What is Cannabinoid Hyperemesis Syndrome?
Cannabinoid Hyperemesis Syndrome is the resultant of recurrent use of Cannabis. The primary factor involves the development of Cannabinoid Hyperemesis Syndrome is cannabis abusing1.
Cannabis is considered as a most illicit drug used worldwide for abusing purpose. Teenagers and young generation are mostly abused this drug. Most of the Western countries are seriously affected by drug addiction by using cannabis formulations. The rate of incidence increasing with time. Almost 2.6 million U.S population get addicted to Cannabis in every year2.
Chronic cannabis use initiates Cannabinoid Hyperemesis Syndrome. The characteristic features are repeated occurrence of nausea and vomiting.
The attack of nausea and vomiting is not continuous, but it often occurs periodically with asymptomatic (without giving any symptom) gap. Severe nausea and vomiting often lead to dehydration, which requires immediate admission in the emergency department2.
Two distinct cannabinoid receptors, CB1 and CB2 present in our body. CB1 is located in the brain, gastrointestinal system, heart, spleen, liver, uterus, bladder and in the male genital duct and CB2 is present in immune cells and in some area of the Gastrointestinal tract.
Δ9-tetrahydrocannabinol (THC), a psychoactive component present in cannabis. After administration of cannabis preparation, THC are bind with body fat and stay in the body for prolonged period. Chronic administration of cannabis produces a “reintoxication effect”, which causes food deprivation and also increase the stress level. Both these factors induce Cannabinoid Hyperemesis Syndrome.
Cannabis has an anti-emetic effect. It is surprising that chronic cannabis administration in the body causes a cyclic attack of nausea and vomiting. Cannabidiol (CBD) and cannabigerol (CBG) are two other active compounds present in cannabis and provide an anti-emetic effect in a lower dose.
Both of these components are non-psychotic, as they don’t bind with CB1 and CB2 receptor, but they bind with 5-HT1A receptor. But cannabidiol increases the expression of CB1 receptors in the brain and augment the hypothermic effects obtained by THC.
In a large dose of Cannabis, cannabidiol induces vomiting due to the development of the toxicity. In addition, cannabigerol provides an antagonistic effect on CB1 and 5-HT1A receptors and that also provides reversed anti-emetic effect.
Cannabidiol acts as pro-emetic at higher doses due to CB1 receptor activation in the brain and enteric plexus (nerve present in GI tract) causes delayed stomach emptying. In addition, CBG promotes recurring of severe nausea and vomiting. Both of this mechanisms involve in the onset of Cannabinoid Hyperemesis Syndrome2,3,4.
The etiology of Cannabinoid Hyperemesis Syndrome is mediated through CB1 receptor activation in the GI tract. The resultant of this is a reduction of gastric acid, esophageal sphincter becomes constricted and also alter intestinal motility. Decreased gastric motility causes delayed gastric emptying, in higher doses.
This becomes an adverse effect and appears due to opposing to the development of tolerance. Moreover, a higher dose of cannabis also alters gastric motility, which also influences delayed gastric emptying and promote nausea and vomiting2,5,6.
Clinical presentation analysis is important to diagnose the Cannabinoid Hyperemesis Syndrome. The patients most often in young adult aged.
The patient’s medical history analysis usually shows the chronic use of Cannabis. The chronic use indicates almost continuous administration of cannabis formulation for approximately three years in three to five times per day.
The symptom-free interval between the cyclic episode of nausea and vomiting is a classic feature of Cannabinoid Hyperemesis Syndrome. The cyclic episode of nausea and vomiting in Cannabinoid Hyperemesis Syndrome is divided into three phases: pre-emetic, hyperemetic, and recovery phase.
The duration of this phase usually extends from months to years. During this period, the patient has nausea at an early stage and that creates a panic of vomiting.
In addition, abdominal discomfort also persists. No anorexia reported during this period and maintain the normal eating habit. The addicted individual usually continues to take cannabis, as they thought it can provide the anti-emetic effect.
The patient usually suffering from extreme and continual nausea and vomiting commonly occurs due to the irresistible and debilitating effect of cannabis. During this phase, patients have profuse vomiting frequently occur without warning. The severity of the vomiting can be such an extent that patient vomit out up to 5 times/ hour. Along with this most of the patients complain mild to moderate abdominal pain and dehydration.
Usually, no hemodynamic alteration occur during this period. The patient often takes frequent hot showers throughout the day. This idiosyncratic action may appear due to they build a concept that this helps to lessen the discomfort and can control the symptom. But this habit rapidly turns to a compulsive behavior.
This phase can end up within a few days or may extend to weeks, or months. During this period, the patient condition is gradually improving with the normal eating pattern. The body weight steadily increases and bathing frequency reduces and normalize2,6,7,8.
Following are some diagnostic tests are performed to rule out the exact cause of recurring nausea and vomiting.
- Initially through knowledge of medical history and screening tests perform to exclude the possibility of intestinal obstruction, pancreaticobiliary disease, and pregnancy.
- A blood test like CBC or complete blood count and DLC differential leucocytes count, blood glucose level, pancreatic and hepatic enzymes levels in blood and pregnancy test are performed in the laboratory. In addition, the doctor also orders to perform urinary drug screening and urinalysis.
- Plain flat radiographic series also recommended for getting basic internal images
- Upper endoscopy usually perform
- CT scan of brain also perform to diagnose the neurological involvement
- Abdominal CT scan also requires obtaining the images of intestinal motility and/or presence of any obstruction9.
The following are the different treatment options available to treat Cannabinoid Hyperemesis Syndrome:
- Anti-emetic therapy helps to control vomiting in the emergency department.
- Supportive therapy like I.V. infusion is given to maintain the hydration and prevent dehydration
- Abdominal pain can be controlled by providing narcotic drugs, but it is prescribed only for intolerable pain symptom
- Acid suppression therapy like proton pump inhibitors can be prescribed for treating esophagitis and gastritis
- Hot showers is an alternative therapy. It is very effective to control the associated discomfort like controlling nausea and vomiting, abdominal pain, and decreased appetite during the hyperemetic phase. But this therapy provides temporary benefits10.
- Sirius J, (2014); WHAT IS CANNABINOID HYPEREMESIS SYNDROME?;http://hightimes.com/medicinal/what-is-cannabinoid-hyperemesis-syndrome/
- Jonathan A. Galli, Ronald Andari Sawaya, Frank K. Friedenberg; Cannabinoid Hyperemesis Syndrome; Curr Drug Abuse Rev. Author manuscript;PMC 2013 Feb 20.
- Published in final edited form as: Curr Drug Abuse Rev. 2011 Dec; 4(4): 241–249.
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- Russo EB, Burnett A, Hall B, et al. Agonistic properties of Cannabidiol at 5-HT1a receptors. Neurochem Res. 2005;30:1037–43.
- Rock EM, Goodwin JM, Limebeer CL, et al. Interaction between non-psychotropic cannabinoids in marihuana: effect of cannabigerol (CBG) on the anti-nausea or anti-emetic effects of cannabidiol (CBD) in rats and shrews. Psychopharmacology. 2011 [Epub ahead of print]
- Hinds NM, Ullrich K, Smid SD. Cannabinoid 1 (CB1) receptors coupled to cholinergic motorneurones inhibit neurogenic circular muscle contractility in the human colon. Br J Pharmacol. 2006;148:191–99.
- Quigley E, Hasler W, Parkman H. AGA Technical review on nausea and vomiting. Gastroenterology. 2001;120:263–86.
- Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States. Dig Dis Sci. 2010;55:3113–9.