Our mission is to inform, assist, and support people affected by gastrointestinal disorders.Our original content is authored specifically for IFFGD readers, in response to your questions and concerns. MR and EPH conceptualized the article, reviewed the literature, and drafted the first version. All authors read, corrected, developed figures/tables, and approved the final manuscript. All data generated or analyzed during this study are included in this published article. Using the keywords “Cannabis,” “Hyperemesis,” “Syndrome,” “Withdrawal,” and “Emergency Medicine,” we performed an in-depth literature review of 3 electronic databases (PubMed®, Google scholar®, and Cochrane®), aimed at all articles containing any of the above keywords, until November 2021.

• The fact that not all chronic users develop CHS suggests genetic predisposition, a feature recently described, via the identification of five gene mutations which seem to confer some level of protection from paradoxical effects of overstimulation of the endocannabinoid system 7.
• An intriguing point to keep in mind is that the Rome IV criteria include the phrase “resembling cyclical vomiting syndrome.” In that regard, it is important to distinguish between the two.
• Thus, chronic users seem to develop symptoms from stimulation of already overstimulated CB receptors (CHS) but can also develop symptoms upon cessation through decreased central nervous system stimulation (CWS).
• He says more research is needed to understand why some people suffer from the condition after prolonged cannabis exposure and others do not.
• Like many EDs worldwide, the normalization of cannabis consumption has led to an increase in the number of cannabis-related consults in the ED (positive delta from 2.3 to 13.3 cases per 100,000 ED visits in the USA from 2006 to 2013) 43.
• Since the early 2000s, both CHS and CWS have been recognized by the ICD-10 (F12.241 and F12.30 of the 10th edition of the International Classification of Diseases, respectively).

Pertinent Studies and Ongoing Trials

We know emergency departments are witnessing increasing incidents of cannabis related pathology (1). These patients often receive expansive diagnostic workups, numerous pharmacological interventions, and frequently require observation or hospitalization. A recent systematic review found poor quality of evidence beyond case reports many pharmaceuticals (20) and no randomized trials have been completed. While research continues to be in its early stages, the early recognition of CHS and treatment may prevent costly work ups, admissions and prolonged symptoms of patients suffering from CHS (17). Serotonin antagonism in the gastrointestinal tract from medications such as ondansetron, dolasetron, and granisetron likewise have varying levels of efficacy. Tricyclic antidepressants also antagonist serotonin receptors and may limit nausea due to this mechanism, though their extensive side effect profile such as transaminitis and predisposition to various dysrhythmias via QTc prolongation and QRS widening make appropriate dosing of these medications a priority.

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The incidence of cannabinoid hyperemesis syndrome in patients presenting to U.S. emergency departments is increasing. Awareness of the syndrome, along with education regarding diagnostic criteria and treatment options, may help avoid increased costs of and potential harms from testing for other conditions while providing more targeted and definitive treatment for CHS patients. As highlighted by the public health opioid crisis, emergency physicians have a responsibility to prescribe opioids only for conditions where they would benefit patients.25 A novel CHS treatment guideline is presented to assist frontline clinicians with managing this increasingly common condition. Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment.

Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review

Cannabinoid Hyperemesis Syndrome (CHS) is a condition linked to chronic, heavy cannabis use, causing severe nausea, vomiting, and a compulsive need for hot showers. While some patients use cannabis to manage GI symptoms, excessive use can actually worsen vomiting episodes, often resembling Cyclic Vomiting Syndrome (CVS). With a high potential for relapse (54% of patients achieving 2-week abstinence, and 71% relapse within 6 months 39), follow-up of patients should be initiated, if possible, from acute care 39, 44. This can be done through healthcare liaison officers, dedicated community outreach nurses, and/or group counseling sessions such as Marijuana Anonymous which works in a similar fashion to Alcoholics Anonymous, with sponsors and group discussions.

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Cannabinoid hyperemesis syndrome (CHS) is linked to long-term, frequent cannabis use, causing nausea, vomiting, and pain, often leading to hospital visits. A survey of 1,052 individuals with CHS found 85% had emergency department visits, and 44% were hospitalized. Daily cannabis use was nearly universal among sufferers, with many using it more than five times daily. To assess the burden of disease, Meltzer and his colleagues conducted a survey of 1,052 people who reported suffering from cannabinoid hyperemesis syndrome. The researchers asked questions about frequency of use, duration of the habit, the age they started using the drug, and need for emergency department or hospital care.

Encoding study reveals how the brain uses past experiences to predict the unfolding of similar events over time

CWS, on the other hand, tends to present in chronic users within 1–10 days after last THC intake, with a peak incidence between days 2 and 6. No correlation has been established between symptoms severity and quantity (of THC) previously consumed, and initial presentation (to acute care) tends to vary, with a clinical course not well defined. Symptoms, which include nausea and vomiting as well as psychological and other somatic issues, generally worsen the further the patient is from last consumption, and can last up to 4 weeks. This likely corresponds to the time needed for CB1 receptors to return to their original state in the central dopaminergic pathways; this important feature is key to long-term management of these patients, who require ambulatory follow-up rather than simple symptomatic relief 13. Cannabis-related medical consultations chs symptoms and signs are increasing worldwide, a non-negligible public health issue; patients presenting to acute care traditionally complain of abdominal pain and vomiting.

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In addition, it is drug addiction unclear why cannabis changes from a drug that has been known to ease nausea and vomiting, especially among patients undergoing chemotherapy, to causing nausea and vomiting in a subset of people. The correct identification of the underlying cannabis-related syndrome, and subsequent therapeutic choice, may help decrease ED presentations. Our study emphasizes the importance of both acute care and long-term outpatient follow-up, as key processes in cannabis-related disorder treatment. Meltzer says it is important for clinicians to advise those with frequent cannabinoid use or hyperemesis about the risks and subsequent disease burden.

This factor is a key distinguishing feature from cannabis hyperemesis syndrome, where the toxicokinetics of cannabis itself influence the course of the disease. Cannabinoid receptors CB1 and CB2 are the main receptors responsible for THC’s effects on the body (3). Some authors postulate the cannabinoid receptors in the medulla allow for the antiemetic properties of THC, while the cannabinoid receptors in the gastrointestinal tract are suspected to be the source of symptoms due to dysregulation (4,14). Others believe the TRPV1 receptor (transient receptor potential vanilloid subtype 1), which is activated by marijuana, capsaicin and heat, is altered by chronic marijuana use, and responsible for CHS (8).