Gastroenterology

AGA: Cannabinoid hyperemesis syndrome is on the rise

August 20, 2024

Cannabinoid hyperemesis syndrome (CHS), a gut-brain interaction disorder, is a cyclical vomiting syndrome linked to cannabis use that is chronic (typically for years) and heavy (daily or nearly so). Males make up around 69% of cases. Symptoms include cyclic vomiting, nausea, and abdominal pain. Prolonged hot water exposure (baths, showers) has been associated with some cases. Complications include volume depletion, acute kidney injury, electrolyte and metabolic imbalances; and, rarely, pneumothorax, pneumomediastinum, or death.

Proposed criteria: 1) acute-onset vomiting episodes 3+ times a year; 2) cannabis use >1 year before symptom onset with use 4+ times/week on average; 3) symptoms resolve with cannabis abstinence for 6+ months (or equal to the total duration of 3 typical vomiting cycles).

Diagnosis: There is no confirmatory test for CHS. For chronic nausea and vomiting in general, a thorough history and potentially individualized imaging or endoscopy may sometimes be indicated in the outpatient setting to rule out other causes. In the ED setting, immediate evaluation for life-threatening conditions is warranted.

Management: Counseling for marijuana cessation and tricyclic antidepressants (e.g., amitriptyline 25 mg QHS, titrating weekly to reach the minimally effective dose of 75–100 mg at bedtime, closely monitoring efficacy, adverse effects) are recommended. Evidence is limited to case series and small trials regarding drugs such as ondansetron, olanzapine, benzodiazepines, promethazine, haloperidol, or topical capsaicin (0.1% cream applied to upper abdomen). Opioids should be avoided, as they may worsen nausea and pose addiction risks. Switching to lower THC forms or to edibles, or avoiding THC concentrates have been proposed, yet these lack scientific validation. Anxiety and depression may be concomitant conditions.

Source:

Rubio-Tapia A, et al. (2024, March 5). Gastroenterology. AGA Clinical Practice Update on Diagnosis and Management of Cannabinoid Hyperemesis Syndrome: Commentary. https://pubmed.ncbi.nlm.nih.gov/38456869/