Case Presentation: A 50-year-old female with history of seropositive rheumatoid arthritis, peptic ulcer disease, and chronic idiopathic pancreatitis status post Whipple procedure presented with one-week history of nausea, vomiting, and diarrhea. Her symptoms began prior to a cruise vacation, though she denied any other recent travel or sick contacts. The patient endorsed similar episodes up to five times yearly, starting when she was diagnosed with rheumatoid arthritis. For five years, she had been self-medicating three to four times per day with marijuana for persistent rheumatoid arthritis-related joint pain. She noted warm baths were the primary remitting factor. Laboratory workup was significant for potassium of 2.7, chloride 92, anion gap 18, and sodium 132. CT Abdomen was negative for acute pathology. Following admission, her symptoms were well-managed with lorazepam, prochlorperazine, and topical capsaicin. Her electrolyte abnormalities resolved with intravenous repletion and fluid resuscitation. Given her presentation and lack of infectious or intra-abdominal findings, she was felt to have cannabinoid hyperemesis syndrome. Within 48 hours of these interventions, her nausea and vomiting subsided and she was discharged home.
Discussion: Cannabinoid hyperemesis syndrome (CHS) is a functional gut-brain disorder, which presents like a cyclical vomiting syndrome. Patients use cannabis frequently, often daily, for over one year and are predominately young males with comorbid depression and anxiety. The prevalence of CHS is unknown, as patients rarely self-report symptoms, nor is there an associated diagnostic test. The mechanism of CHS is not well understood but is suspected to be due to tolerance within endocannabinoid receptors. Patients experience severe nausea, vomiting and abdominal pain within 24 hours of cannabis use. They may also exhibit pathologic bathing behavior, reporting that hot showers and baths relieve symptoms. Diagnosis is clinical, based on the Rome IV diagnostic criteria. Namely, patients experience stereotypical episodes of vomiting, resembling cyclic vomiting syndrome, with symptoms at least 6 months prior to diagnosis and relief of symptoms with cannabis cessation. Acute management includes symptomatic care with intravenous fluids and correction of electrolyte deficiencies. Dopamine antagonist antiemetics and benzodiazepines are preferred for nausea. Additionally, topical capsaicin applied to the abdomen has been shown in early retrospective studies to provide symptomatic relief. Patients should be instructed to abstain from cannabis use and directed to mental health or addiction resources for support. In this case, the patient was recommended to follow up with her rheumatologist to consider alternative therapies to reduce pain symptoms and cannabis consumption.
Conclusions: As cannabis is legalized throughout the US, greater proportions of patients will present with sequelae related to chronic, frequent cannabis use. Recognizing cannabinoid hyperemesis syndrome is the first step to providing patients with appropriate symptomatic care. It is important to consider offering resources and support for patients prior to discharge to prevent recurrence of symptoms in the outpatient setting.