Does anyone have a dry towel?
by DR. DEREK JOHNSON
Let’s talk about a serious and growing problem, Cannabinoid Hyperemesis Syndrome, aka CHS.
First described in 2004 and becoming more prominent in emergency rooms across the country with the legalization of medical and adult-use cannabis, Cannabinoid Hyperemesis (literally, “excessive vomiting”) Syndrome now accounts for approximately 6% of cyclic vomiting diagnoses in emergency rooms across the country.
CHS is described as cyclic abdominal pain symptoms with intractable nausea and vomiting seen predominantly in regular cannabis users. Specifically characteristic for this syndrome is the use of repetitive hot showers and baths (reportedly upwards of 30+/day) taken by patients, wherein they find temporary solace from their symptoms.
Risks of the syndrome include dehydration, electrolyte abnormalities, renal failure, and scalding burns from self-treatment. There have been several reported fatalities, with complications increased secondary to delayed diagnosis.
Reports are suggesting an average of a 4-year delay in diagnosis, likely for several reasons. Firstly, cannabis is primarily thought of as an effective anti-emetic and anti-nausea medicine. Secondly, cannabis users are often in denial about the cause of their symptoms and have no interest in abstaining. The diagnosis is history-based mainly, as additional tests/studies effectively rule out other causes.
CHS is often confused and misdiagnosed as Cyclic Vomiting Syndrome (CVS), with the difference being that these CVS patients frequently don’t report a history of repetitive showers/baths and often have a more significant account of anxiety and depression.
Short-term treatment/therapy is directed toward symptomatic improvement and breaking the cycle of nausea and vomiting. Traditional anti-emetics are ineffective, but we have seen some success using benzodiazepines (a class of sedative medications, e.g., valium). Fluid and electrolyte replacement is essential to avoid negative short- and long-term consequences. Some patients report benefit from applying capsaicin (hot pepper extract) cream/ointment topically on the abdomen. Others see symptoms disappear during heavy exercise, though stopping brings immediate recurrence. Long-term treatment is singular: absolute cessation of cannabis use.
Upon cessation, most patients report complete relief of symptoms within 24-48 hrs, with symptoms returning following recurrent use. It is mostly unknown whether these patients can eventually return to using cannabis in any form or if complete and permanent cessation is required to avoid recurrence. The pathophysiology is mainly unfamiliar with multiple hypotheses, most prominently is mesenteric congestion and inefficient metabolism of the plant. As always, we need controlled trials.
Derek Johnson D.O., MBA
Board Certified Anesthesiologist
This article was originally posted on TRUCE.
