Cannabinoid hyperemesis syndrome

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Cannabinoid hyperemesis syndrome is a disorder that is characterized by recurrent nausea, vomiting and colicky abdominal pain. These symptoms have been reported to be alleviated temporarily by taking a hot shower or bath or more permanently by abstaining from the use of cannabis. The syndrome is recognized by Allen and colleagues (2004), and Sontineni and colleagues (2009) who offer simplified clinical diagnostic criteria.[1][2] While there have been anecdotal testimonies to the veracity of this condition, caution should be exercised concerning this medical evidence due to small numbers of patients studied. However, a subsequent study reporting the clinical features of Cannabinoid hyperemesis in 98 subjects has confirmed the earlier reported findings.[3]

Contents

Epidemiology

Cannabinoid hyperemesis was first reported in the Adelaide Hills of South Australia.[1] Since then, several cases have been recognized worldwide.[4] Cannabis is by far the most widely cultivated, trafficked and used illicit drug. Half of all drug seizures worldwide are cannabis seizures.[5] The geographical spread of those seizures is also global, covering practically every country of the world. About 147 million people, 2.5% of the world population, consume cannabis, compared with 0.2% consuming cocaine and 0.2% consuming opiates. In the present decade, cannabis use has grown more rapidly than cocaine and opiate use. The most rapid growth in cannabis use since the 1960s has been in developed countries in North America, Western Europe and Australia. Cannabis has become more closely linked to youth culture and the age of initiation is usually lower than for other drugs.[5] "Given such a widespread use of cannabis, the cannabinoid hyperemesis syndrome is afflicting large number of people and is steadily rising in its incidence".[6]

Clinical presentation

Cannabis has been used recreationally for millennia. Some chronic negative health effects of the drug have only recently surfaced. The long-term and short-term toxicity of cannabis abuse is associated with pathological and behavioural effects leading to a wide variety of effects on the body systems and physiologic states.[2] The phenomenon of cannabinoid hyperemesis and clinical diagnosis remained obscure until recently even though its features were beginning to be understood by leading physicians worldwide. In spite of these early reports, uncertainty remained among the doctors and scientists regarding the existence of the cannabinoid hyperemesis syndrome.[7] Sontineni and colleagues (2009) discuss the cannabinoid hyperemesis syndrome to offer guidelines for the clinical diagnosis.[2] The "suggested criteria for the diagnosis" are: Essential feature: 1) history of regular cannabis use for years; Major clinical features of syndrome: 2) severe nausea and vomiting, 3) vomiting that recurs in a cyclic pattern over months and 4) resolution of symptoms after stopping cannabis use. In addition diagnosis has supportive features of - 1) compulsive hot baths with symptom relief; 2) colicky abdominal pain; and 3) no evidence of gall bladder or pancreatic inflammation. Since the publication of these clinical guidelines, the syndrome is more easily recognized and treated. A series of 98 cases and review suggested modifications to original set of criteria that are listed below.

Sontineni et al. criteria for the diagnosis of "cannabinoid hyperemesis syndrome"[2]

EssentialCannabis use for years
MajorSevere nausea and vomiting

Vomiting that recurs in a cyclic pattern over months

Resolution of symptoms after stopping cannabis use.

SupportiveCompulsive hot baths with symptom relief

Colicky abdominal pain

No evidence of gall bladder or pancreatic inflammation


Modified criteria for the diagnosis of "cannabinoid hyperemesis syndrome"[3]

EssentialLong-term cannabis use
MajorSevere cyclic nausea and vomiting

Resolution with cannabis cessation

Relief of symptoms with hot showers or baths

Abdominal pain, epigastric or periumbilical

Weekly use of marijuana.

SupportiveAge less than 50 y

Weight loss of >5 kg

Morning predominance of symptoms

Normal bowel habits

Negative laboratory, radiographic, and endoscopic test results

One of the key feature that makes cannabinoid hyperemesis syndrome relevant to health care systems and physicians is its acute nature with nausea and vomiting, frequently requiring emergency room visits. Such emergency room visits often necessitate expensive diagnostic evaluations especially if the physician's awareness of the syndrome is lacking. In 2002, Americans made 110.2 million total visits to hospital emergency rooms with abdominal pain leading as a cause, a population-adjusted 2.6 percent increase over the 90 million visits made in 1992.[8] Such an enormous increase in the number of emergency room visits increases health care costs. Given the implications and lack of clarity, it is of major significance that leading researchers in the field offer simplified clinical diagnostic guidelines to improve the recognition of the syndrome and increase awareness at a time when cannabis use is on the rise.[9] It is also suspected that cannabinoid hyperemesis that is observed in emergency room departments is probably the tip of the iceberg and that far larger numbers of milder symptoms do not come to attention in the broader community.[10]

Pathogenesis

Various pathogenic mechanistic theories attempting to explain symptoms have been put forward. These theories fall into two themes: 1) dose dependent build up of cannabinoids and related effects of cannabinoid toxicity, and 2) the functionality of cannabinoid receptors in the brain and particularly in the hypothalamus (which regulates body temperature and the digestive system). But the mechanisms by which cannabis causes or controls nausea and the adverse consequences of long-term cannabis toxicity remain unknown and organic disease should not be ruled out as a possible cause.[11]

The neurobiology of the compound has led to the discovery of an endogenous cannabinoid system.[12] The therapeutic potential of cannabinoids has been recognized and these compounds are utilized as anti-emetics. Several studies have demonstrated the therapeutic effects of cannabinoids for nausea and vomiting in the advanced stages of illnesses such as cancer and AIDS.[5]

References

  1. ^ a b Allen, J H; De Moore, GM; Heddle, R; Twartz, JC (2004). "Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse". Gut 53 (11): 1566–70. doi:10.1136/gut.2003.036350. PMC 1774264. PMID 15479672. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1774264/. 
  2. ^ a b c d Sontineni, Siva-P; Chaudhary, S; Sontineni, V; Lanspa, SJ (2009). "Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse". World Journal of Gastroenterology 15 (10): 1264–6. doi:10.3748/wjg.15.1264. PMC 2658859. PMID 19291829. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2658859/. 
  3. ^ a b Simonetto, Douglas A.; Oxentenko, Amy S.; Herman, Margot L.; Szostek, Jason H. (2012). "Cannabinoid Hyperemesis: A Case Series of 98 Patients". Mayo Clinic Proceedings 87 (2): 114–9. doi:10.1016/j.mayocp.2011.10.005. PMID 22305024. 
  4. ^ Roche, E; Foster, PN (2005). "Cannabinoid hyperemesis: Not just a problem in Adelaide Hills". Gut 54 (5): 731. PMC 1774504. PMID 15831930. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1774504/. 
  5. ^ a b c World health Organization, Cannabis - epidemiology.
  6. ^ Fox News, New 'Severe Vomiting' Syndrome Linked to Chronic Pot Use.
  7. ^ Byrne, A; Hallinan, R; Wodak, A (2006). "'Cannabis hyperemesis' causation questioned". Gut 55 (1): 132; author reply 132. PMC 1856368. PMID 16344581. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1856368/. 
  8. ^ National Center for Health Statistics Data on Emergency Department Visits (reported on March 18, 2004; Advance Data Number 340. 35 pp. (PHS) 2004-1250).[1]
  9. ^ Reuters, Chronic marijuana abuse linked to severe vomiting
  10. ^ Danny, By (2009-03-23). "Cannabis users 'suffering new syndrome'". News.com.au. http://www.news.com.au/national/cannabis-users-suffering-new-syndrome/story-e6frfkvr-1225692724003. Retrieved 2012-05-24. 
  11. ^ "NCPIC.Cannabinoid hyperemesis syndrome". Ncpic.org.au. http://ncpic.org.au/ncpic/publications/research-briefs/article/cannabinoid-hyperemesis-syndrome. Retrieved 2012-05-24. 
  12. ^ Davis, Mellar; Maida, Vincent; Daeninck, Paul; Pergolizzi, Joseph (2006). "The emerging role of cannabinoid neuromodulators in symptom management". Supportive Care in Cancer 15 (1): 63–71. doi:10.1007/s00520-006-0180-0. PMID 17139494. 

Further reading