Title: Hyperemesis Cannabinoid Syndrome<br/>Author: Kathy Prybys<br/><a href='http://umem.org/profiles/faculty/121/'>[Click to email author]</a><hr/><div>
<span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:16px;"><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">Despite the well established antiemetic properties of marijuana, Cannabinoid Hyperemesis Syndrome (CHS) is a distinct under recognized syndrome characterized by severe cyclic vomiting and refractory abdominal pain</span></span><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">.</span></span><span style="font-size:16px;"><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"> <span inline="" new="" style="text-align: left; color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-family: " times="">CHS <span style="font-family:arial,helvetica,sans-serif;">can be divided into three phases with varying time lags: pre-emetic or prodromal, hyperemetic, and recovery phase</span></span></span></span><span style="font-family:arial,helvetica,sans-serif;"><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span style="font-size:16px;"><span style="text-align: left; color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">. </span></span></span></span><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span style="font-size:16px;"><span style="text-align: left; color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span inline="" new="" style="color: rgb(0, 0, 0); font-family: " times=""><span style="font-family:arial,helvetica,sans-serif;">The hyperemetic phase consists of paroxsyms of overwhelming incapacitating nausea and vomiting.</span></span></span></span></span><span style="font-family:arial,helvetica,sans-serif;"><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">T</span><span style="text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span style="text-align: left; text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 15.99px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span style="text-align: left; text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 15.99px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">he underlying mechanism of the hyperemesis in CHS is not well understood but appears to be</span> associated with cummulative and toxic effects of Δ</span><sub style="top: 0.25em; text-align: left; bottom: -0.25em; text-transform: none; line-height: 1.63em; text-indent: 0px; letter-spacing: normal; font-size: 0.84em; font-style: normal; font-weight: 400; word-spacing: 0px; vertical-align: baseline; white-space: normal; position: relative; orphans: 2; widows: 2; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><font size="3">9</font></sub><span style="text-align: left; text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 15.99px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">-tetrahydrocannabinol (Δ</span><sub style="top: 0.25em; text-align: left; bottom: -0.25em; text-transform: none; line-height: 1.63em; text-indent: 0px; letter-spacing: normal; font-size: 0.84em; font-style: normal; font-weight: 400; word-spacing: 0px; vertical-align: baseline; white-space: normal; position: relative; orphans: 2; widows: 2; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><font size="3">9</font></sub><span style="text-align: left; text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 15.99px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">-THC) in predisposed patients. </span></span></span></div>
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<span style="font-family:arial,helvetica,sans-serif;"><span style="text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 14px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);"><span style="text-align: left; text-transform: none; text-indent: 0px; letter-spacing: normal; font-size: 15.99px; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">Diagnostic criteria include:</span></span></span></div>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;">H<span style="text-align: left; color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">istory of regular cannabis use at least weekly for <u>any</u> duration of time.</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><strong>Compulsive hot water bathing multiple times per day </strong>for symptom relief which is mediated by the TRPV capsaicin receptors.</span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;">Resolution of symptoms with cannabis cessation.</span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;">Prior nonrevealing extensive diagnostic work up.</span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;">CHS Treatment:</span></span></p>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="color: rgb(34, 34, 34); text-transform: none; text-indent: 0px; letter-spacing: normal; font-style: normal; font-weight: 400; word-spacing: 0px; display: inline !important; white-space: normal; orphans: 2; widows: 2; float: none; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);">Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;">Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.</span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><b><u>Bottom line:</u> </b></span><strong><span inline="" new="" style="color: rgb(0, 0, 0); font-family: " times=""><span style="font-family:arial,helvetica,sans-serif;">Patient education should </span><span style="font-family:arial,helvetica,sans-serif;">be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea.</span></span></strong><strong><span inline="" new="" style="color: rgb(0, 0, 0); font-family: " times=""><span style="font-family:arial,helvetica,sans-serif;"><span> </span></span></span></strong></span></p>
<fieldset><legend>References</legend>
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<span style="color: rgb(51, 51, 51); font-family: Georgia, serif; font-size: 17px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: 0.102px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: rgb(252, 252, 252); text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"> Cannabinoid hyperemesis: a case series of 98 patients. Simonetto DA, Oxentenko AS, et al,Mayo Clin Proc. 2012;87(2):114–9</span></p>
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<span style="color: rgb(51, 51, 51); font-family: Georgia, serif; font-size: 17px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: 0.102px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: rgb(252, 252, 252); text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Cannabinoid hyperemesis syndrome: potential mechanisms for the benfit of capsaicin and hot water hydrotherapy in treatment. Richards JR, Lapoint JM, et al. Clin Tox(phila) 2018 Jan :56(1): 15-24.</span></p>
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<span style="color: rgb(51, 51, 51); font-family: Georgia, serif; font-size: 17px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: 0.102px; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: rgb(252, 252, 252); text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Cannabinoid Hyperemesis Syndrome: Public Health Implications and Novel Model Treatment Guidelines. West J Emerg Med. 2018 Mar:19(2):380-386.</span></p>
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