{"id":4390,"date":"2009-08-18T14:39:23","date_gmt":"2009-08-18T13:39:23","guid":{"rendered":"https:\/\/drugprevent.org.uk\/ppp\/?p=4390"},"modified":"2010-06-11T13:06:49","modified_gmt":"2010-06-11T13:06:49","slug":"wwwwjgnetcom","status":"publish","type":"post","link":"https:\/\/drugprevent.org.uk\/ppp\/2009\/08\/wwwwjgnetcom\/","title":{"rendered":"Cannabinoid hyperemesis syndrome"},"content":{"rendered":"<p><span style=\"font-size: 10pt; font-family: Verdana;\"> <\/p>\n<p>CASE REPORT<\/p>\n<p>Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse<\/p>\n<p>Siva P Sontineni, Sanjay Chaudhary, Vijaya Sontineni, Stephen J Lanspa<br \/>\nOnline Submissions: wjg.wjgnet.com World J Gastroenterol 2009 March 14; 15(10): 1264-1266<br \/>\nwjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327<br \/>\ndoi:10.3748\/wjg.15.1264 \u00a9 2009 The WJG Press and Baishideng. All rights reserved.<br \/>\nSiva P Sontineni, Sanjay Chaudhary, Vijaya Sontineni,<br \/>\nStephen J Lanspa, Department of Medicine, Creighton<br \/>\nUniversity, Suite 5850, 601 N 30th Street, Omaha, NE 68131,<br \/>\nUnited States<br \/>\nAuthor contributions: Sontineni SP provided the patient\u2019s data,<br \/>\norganized, conceptualized and contributed to the manuscript<br \/>\nwriting and final approval; Chaudhary S collected the patient<br \/>\ndata, reviewed the literature and contributed to the manuscript<br \/>\nwriting; Sontineni V reviewed the literature and compiled the<br \/>\nreferences; Lanspa SJ supervised, provided critical review<br \/>\nand obtained financial support from the division; All authors<br \/>\napproved the final manuscript.<br \/>\nCorrespondence to: Siva P Sontineni, MD, Department<br \/>\nof Internal Medicine, 601 N 30th St Suite 5850, Creighton<br \/>\nUniversity Medical Centre, Omaha, NE 68131,<br \/>\nUnited States. ssontineni@gmail.com<br \/>\nTelephone: +1-402-4158319 Fax: +1-402-2804220<br \/>\nReceived: October 25, 2008 Revised: February 8, 2009<br \/>\nAccepted: February 15, 2009<br \/>\nPublished online: March 14, 2009<\/p>\n<p><strong>Abstract<\/strong><\/p>\n<p>Cannabis is a common drug of abuse that is associated with various long-term and short-term adverse effects.<br \/>\nThe nature of its association with vomiting after chronic abuse is obscure and is underrecognised by<br \/>\nclinicians. In some patients this vomiting can take on a pattern similar to cyclic vomiting syndrome with<br \/>\na peculiar compulsive hot bathing pattern, which relieves intense feelings of nausea and accompanying<br \/>\nsymptoms. In this case report, we describe a twentytwo year-old-male with a history of chronic cannabis<br \/>\nabuse presenting with recurrent vomiting, intense nausea and abdominal pain. In addition, the patient<br \/>\nreported that the hot baths improved his symptoms during these episodes. Abstinence from cannabis led<br \/>\nto resolution of the vomiting symptoms and abdominal pain. We conclude that in the setting of chronic<br \/>\ncannabis abuse, patients presenting with chronic severe nausea and vomiting that can sometimes be<br \/>\naccompanied by abdominal pain and compulsive hot bathing behaviour, in the absence of other obvious<br \/>\ncauses, a diagnosis of cannabinoid hyperemesis syndrome should be considered.<br \/>\n\u00a9 2009 The WJG Press and Baishideng. All rights reserved.<\/p>\n<p>INTRODUCTION<br \/>\nCannabis has been used recreationally for millennia and is the third most commonly used drug after tobacco<br \/>\nand alcohol[1,2]. Research into the neurobiology of the compound has led to the discovery of an endogenous<br \/>\ncannabinoid system. The therapeutic potential of cannabinoids has been recognized and these compounds are<br \/>\nutilized as anti-emetics[3-5]. Recently, a distinct syndrome in chronic cannabis abusers characterized by recurrent<br \/>\nvomiting associated with abdominal pain and a tendency to take hot showers has been increasingly recognised.<br \/>\nThis clinical manifestation is paradoxical to the previously identified therapeutic role of cannabinoids as antiemetics.<br \/>\nWe describe the case of a young male seeking repeated emergency room care with recurrent nausea<br \/>\nand vomiting.<\/p>\n<p>CASE REPORT<br \/>\nA 22-year male presented with recurrent episodes of nausea, refractory vomiting, and colicky epigastric pain<br \/>\nfor one week. The symptoms were characterized by treatment-resistant nausea in the morning, continuous<br \/>\nvomiting, and colicky epigastric abdominal pain. Each episode lasted 2 to 3 h and increased with food intake.<br \/>\nHe often had two or more episodes a day during the symptomatic period. He had been treated for the severe<br \/>\nnausea and vomiting in the emergency room on two occasions in the preceding two months. He also reported<br \/>\nhaving learned to help himself by taking a hot bath each time the symptoms appeared, which dramaticallyimproved his symptoms. This habit had become a compulsion for him for symptom relief with each episode<br \/>\nof hyperemesis. On physical examination his mucous membranes were dry, his pulse rate was 102\/min and<br \/>\nblood pressure was 140\/100 with positive orthostasis. The remainder of the physical examination was unremarkable.<br \/>\nHis complete blood count and comprehensive metabolic panel were unremarkable. In addition, serum<br \/>\namylase and lipase levels were within the normal range. His urine drug screen was positive for tetrahydrocannabinol<br \/>\n(THC). Abdominal X-ray series and ultrasonography were within normal limits.<br \/>\nOesophagogastroduodenoscopy revealed Grade 2 distal oesophagitis and hiatal hernia. On further interviewing,<br \/>\nhe admitted to consistent marijuana abuse for the past 6 years, often smoking cannabis every hour or<br \/>\ntwo on a daily basis. The patient and his mother did not recall any significant past illnesses or recurrent vomiting<br \/>\nwhen he was a child. He was treated with intravenous fluids with steady improvement in symptoms, and metoclopramide,<br \/>\npantoprazole and morphine for the abdominal pain. It was explained that marijuana was the cause<br \/>\nof his symptoms and he was advised not to resume marijuana abuse. On subsequent follow-up, he had abstained from cannabis and remained symptom-free.<\/p>\n<p>DISCUSSION<br \/>\nCannabis is one of the most commonly abused drugs worldwide. Over the past decade, marijuana has<br \/>\nremained the most commonly used illicit substance with close to 50% of high school seniors admitting use at<br \/>\nsome time[1]. It is estimated that each year 2.6 million individuals in the USA become new users and most are<br \/>\nyounger than 19 years of age[6].<br \/>\nThe long-term and short-term toxicity of cannabis abuse is associated with pathological and behavioural<br \/>\neffects. However, cannabis has also been suggested to have therapeutic properties with anticonvulsive,<br \/>\nanalgesic, antianxiety and anti-emetic activities. Cannabis has also been used to treat anorexia in patients with<br \/>\nacquired immunodeficiency syndrome[3-5]. The actions of cannabis are mediated by specific cannabinoid<br \/>\nreceptors. The first of the cannabinoid receptors-CB-1- was identified in 1990 and this finding revolutionized the<br \/>\nstudy of cannabinoid biology. Since then, a multitude of roles for the endogenous cannabinoid system has been<br \/>\nproposed. A large number of endogenous cannabinoid neurotransmitters or endocannabinoids have been<br \/>\nidentified, and the CB-1 and CB-2 cannabinoid receptors have been characterized[7]. The CB-1 receptors exert<br \/>\na neuromodulatory role in the central nervous system and enteric plexus[8]. Cannabinoid type 2 receptors<br \/>\nhave an immunomodulatory effect and are located on tissues such as microglia[5]. The presence of other<br \/>\nreceptors, transporters, and enzymes responsible for the synthesis or metabolism of endocannabinoids are<br \/>\nbeing recognised at an extraordinary pace. Cannabinoids have a wide variety of effects on the body systems and<br \/>\nphysiologic states (Table 1) due to their actions on the receptors as well as direct toxic effects.<br \/>\nThe anti-emetic effect of cannabinoids is largely mediated by CB-1 receptors in the brain and the<br \/>\nintestinal tract, although some of their effect may also be receptor-independent. However, in this report,<br \/>\nwe were presented with the paradoxical effect of hyperemesis in a susceptible chronic cannabis abuser.<br \/>\nSuch a paradoxical response has previously only been demonstrated following acute toxicity to an intravenous<br \/>\ninjection of crude marijuana extract[9]. Proposed mechanisms of cannabinoid hyperemesis include<br \/>\ntoxicity due to marijuana\u2019s long half-life, fat solubility, delayed gastric emptying, and thermoregulatory and<br \/>\nautonomic disequilibrium via the limbic system[10].<br \/>\nCannabinoids are known to impair peristalsis in a dosedependent manner[11,12], which can theoretically override<br \/>\nthe centrally mediated anti-emetic effects, thus leading to hyperemesis. It is not known why the hyperemesis<br \/>\nsyndrome surfaces after several years of cannabis abuse. The effects of cannabinoids on the functions of the<br \/>\nthermoregulatory and autonomic mechanisms of the brain can lead to behavioural changes[10]. Such effects<br \/>\nmight be the underlying mechanism for the compulsive hot bathing behaviour. There is also a supposition that<br \/>\nthe syndrome could represent a type of cyclic vomiting.<br \/>\nCyclic vomiting syndrome (CVS) in adults is now very well recognized, and it has been proposed that marijuana<br \/>\ncontributes to CVS[13]. However, unlike the other forms of CVS, patients with cannabinoid hyperemesis are not<br \/>\nlikely to have a history of migraine or other psychosocial stressors and the peculiar behaviour of hot showers is<br \/>\nCognitive and mental health<br \/>\nImpaired memory<br \/>\nImpaired attention, organization and integration of complex information<br \/>\nAssociation with schizophrenia<br \/>\nIncreased risk for depression<br \/>\nPulmonary<br \/>\nCarcinogenic effect<br \/>\nObstructive lung disease<br \/>\nIncreased propensity toward infections<br \/>\nAcute and chronic bronchitis<br \/>\nBehavioural<br \/>\nWeapon possession and physical fighting<br \/>\nUnwanted and unprotected sexual encounters<br \/>\nUnwanted pregnancies<br \/>\nSchool dropout<br \/>\nAmotivational syndrome<br \/>\nImpairment of driving skill and coordination<br \/>\nEndocrine<br \/>\nDecreased testosterone, sperm motility and production, disruption of<br \/>\novulatory cycle<br \/>\nPregnancy<br \/>\nLow birth weight<br \/>\nProblems with attention, memory and higher cognitive function<br \/>\nCardiovascular<br \/>\nStroke<br \/>\nDose-dependent increase in HR<br \/>\nOrthostasis<br \/>\nDecreased exercise tolerance<br \/>\nPrecipitation of angina or myocardial infarction unique to this syndrome.<\/p>\n<p>Allen et al[10] first noted this condition in a group of nineteen patients from Australia with chronic<br \/>\ncannabis abuse and cyclical vomiting illness. An earlier case report by de Moore et al[17] described a chronic<br \/>\ncannabis abuser with psychogenic vomiting, which was complicated by spontaneous pneumomediastinum.<br \/>\nSubsequent reports have identified similar clinical presentations[7-9,18]. Given the high prevalence of chronic<br \/>\ncannabis abuse worldwide and the paucity of reports in the literature, clinicians need to be more attentive to the<br \/>\nclinical features of this underrecognised condition.<\/p>\n<p>REFERENCES<br \/>\n1 National Institutes of Health website: NIDA Info Facts:<br \/>\nMarijuana. National Institute on Drug Abuse. Available<br \/>\nfrom: URL: http\/\/www.nida.nih.gov\/Infofacts\/marijuana.<br \/>\nhtml. Accessed January 23, 2008<br \/>\n2 Baker D, Pryce G, Giovannoni G, Thompson AJ. The<br \/>\ntherapeutic potential of cannabis. Lancet Neurol 2003; 2: 291-298<br \/>\n3 Walsh D, Nelson KA, Mahmoud FA. Established and<br \/>\npotential therapeutic applications of cannabinoids in<br \/>\noncology. Support Care Cancer 2003; 11: 137-143<br \/>\n4 Tram\u00e8r MR, Carroll D, Campbell FA, Reynolds DJ, Moore<br \/>\nRA, McQuay HJ. Cannabinoids for control of chemotherapy<br \/>\ninduced nausea and vomiting: quantitative systematic<br \/>\nreview. BMJ 2001; 323: 16-21<br \/>\n5 Davis M, Maida V, Daeninck P, Pergolizzi J. The emerging<br \/>\nrole of cannabinoid neuromodulators in symptom<br \/>\nmanagement. Support Care Cancer 2007; 15: 63-71<br \/>\n6 Foley JD. Adolescent use and misuse of marijuana. Adolesc<br \/>\nMed Clin 2006; 17: 319-334<br \/>\n7 Childers SR, Breivogel CS. Cannabis and endogenous<br \/>\ncannabinoid systems. Drug Alcohol Depend 1998; 51: 173-187<br \/>\n8 Simoneau II, Hamza MS, Mata HP, Siegel EM, Vanderah<br \/>\nTW, Porreca F, Makriyannis A, Malan TP Jr. The cannabinoid<br \/>\nagonist WIN55,212-2 suppresses opioid-induced emesis in<br \/>\nferrets. Anesthesiology 2001; 94: 882-887<br \/>\n9 Vaziri ND, Thomas R, Sterling M, Seiff K, Pahl MV, Davila<br \/>\nJ, Wilson A. Toxicity with intravenous injection of crude<br \/>\nmarijuana extract. Clin Toxicol 1981; 18: 353-366<br \/>\n10 Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid<br \/>\nhyperemesis: cyclical hyperemesis in association with<br \/>\nchronic cannabis abuse. Gut 2004; 53: 1566-1570<br \/>\n11 Pertwee RG. Cannabinoids and the gastrointestinal tract.<br \/>\nGut 2001; 48: 859-867<br \/>\n12 McCallum RW, Soykan I, Sridhar KR, Ricci DA, Lange<br \/>\nRC, Plankey MW. Delta-9-tetrahydrocannabinol delays the<br \/>\ngastric emptying of solid food in humans: a double-blind,<br \/>\nrandomized study. Aliment Pharmacol Ther 1999; 13: 77-80<br \/>\n13 Abell TL, Adams KA, Boles RG, Bousvaros A, Chong SK,<br \/>\nFleisher DR, Hasler WL, Hyman PE, Issenman RM, Li BU,<br \/>\nLinder SL, Mayer EA, McCallum RW, Olden K, Parkman<br \/>\nHP, Rudolph CD, Tach\u00e9 Y, Tarbell S, Vakil N. Cyclic<br \/>\nvomiting syndrome in adults. Neurogastroenterol Motil 2008;<br \/>\n20: 269-284<br \/>\n14 Roche E, Foster PN. Cannabinoid hyperemesis: not just a<br \/>\nproblem in Adelaide Hills. Gut 2005; 54: 731<br \/>\n15 Boeckxstaens GE. [Cannabinoid hyperemesis with the<br \/>\nunusual symptom of compulsive bathing] Ned Tijdschr<br \/>\nGeneeskd 2005; 149: 1468-1471<br \/>\n16 Chepyala P, Olden KW. Cyclic vomiting and compulsive<br \/>\nbathing with chronic cannabis abuse. Clin Gastroenterol<br \/>\nHepatol 2008; 6: 710-712<br \/>\n17 de Moore GM, Baker J, Bui T. Psychogenic vomiting<br \/>\ncomplicated by marijuana abuse and spontaneous<br \/>\npneumomediastinum. Aust N Z J Psychiatry 1996; 30: 290-294<br \/>\n18 Chang YH, Windish DM. Cannabinoid hyperemesis relieved<br \/>\nby compulsive bathing. Mayo Clin Proc 2009; 84: 76-78<br \/>\nS- Editor Li LF L- Editor Kerr C E- Editor Yin DH<br \/>\nEssential for diagnosis:<br \/>\nHistory of regular cannabis use for years<br \/>\nMajor clinical features of syndrome<br \/>\nSevere nausea and vomiting<br \/>\nVomiting that recurs in a cyclic pattern over months<br \/>\nResolution of symptoms after stopping cannabis use<br \/>\nSupportive features<br \/>\nCompulsive hot baths with symptom relief<br \/>\nColicky abdominal pain<br \/>\nNo evidence of gall bladder or pancreatic inflammation<br \/>\nTable 2 Clinical diagnosis of cannabinoid hyperemesis<\/p>\n<p><em>Source: 1266 ISSN 1007-9327 CN 14-1219\/R World J Gastroenterol March 14, 2009 Volume 15 Number 10<br \/>\nwww.wjgnet.com<\/em><\/p>\n<p><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>CASE REPORT Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse Siva P Sontineni, Sanjay Chaudhary, Vijaya Sontineni, Stephen J Lanspa Online Submissions: wjg.wjgnet.com World J Gastroenterol 2009 March 14; 15(10): 1264-1266 wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327 doi:10.3748\/wjg.15.1264 \u00a9 2009 The WJG Press and Baishideng. All rights reserved. Siva [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[22],"tags":[],"class_list":["post-4390","post","type-post","status-publish","format-standard","hentry","category-effects-of-drugs-papers"],"_links":{"self":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/4390","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/comments?post=4390"}],"version-history":[{"count":0,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/4390\/revisions"}],"wp:attachment":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/media?parent=4390"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/categories?post=4390"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/tags?post=4390"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}