Cannabis Hyperemesis (UPDATED)
January 28, 2010
Most of my readers are aware of the growing head of steam being perked up by the medical marijuana movement (and that I think it is a Trojan Horse for recreational consumption). I have also described how perceptions of the harms associated with cannabis are associated with population level use. This suggests to me that it is important to identify adverse health consequences of cannabis smoking ranging from oral health complications to paradoxical potentiation of Ecstasy-induced hyperthermia, to a dependence syndrome in some users that shares some features with nicotine dependence.
I have a new and fascinating consequence of cannabis smoking for your consideration today, Dear Reader. There is an odd syndrome of cyclical vomiting that has resulted in a series of Case Reports. One theme that runs through these is the apparently mysterious presentation at the hospital, since most of the expected causes of severe episodic vomiting were painstakingly ruled out.
Allen and colleagues (2004) reported a series of 14 consenting (of 19 approached) individuals from South Australia, 9 of whom could not be excluded for obvious confounds. The remaining 9 cases all had suffered from a cyclical pattern of sustained episodes of vomiting which remitted and then returned weeks or months later. They also comment on a case one of the authors had published in 1996 of a similar case attributed to “psychogenic vomiting”.
Roche and Foster (2005) identified a case of a 21 yr old New Zealand man who was admitted to hospital seven times over a two year period with severe vomiting. All of the usual suspects were excluded in medical tests and workups.
Sontineni and colleagues (2009) report a single case of a 21 yr old male from Omaha Nebraska in the United States who suffered from 2-3 hr bouts of uncontrolled vomiting several times per day during a symptomatic episode.
Donnino and colleagues (2009) report on three cases from the Boston area of the United States. In this case all three were males (22, 23, 51 yo) and were found to have visited the Emergency Department many times over approximately 2 year intervals with episodes of severe emesis. The striking thing about this case report is the description of extensive medical workup undergone trying to determine or rule out various causes for the vomiting. E.g.,
a 51-year-old man who presented to the ED with nausea, vomiting, and abdominal pain. The patient had experienced similar episodes over the previous 2 years (2006 -2008), involving 10 ED visits and four hospital admissions, during which he underwent a total of two EGDs, one colonoscopy, several abdominal
ultrasound examinations, and four abdominal CT scans, with no clear cause for his symptoms identified.
There were two striking similarities across all these cases. The first is that patients had discovered on their own that taking a hot bath or shower alleviated their symptoms. So afflicted individuals were taking multiple hot showers or baths per day to obtain symptom relief.
The second similarity is, as you will have guessed, they were all cannabis users. The cannabis use predated the cyclic hyperemesis, typically by many months to a few years. Cannabis use was also fairly heavy with the afflicted individuals smoking multiple times per day. In those cases where individuals were able/willing to stop using cannabis, the cyclic vomiting remitted. In at least three cases (from Allen et al) individuals were unable or unwilling and the cyclic hyperemesis continued.
It will not escape your attention that one of the supposed medical indications for cannabis smoking is the prevention of nausea and emesis, particularly in those undergoing chemotherapy for cancer. Anti-emesis is an expected property of cannabis ingestion. Cyclical hyperemesis is not. The symptom relief provided by hot showers or baths only fuels additional curiosity. Consequently, there are very intriguing scientific questions arising from these Case Reports. Very intriguing indeed.
Overall this is a fascinating tale and clearly, given the timeline of the publications (this is not an exhaustive list), an association that is only beginning to be recognized. Presumably it is not a highly common syndrome because the cases are often relatively young and there have been plenty of chronic cannabis smokers around for decades. If it were a common feature of chronic cannabis you might expect it would have been identified earlier. Nevertheless, even if this is rare, if we continue to enact polices which will increase the amount of cannabis smoking or the number of chronic smokers this syndrome might be expected to rise.
UPDATE (02/18/10): I was actually motivated to do the research into this by news of another paper which has finally become available. It describes eight more cases of the syndrome.
Allen, J. (2004). Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse Gut, 53 (11), 1566-1570 DOI: 10.1136/gut.2003.036350
Donnino MW, Cocchi MN, Miller J, & Fisher J (2009). Cannabinoid hyperemesis: A case series. The Journal of emergency medicine PMID: 19765941
Roche E, & Foster PN (2005). Cannabinoid hyperemesis: not just a problem in Adelaide Hills. Gut, 54 (5) PMID: 15831930
Sontineni SP, Chaudhary S, Sontineni V, & Lanspa SJ (2009). Cannabinoid hyperemesis syndrome: clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse. World journal of gastroenterology : WJG, 15 (10), 1264-6 PMID: 19291829