ED Management of Cannabinoid Hyperemesis Syndrome: Breaking the Cycle

What is cannabinoid hyperemesis syndrome? Cannabinoid hyperemesis syndrome (CHS) is a condition in which patients who have been using cannabis or synthetic cannabinoids for a prolonged period of time develop a pattern of episodic, severe vomiting (usually accompanied by abdominal pain) interspersed with prolonged asymptomatic periods. When should you consider cannabinoid hyperemesis syndrome as a diagnosis? The diagnostic criteria for CHS require evidence of relief of symptoms with sustained cessation from cannabis, which makes them of limited utility in the Emergency Department (ED) [1]. However, a number of ED-based diagnostic criteria have been proposed with overlapping features [1,2]. There are 3 key components to assess for when making a presumed diagnosis: An episodic pattern of vomiting Episodes of vomiting should last < 7 consecutive days Asymptomatic periods often last > 1 month between episodes Prolonged cannabis use Criteria vary: normally >1 time per week (often daily) for at least 1 year Importantly, this is not an intoxication effect from a single large ingestion Exclusion of alternative diagnoses Look for atypical features on history & exam including abnormal vital signs, diarrhea, focal abdominal pain, peritonitis, and jaundice It is important to exclude pregnancy in all female patients If a patient has never had an esophagogastroduodenoscopy (EGD), it is reasonable to refer newly diagnosed patients to gastroenterology for a non-emergent EGD to assess for a structural cause of the patient’s symptoms What causes cannabinoid hyperemesis syndrome? There is no singular theory that fully explains CHS. Importantly, the pattern of illness does not correlate well with the amount of cannabis consumed acutely, suggesting it is not related to a direct effect of the delta-9-tetrahydrocannabinol (THC) or a withdrawal effect. There are two prevailing theories related to changes in … Continue reading ED Management of Cannabinoid Hyperemesis Syndrome: Breaking the Cycle