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:

Cannabinoid Hyperemesis Syndrome

• Cannabis is commonly used and its potency has been increasing (3 times more potent over past 20 years). [Venkatesan, 2019; Richards, 2018]

• Cannabis has been associated with a variant of Cyclic Vomiting Syndrome. [Venkatesan, 2019; Richards, 2018; Felton, 2015; Desjardins, 2015]
  • First described in 2004.
  • Pathophysiology is not well understood at this time. [Venkatesan, 2019; Richards, 2018; Graham, 2017]
  • Often leads to ED presentation for symptom relief.
  • Often leads to many tests being done: labs and imaging.

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

• 3 phases of Cannabinoid Hyperemesis Syndrome: [Richards, 2018]
  • Prodrome – nausea, anorexia, vague abdominal pain
  • Hyperemesis – episodic vomiting, diffuse abdominal pain, can last for hours.
  • Recovery – slow resolution of symptoms

Cannabinoid Hyperemesis Syndrome: Management

• Don’t jump to conclusions!
  • Marijuana use may also be associated with other substance use that may cause other conditions, like pancreatitis!
  • Be diligent and vigilant and don’t jump to conclusions.
  • BUT, be reasonable and don’t order tests that you don’t think will help you manage the patient! (that is a generally good idea)

• 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, 2019; Richards, 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, 2017; Miller, 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]

• Long-Term Therapy = STOP USING CANNABINOIDS!

Moral of the Morsel

• Don’t Jump to Conclusions! The use of Cannabis does not equate to Cannabinoid Hyperemesis Syndrome.
• Zofran doesn’t fix everything! Sad, but true. You may need to consider utilizing other non-traditional therapies.
• Chili-Peppers are useful for more than seasoning. Topical Capsaicin may be a way to avoid lots of Haldol… plus can be used at home!

References