed with h-pilora in August of 2010,received treatment from my gastro doctor the h-pilora was eradicated but I seemed no better,with frequent visits to the Emergency room with bouts of nausea. The battery of test were conducted all came back negative … but my symptoms all persisted with devastating effects in my life.My employment suffered , I lost weight spent days in hospital with no cure in sight until one of my doctors said I think you have C.H.S .He was reading his journals.Something I never heard of .Knowing of my cannabis use I became curious but still in a state of deep denial.it could not be related to marijuana which was used to help with nausea not be the cause..looking on the internet I found C.H.S I was still just not sure that this could be happening to me.After seeking professional help with my addictions .l have abstained from cannabis use and since I have not had any reoccurring events…until a relapse in December 2012 I’ve started to feel the effects of C.H.S again so it does come back ..

  10. Leon Says:

    Tim:

    I’m glad your condition was correctly diagnosed. Many physicians are still not aware of cannabinoid hyperemesis syndrome, and the diagnosis is often missed. The only way to prevent recurrences is to avoid exposure to cannabis and similar products.