Vomiting and Emesis
16 min.

Introduction 

Any disease is a condition that indicates that the body is unable to cure itself and signals for the need for external support. Having said that, timely diagnosis and adequate treatment are the two most important aspects that need to be taken into account for disease management.

This review article aims to bring together research findings and conclusions conducted on the condition of Cannabinoid hyperemesis syndrome. 

The objectives of this review article are two-fold:

(1) seek fundamental understanding from published studies 

(2) discuss and present the prevailing knowledge gap about cannabinoid hyperemesis syndrome to cannabis and medical marijuana users. 

Fundamental Understanding 

What is Cannabinoid Hyperemesis Syndrome (CHS)

In short, Cannabinoid Hyperemesis Syndrome is frequent or cyclical vomiting associated with the heavy use of Cannabis or Marijuana. 

According to a 2011 Medical Journal1 “Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting and compulsive bathing behavior in people who chronically use cannabis on a daily basis”.

According to a 2019 case note2 “Cannabinoid hyperemesis syndrome is a paradoxical syndrome characterized by hyperemesis (persistent vomiting), as opposed to the better known antiemetic properties of cannabinoids”

In the same vein, a 2020 patient information factsheet on CHS states that Cannabinoid hyperemesis syndrome (CHS) is a rare condition caused by a regular (daily) and long-term use of marijuana. The syndrome is characterized by repeated and severe bouts of vomiting.

It is clear that Cannabinoid Hyperemesis syndrome is a condition of severe vomiting and nausea in cases of chronic cannabis and marijuana users. 

Epidemiology 

The wikipedia reports that the syndrome was first described in 2004, and simplified diagnostic criteria was published in 2009.

A strong point of argument at this point is that, given the rise in Cannabis and Marijuana legalizations, and decriminalization of possession or use, have subsequently led to the rise in the incidence of Cannabinoid hyperemesis syndrome. Hospitalizations, visits to Emergency departments are becoming common as more and more people have begun to abuse cannabis.

As per the 2020 Cannabis reform proposal, at the beginning of 2020, 11 U.S. states have fully legalized cannabis. It is expected that by the end of 2020 at least 40 states would attain some form of legalization.

Several studies highlight that “Cannabis is the most commonly used illicit drug in the United States” 

According to a 2011 National Institute of Health Research report3

  • In the year 2009, the US reported over 16.7 million users of marijuana 
  • Majority of individuals less than 19 years of age, the highest prevalence falling in the interval of 18–25 years 

The 2011 Medical Journal4 reports that

  • 2008 data reveals 2.2 million first time users of marijuana 
  • The age of users falling in the category of  12 – 17 years
  • 5.4% use cannabis on a daily basis.

Estimates of cannabis users worldwide from the year 2010 to 2018 shows that there are currently over 250 million users. The highest number of users is reported to be found in Asia, followed by America and Africa. Besides legalization policies, the acceleration of public approval of medical marijuana could also be one of the driving factors that remained above 77 % since 2011. 

Cyclical vomiting Syndrome (CVS)

Cyclic vomiting syndrome, or CVS, is a disorder that causes sudden, repeated attacks—called episodes—of severe nausea and vomiting. This condition could last from a few hours to several days or longer periods with no symptoms.  

The 2019 case note5 presents another perspective to CHS.

It reports that the medical literature recognizes two syndromes – the cannabinoid hyperemesis syndrome (CHS) and cyclic vomiting syndrome (CVS) in adults – both characterized by recurrent episodes of heavy nausea, vomiting and relative wellbeing between episodes. 

Discussion 1.

Most studies on Cannabinoid hyperemesis syndrome, unanimously recognize and highlight the diagnostic gaps that prevail around CHS and CVS. The possible reasons for this could be:

  • Patients failing to reveal fully the symptoms either due to fear of disclosing about cannabis abuse or ignoring symptoms 
  • Lack of patient history could mislead primary health care providers leading to diagnostic gaps and inadequate or improper treatment.  
  • In CHS and CVS, the organic cause of the condition remains apparently unknown in the beginning stages

Difference between Cannabinoid Hyperemesis Syndrome and Cyclical Vomiting Syndrome

According to the 2011 Medical Journal6 the causes of CVS remain unclear due to which implementing diagnosis procedures for CHS is confusing. 

Some of the associated disease components and symptoms of CHS and CVS are:

  • Chronic cannabis use, compulsive bathing behaviors are the distinctive reasons for CHS
  • Whereas in the case of CVS, a family history of migraine headaches and psychological stressors, which are not associated with CHS are noted
  •  CVS patients usually have important psychological comorbidities including depression and anxiety.

Causes of Cannabinoid Hyperemesis syndrome

Generally the root cause of the syndrome is chronic and prolonged use of Marijuana. Having said that, it is noteworthy to briefly discuss the difference between Cannabis, Hemp, and Marijuana to steer clear from confusion. Because cannabis and marijuana are generally getting used interchangeably, that is causing confusion to a set of populations who are seeking medical support from the therapeutic properties of the drug.  

Broadly speaking, Cannabis, hemp, and marijuana all belong to the Cannabaceae family. The term Cannabis is conventionally used to refer to both hemp and marijuana plants. Although they vastly differ.

From a more technical perspective, research reports that Hemp and marijuana are distinct in several ways: 

(1) statutory definitions and regulatory oversight,

(2) chemical and genetic compositions, and 

(3) production practices and use.

  • Marijuana plants are used as a psychotropic drug for medicinal or recreational purposes. The content of THC (Tetrahydrocannabinol) the psychoactive component is high in marijuana plants ranging from 25-30%
  • Whereas, the chemical composition of Hemp contains more than 60 cannabinoids including CBD and other non-psychoactive drugs, with less than 0.3% THC. 

Hemp is used to manufacture a wide range of products that include foods and beverages, personal care products, nutritional supplements, fabrics and textiles, paper, construction materials, and other manufactured and industrial goods. 

Therefore, it is clear that the main psychoactive component THC that is high in marijuana is the root cause of cannabinoid hyperemesis syndrome in chronic or long term users.

Moreover, further clarification of the causes of the syndrome summarized from the literature and the 2020 patient information factsheet on CHS is as follows:

The several active substances in Marijuana integrate with the endocannabinoid system through which it binds with the central nervous system. This inturn affects the various parts of the body.  

For example, 

  • The psychoactive compounds  affect the brain and cause the drug ‘high’ that users feel
  • They affect the way the molecules in the gut function and can alter the time it takes the stomach to empty.
  •  The drug also affects the esophageal sphincter, which is the tight band of muscle that opens and closes to let food pass from the oesophagus (food pipe) into the stomach. 

Therefore the effects of marijuana on the digestive system could be the major cause of the symptoms of CHS. 

Discussion 2

A reference from a  2011 study7 would be helpful in understanding the positive anti-emetic properties of cannabinoids. 

It reports that:

  • There is reasonable evidence to  demonstrate that the manipulation of the endocannabinoid system regulates nausea and vomiting in humans and other animals.
  • The primary non-psychoactive compound in cannabis, cannabidiol (CBD), also suppresses nausea and vomiting within a limited dose range. 
  • Preclinical research indicates that cannabinoids, including CBD, may be effective clinically for treating both nausea and vomiting produced by chemotherapy or other therapeutic treatments.
  • THC, the main ingredient in marijuana has anti-nausea (anti-sickness) effects. Studies show positive outcomes of the medicinal properties of marijuana in treating nausea caused by chemotherapy treatment. 

Symptoms of Cannabinoid Hyperemesis Syndrome 

Studies8 9 presents the CHS syndrome in three phases. 

Each phase is characterized by mild to chronic symptoms of CHS. The following table outlines the symptoms.

1.Prodromal phase2.Hyperemesis phase3.Recovery phase
Predominance of nausea, usually without emesis, abdominal pain, and fear of vomiting.Heavy nausea, (five times per hour) vomiting, vague abdominal pain, and learned compulsive hot bathing. Comparatively free of symptoms. 
Normal eating patternsLoss of appetite and weight lossHunger and oral intake return to normal.
Several years1 to 3 monthsDays up to months.
*Please note that the table is only a general presentation of symptoms. Case to case variation should be considered.

Diagnosis for Cannabinoid Hyperemesis Syndrome

The 2017 study10 reports on the diagnostic workup undertaken for treating CHS. They are laboratory, radiographic, and endoscopy procedures.

National Institute of Health Research 201111 report details out that the diagnostic procedures undertaken for CHS patients are broad and extensive. CHS affects:

  • The Gastrointestinal tract, 
  • The Peritoneal cavity,
  • Central Nervous System 
  • Endocrine and metabolic functions 

Diagnosis includes:

  • Laboratory tests that include a complete blood count and differential ( for testing anemia and infection), glucose, basic metabolic panel, pancreatic and hepatic enzymes, pregnancy test, urine analysis( for drug screening) urinary drug screen, 
  • Tests for electrolytes
  • Abdominal Radiography 
  • Imaging for neurological findings on brain, and abdominal CT 
  • Endoscopy, Upper endoscopy to view the stomach and esophagus for possible causes of vomiting.

Treatment for Cannabinoid Hyperemesis Syndrome

2020 patient information factsheet on CHS summarizes the following treatment procedures:

  • IV (intravenous) fluid replacement for dehydration 
  • Anti-sickness medicines
  • Pain-relief medicines 
  • Proton-pump inhibitors (to treat stomach inflammation) 
  • Frequent hot showers 
  • Capsaicin cream (to reduce pain and nausea)

CHS was only recently discovered. This is why there is no ‘one single’ method or foolproof medication currently available for CHS. There exists a knowledge gap about the syndrome to conduct correct and timely diagnosis and provide appropriate treatment.

Several studies strongly recommend the complete cessation of consuming marijuana for recovery to avoid the recurrence of the hyperemesis phase.  

Prevailing Knowledge Gap 

Now, addressing the second part of this review article. Cite the existing knowledge gap about this medical condition to cannabis and medical marijuana users. 

The 2017 study10 points out that the diagnosis of cannabinoid hyperemesis syndrome is a ‘diagnosis of exclusion’. 

Diagnosis of exclusion is reached by a process of elimination if the prevalence of a condition cannot be confirmed by conducting usual diagnostic procedures such as tests, examination, or medical history. Therefore, the elimination of other reasonable possibilities becomes a part of differential diagnosis. 

Theories state that such circumstances are typical in psychiatric conditions where the scientific method of diagnosing a disease becomes complex. 

Therefore, when the objective approach of finding a solution to a case is limited, subjective, and artistic approaches could bridge the gap. For example, while analyzing the medical literature for this article, some case notes brought forward case studies of patients who suffered from Cannabinoid Hyperemesis syndrome. A change in the diagnostic approach led to new dimensions of providing treatment.

The 2019 case note12 refers to a 22-year-old Caucasian gentleman who got admitted in the hospital with a three-day history of acute nausea and persistent vomiting.

Moreover, his course of treatment involved, tracing his personal history right from his childhood, family, education, and medical history. This research on the patient revealed a history of self-harm, suicidal attempts, lack of social life, separated family situation, and depression conditions. And that he is a long term cannabis user. 

Medical professionals supported him by admitting him to the psychiatric inpatient hospitalization, under the Mental Health Act. The therapeutic intervention showed noticeable improvement and progress in his mental health and physical health. His habits began to stabilize and had no complaints of vomiting or nausea. 

As a concluding note, this report would like to remind medical marijuana users to take individual responsibility in usage and possession.

Conclusion

  1. Chronic daily users of marijuana with high THC may be at the highest risk for developing CHS
  2. No reports so far that have studied the association of CBD use and Cannabinoid Hyperemesis syndrome.
  3. This syndrome is becoming more common as more people are abusing cannabis.
  4. CHS could be called a subclinical disease that lacks detectable signs, especially during the prodromal phase. 
  5. The medical literature contains a growing number of studies on cannabinoids as well as case studies and anecdotal reports that discuss the therapeutic potential of Cannabis plants. At the same time, one should not take it for granted as a self-medication method or abuse cannabis. Chronic use or abuse of cannabis must stop considering personal and societal safety.
  6. Mental health considerations are of utmost importance to treat patients suffering from CHS. Case studies report on social and economic factors that play a role in the life of people who resort to cannabis abuse. 
  7. There is a necessity to involve psychiatrists and physicians to work together and develop an integrated approach to cure patients who suffer from cannabis abuse.

References

  1. Wallace EA, Andrews SE, Garmany CL, Jelley MJ. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. Southern Medical Journal. 2011 Sep;104(9):659-664. DOI: 10.1097/smj.0b013e3182297d57. []
  2. Rehman, A.‐U., Pervaiz, A., Narayan, M. and Saqib, S. (2019), Cannabinoid hyperemesis syndrome – recognition, diagnosis and treatment. Prog. Neurol. Psychiatry, 23: 13-15. doi:10.1002/pnp.524 []
  3. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev. 2011;4(4):241-249. doi:10.2174/1874473711104040241 []
  4. Wallace EA, Andrews SE, Garmany CL, Jelley MJ. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. Southern Medical Journal. 2011 Sep;104(9):659-664. DOI: 10.1097/smj.0b013e3182297d57 []
  5. Rehman, A.‐U., Pervaiz, A., Narayan, M. and Saqib, S. (2019), Cannabinoid hyperemesis syndrome – recognition, diagnosis and treatment. Prog. Neurol. Psychiatry, 23: 13-15. doi:10.1002/pnp.524 []
  6. Wallace EA, Andrews SE, Garmany CL, Jelley MJ. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. Southern Medical Journal. 2011 Sep;104(9):659-664. DOI: 10.1097/smj.0b013e3182297d57. []
  7. Parker LA, Rock EM, Limebeer CL. Regulation of nausea and vomiting by cannabinoidsBr J Pharmacol. 2011;163(7):1411-1422. doi:10.1111/j.1476-5381.2010.01176.x []
  8. Rehman, A.‐U., Pervaiz, A., Narayan, M. and Saqib, S. (2019), Cannabinoid hyperemesis syndrome – recognition, diagnosis and treatment. Prog. Neurol. Psychiatry, 23: 13-15. doi:10.1002/pnp.524 []
  9. Fleming JE, Lockwood S. Cannabinoid Hyperemesis Syndrome. Fed Pract. 2017;34(10):33-36. []
  10. Fleming JE, Lockwood S. Cannabinoid Hyperemesis Syndrome. Fed Pract. 2017;34,10:33-36. [] []
  11. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndromeCurr Drug Abuse Rev. 2011;4(4):241-249. doi:10.2174/1874473711104040241. []
  12. Rehman, A.‐U., Pervaiz, A., Narayan, M. and Saqib, S. (2019), Cannabinoid hyperemesis syndrome – recognition, diagnosis and treatment. Prog. Neurol. Psychiatry, 23: 13-15. doi:10.1002/pnp.524 []

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