“Cannabinoid Hyperemesis Syndrome” From Dr. Fox With Additional Resources

Please see Additional Resources after this post for articles on Cannabinoid Hyperemesis Syndrome.

This post contains a link to and excerpts from Dr. Fox’s post, Cannabinoid Hyperemesis Syndrome, from his outstanding blog, Pediatric EM Morsels:

HYPER-Emesis sounds gross! It sounds like something from a horror movie and invokes thoughts of demonic possession. Of course we deal with vomiting a lot (ex, Pyloric Stenosis, Malrotation, Testicular Torsion, Ovarian Torsion, Vertigo, Ogilvie’s Syndrome) and fortunately, we have good therapies to fight off the potential dehydration; however, sometimes the demonic possess persists. Thanks to our good friend, Dr. Simone Lawson, I was reminded that some unique therapies may need to be employed in such cases. Let us take a minute to review one specific cause of vomiting that thwarts our common therapies – Cannabinoid Hyperemesis Syndrome:

But first we want to remind ourselves that vomitting, especially without diarrhea, can be a sign of serious pathology[something more than acute gastroenteritis]  including increased intracranial pressure, initial presentation of pediatric diabetic ketoacidosis, bowel obstruction, pancreatitis, etc. So we want to consider all the possibilities.

The pathology of Cannabinoid Hyperemesis Syndrome is not well understood.

Resuming excerpts from Dr. Fox’s post:

Clinical Features of Cannabinoid Hyperemesis Syndrome: [Venkatesan, 2019; Richards, 2018; Felton, 2015; Desjardins, 2015Miller, 2010]

  • Frequent and Prolonged Marijuana Use (natural or synthetic)
    • Duration > 1 year preceding onset of symptoms [Venkatesan, 2019]
    • Frequency of use > 4 times a week on average [Venkatesan, 2019]
  • Abdominal Pain
  • Cyclic Nausea and Vomiting
  • Resolution with Cessation of Marijuana
  • Symptom Relief with HOT Showers/Baths
  • Weight loss often noted
  • Symptoms Worse in Morning
  • Normal Bowel Habits
  • No Radiographic, Laboratory, or Endoscopic Abnormalities (if performed).

Cannabinoid Hyperemesis Syndrome: Management

  • Interestingly, commonly used anti-emetics are not effective in controlling symptoms! [Richards, 2018]
    • Serotonin antagonists are often ineffective.
    • Dopamine antagonists may be somewhat more effective.
  • Off-label, non-traditional therapies are, therefore, tried: [Venkatesan, 2019Richards, 2018]
    • Benzos
    • Haldol has been used with some positive improvement. [Witsil, 2017]
  • Other therapies that have been effective: [Venkatesan, 2019; Richards, 2018; Graham, 2017]
      • Hot Showering/Bathing
        • Often done by patients on their own.
        • Many cases of “compulsive” use of hot showers/baths [Witsil, 2017Miller, 2010]
        • Consistently noted to be effective for short-term relief.
      • Capsaicin Topical Cream
        • Capsaicin: [Richards, 2018]
          • Is an alkaloid extract from a Capsicum, a plant from the night-shade family
          • It is a vanilloid – similar to substances from vanilla, ginger, and cloves.
          • It is responsible for the “Heat” from chili peppers
            • Pure capsaicin is 16 million Scoville Units
            • A red bell pepper is 0 and a habanero is ~350,000
        • Complex interactions between the endocannabinoid systems and transient receptor potential vanilloid 1 play a role in the symptoms and treatments. [Richards, 2018]
          • (nope, I don’t really understand that either … but smart pharmacologists do)
          • There are many theories that are being evaluated to elucidate the pathophysiology and the therapeutic mechanism. [Venkatesan, 2019; Miller, 2010]
        • Topical Capsaicin Therapy: [Richards, 2018]
          • Has been used for Nociceptive and Neuropathic pain
          • Available in some formulations over-the-counter
            • 0.025%, 0.075%, and 0.1% creams
            • An 8% patch also exists.
          • Can lead to local skin irritation and burning.
          • Applied to abdomen, back, and/or arms.
        • Found to help resolve symptoms within ~30-45 min. [Richards, 2018; Graham, 2017]

Additional Resources:

(1) Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline [PubMed Abstract] [Full Text HTML] [Full Text PDF]. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8

(2) Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome in Adolescents: A Case Series [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Pediatrics. 2017 Dec;140(6). Epub 2017 Nov 9.

(3) Is haloperidol the wonder drug for cannabinoid hyperemesis syndrome? [PubMed Abstract] [Full Text HTML] [Full Text PDF]. BMJ Case Rep. 2017 Jan 4;2017. pii: bcr2016218239. doi: 10.1136/bcr-2016-218239.

(4) Resolution of Cannabinoid Hyperemesis Syndrome with Benzodiazepines: A Case Series [PubMed Abstract] [Full Text PDF]. Isr Med Assoc J. 2019 Jun;21(6):404-407.




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