Cannabinoid Hyperemesis CHS & Cyclic Vomiting CVS in Adults ACG

Despite negative workups, physicians must consider CHS when standard treatments fail and patients continue to present with persistent symptoms related to cannabis use. The difficulty in diagnosing CHS arises because its symptoms overlap with other gastrointestinal and metabolic disorders, such as gastroparesis, cyclic vomiting syndrome, or peptic ulcer disease. Overlapping symptoms such as abdominal pain and cyclic vomiting are especially difficult to pinpoint to a specific illness. Initial symptoms are feeling sick to the stomach, belly pain and the feeling like you may throw up.

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If someone presents to the hospital with symptoms of CHS, they must be diagnosed through exclusion, after ruling out all other possible explanations. Swartz and Franceschini argue that the COVID-19 pandemic likely catalyzed the recent rise in CHS through stress, isolation, and increased cannabis use. CHS is a relatively new disorder that is not only difficult to diagnose but to manage.

• Another study showed that emergency department visits for CHS increased more than 10-fold between 2016 and 2023 for adolescents 13-21.
• Pergolizzi et al. 20 provide an in-depth exploration of the pathogenesis of CHS.
• In the gastrointestinal system, CB1 receptors are found on both intrinsic and extrinsic neurons, with the enteric nervous system serving as the major site of action 9.
• If you have CHS and don’t stop using, your symptoms like nausea and vomiting are likely to come back.
• She frequently writes about technology, education, literature and general news.
• Furthermore, gastric emptying rates in patients with CVS are often accelerated rather than delayed 46,65.
• Initial follow-up was every month, where the patient was seen by clinicians and counsellors, both of whom reported good compliance.

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Along with the discovery of the CB1 and CB2 receptors has been the identification of endogenous arachidonic acid derivatives that bind to these receptors (Figure 1). These compounds are referred to as endogenous cannabinoids, or endocannabinoids. The best characterized endocannabinoids are anandamide and 2-arachidonylglycerol (2-AG) 9.

Shortcomings in our knowledge of CHS and areas for future research

The hyperemetic phase is characterized by unrelenting nausea and severe vomiting that is often resistant to conventional anti-nausea medications. Patients frequently discover that hot showers or baths provide temporary but substantial relief from the overwhelming symptoms. This practice, known as hydrothermotherapy, is one of the most distinctive features of the syndrome, though its mechanism is still being investigated. Both cannabinoid hyperemesis syndrome (CHS) and cyclic vomiting syndrome (CVS) cause people to feel sick to the stomach and throw up at times, while feeling normal at other times. This is more common in men than women and usually starts around 35 years old. These two conditions are hard to distinguish between and the main difference is CHS happens with using a lot of marijuana.

Possible contributors include higher use rates, higher potency products, different consumption methods, and better recognition in clinical settings. In severe episodes, people can’t keep fluids down, can’t stop retching, and may need emergency care for dehydration and symptom control. The underlying reason for this necessity involves how the body stores and processes the main psychoactive component, tetrahydrocannabinol (THC). THC and other cannabinoids are fat-soluble and can accumulate in the body’s fat tissues over months or years of heavy use.

Neither the psychological treatments nor the pharmacological treatments seem to be that effective,” he said. Camilleri also said that cannabis use is positively correlated with anxiety and depression, and noted that doctors should treat the whole patient and not just the disorder. Ultimately, the only way to guarantee health is by totally abstaining, he added. If the patient quits cannabis consumption, vomiting due to CHS largely subsides. It’s possible that with lower amounts or lower frequency, patients might be able to use cannabis again, but the science is unclear. Typical antiemetics such as ondansetron, commonly known as Zofran, have often been found ineffective at suppressing nausea caused by CHS.

• A greater understanding of the natural course of the syndrome and response to marijuana cessation may be gained with longer lengths of follow-up.
• Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research.
• Given the rise of CHS cases in regions with legalized cannabis markets, public health agencies should prioritize research funding to fill these gaps and inform future policy.

The criteria are satisfied if the symptoms last for 12 weeks, with symptoms starting 6 months before diagnosis. But it’s also important to acknowledge the positive uses of marijuana, Camilleri said. When Dr. Deepa Camenga began her career about 20 years ago, she rarely if ever saw alcoholism pediatric patients with CHS, she said. Today, hospitals in her area around New Haven, Connecticut, see pediatric CHS cases nearly every day, she added. However, Camilleri said that men are more likely to develop it, as are people who have used marijuana frequently and for many years. Studies that were purely theoretical without clinical data or those that focused exclusively on animal models were excluded, as the review aimed to capture human clinical insights into CHS.

Current recommendations in the diagnosis and management of cannabinoid hyperemesis syndrome

Experts say the medical field is woefully behind on understanding the rapidly changing drugs. “There’s a difference in legalizing the original cannabis on the planet and the products that exist today,” neuroscientist Yasmin Hurd said to the Times. Hurd was the lead author of a 2017 report on the health effects of cannabis from the National Academies of Sciences, Engineering and Medicine, which warned that the lack of evidence-based information posed a public health risk.

• The development of such guidelines would not only benefit clinicians but could also improve patient outcomes by ensuring timely and accurate treatment.
• Some chronic marijuana users experience a condition, dubbed ‘scromiting,’ that causes people to vomit as often as five times per hour.
• People with CHS often find temporary relief from these symptoms by taking hot baths and showers.
• The more severe stage arrives later, when, for a day or two after cannabis use, patients are beset by overwhelming and recurrent vomiting and nausea.

The only known definitive cure for Cannabinoid Hyperemesis Syndrome is the complete cessation of all cannabis products. This includes all forms, such as flower, edibles, concentrates, and synthetic cannabinoids. Continued use, even in small amounts, will almost certainly trigger a recurrence of the hyperemetic phase, restarting the cycle of severe vomiting. Despite the increasing popularity and legalization of cannabis in many states, there remains a lack of consistent and comprehensive public health policies to address cannabis-related disorders like CHS. Unlike alcohol and tobacco, which have well-established health warnings and regulations, cannabis products are not universally required to include health warnings or educational materials.

Other known complications of forceful and uncontrolled vomiting include aspiration and subsequent pneumonitis or aspiration pneumonia as well as injury to the esophageal wall such as Boerhaave’s syndrome. It’s important to be honest about your marijuana use if you have symptoms of CHS. Without knowing this background, providers often misdiagnose CHS as other conditions, like cyclic vomiting syndrome (CVS). Cannabidiol (CBD) and cannabigerol (CBG) are two additional cannabinoids found in cannabis that appear to modulate the anti-emetic properties of THC.

When these receptors are activated, they can influence mood and behavior, and in some individuals, may contribute to adverse psychological effects such as depression and suicidal ideation. This raises important concerns about the safety profile of future cannabinoid-based medications and therapies. As research progresses, careful consideration will be needed to balance therapeutic benefits with the potential for harmful side effects, particularly for vulnerable populations. The modulation of CB1 receptors holds promise but also necessitates further investigation to ensure the safety and well-being of patients undergoing such treatments 44-46. The only treatment identified to fully resolve the symptoms of CHS is cannabis cessation.

• Other pharmacologic alternatives were also explored with mixed to unproven efficacy.
• While clinical features such as chronic cannabis use, intractable vomiting, and relief with hot baths are commonly reported, these are not pathognomonic.
• “It may be that the cannabinoid is only sort of one aspect of the way the patient is hurting that needs to be addressed to really get them to heal,” he said.
• While waiting for answers, she noticed an educational pamphlet on cannabinoid hyperemesis syndrome (CHS), a little-known illness characterized by an onset of intense vomiting.
• Unfortunately, many of these patients relapse upon resuming cannabis 6,59,61,62.

A rare but severe condition, cannabinoid hyperemesis syndrome is caused by heavy cannabis use and is “marked by nausea, vomiting and pain,” said The New York Times. It can lead in some cases to extreme dehydration, seizures, kidney failure and cardiac arrest. The new research suggests that the condition may impose a heavy burden on individuals who suffer from it as it often results in pain, vomiting, and costly trips to the hospital.

Endocannabinoids play their part in allostasis by promoting recovery from stress and further bring back homeostasis of the neurotransmitters, neurohormones, and neuropeptides 32. Other cannabinoids, such as CBD and cannabigerol (CBG), may also contribute to the development of CHS. At low doses, CBD is known to be antiemetic, but at higher doses, it can become proemetic. CBG has the potential to reverse the antiemetic effects of CBD, suggesting that CHS could result from the interplay between high levels of CBD and its reversal by CBG 25,26. In one study, about 84% of people who received treatment for CHS stopped using cannabis, and of those, about 86% reported resolution of symptoms.