Chronic Cannabis Abuse Puts You in Hot Water

Abstract

Purpose: A 36 yr old women presented to the hospital reporting chronic nausea and vomiting. She reported episodes of severe nausea and vomiting lasting for few weeks at a time associated with abdominal pain and intervening periods of relative quiescence. She had underwent an extensive evaluation including routine blood tests, EGD, CT scans of head, chest abdomen and pelvis which were unremarkable. SBFT, Metabolic and endocrine work up was negative. Urine drug screen on multiple occasions was positive for cananbis. On follow up in the clinic she revealed that sitting in the hot water is the only way to get relief from her symptoms. She reported that at times she sleeps in the water tub. On review of the literature it became apparent that chronic cannabis use can present in such a fashion. On confrontation she reported that she smokes cannabis for the last 15 yrs. She also reported that during her last pregnancy and 6 months post partum when she refrained from cannabis she felt better and did not have symptoms. Her current symptoms worsened after her relapse. She agreed on abstinence from cannanbis and is scheduled for close follow up. Discussion: Cannabis is widely known to have anti-emetic properties. Tetrahydrocannabinol is the major ingredient in marijuana. Cannabinoid hyperemesis is a paradoxical reaction which occurs with long term cannabis use resulting in severe nausea and vomiting. It includes a cluster of symptoms characterized by cyclical vomiting and compulsive bathing behaviours. In Southern Australia, Roche et al. found that cases previously termed as psychogenic vomiting are often related to chronic cannabis use. It was observed that cessation of cannabis leads to cessation of cyclical vomiting illness and reuse would result in a relapse of symptoms weeks or months later. The etiology of cannabinoid hyperemesis is not known. The various stages of the illness as discribed by Allen et al., are the prodromal phase which is characterized by early morning nausea and vomiting on one or more days of the week with fear of vomiting and severe nausea at the smell of food. In the later phase of the illness, symptoms are relatively stereotyped with profuse vomiting, intense sweating, colicky abdominal pain accompanied by polydipsia. Patients develop a compulsive bathing behaviour and take multiple hot showers or as in our case sit in a tub filled with hot water for prolonged periods of time. Management during the active phase of illness is supportive. Cessation of cannabis lead to cessation of symptoms. The diagnosis can be made with the aid of an inexpensive consented drug screen. This entity should be included as an important differential diagnosis for unexplained vomiting in communities with high prevalence of cannabis use.