Case Presentation: A 42 year-old male patient with past medical history of asthma presented to the emergency room with acute onset epigastric pain for three days. The epigastric pain worsened over time, and the patient subsequently experienced numerous episodes of vomiting and the inability to tolerate oral intake, including both solids and liquids. He described the pain as severe, sharp, and radiating to the back. Detailed review of systems was negative for fever, shortness of breath, chest pain, or diarrhea. He denied any recent alcohol or tobacco use and claimed that his last drink was 2 weeks ago, where he consumed very little alcohol. He had no known history of gallstones or hyperlipidemia and denied any recent trauma. He admitted, however, to significant daily use of marijuana. Initial vital signs demonstrated a blood pressure of 145/87 mm Hg, pulse of 54 beats per minute, temperature of 37.2 °C (99 °F) (oral), respiratory rate of 17 breaths per minute, and oxygen saturation of 96% on room air. Physical exam was significant for epigastric tenderness. Laboratory evaluation revealed a white blood cell count of 14.7 billion cells per liter and a lipase of 284 units per liter (upper limit of normal: 78 units per liter). Transaminases, alkaline phosphatase, and bilirubin were within normal ranges. CT scan of the abdomen showed enlargement and heterogeneity of the pancreatic head and neck, consistent with pancreatitis. Additionally, hypodense lesions on the liver were found, thought to be hemangiomas. Ultrasound of the abdomen showed no evidence of gallstones.Upon admission to the medicine floor, he received fluid resuscitation with lactated ringers solution running at 200 mL/hour along with treatment for nausea and pain with anti-emetics and analgesics. He demonstrated significant clinical improvement within 24 hours of admission with resolution of symptoms.
Discussion: Cannabis, otherwise known as marijuana, is the most frequently used psychoactive substance in the world and its use has nearly doubled in the past several years. As the usage rates have increased, so have health issues in those using the drug. In fact, cannabis was first postulated as a cause of pancreatitis in 2004 and since then, numerous reports have been made supporting this claim. In one meta-analysis, there were 26 cases of cannabis-induced acute pancreatitis, which correlated with increased cannabis use in 18 of the 26 patients. Additionally, recurrent acute pancreatitis related to the timing of cannabis use occurred in 15 of 26 patients. The researchers concluded that cannabis use is a potential risk factor for acute pancreatitis. Though the mechanism of action is not fully understood, recent research shows that there are two cannabinoid receptors, cannabinoid type 1 (CB1) and cannabinoid type 2 (CB2), within the pancreas. Cannabis can act as an agonist at the CB1 receptors, which is thought to promote pancreatic fibrosis. Nonetheless, further research is needed to better understand the pathophysiology of cannabinoid receptors and the role of marijuana use.
Conclusions: Our patient presents a compelling case of cannabis-induced pancreatitis and supports the notion that cannabis use is one of the etiologies of pancreatitis. Research has shown that stopping marijuana use can actually prevent acute pancreatitis in over 50% of all patients. Thus, understanding cannabis as a potential cause can help clinicians prevent recurrent hospital admissions and improve the quality of life for affected individuals.