Intussusception in an Adult With Chronic Cannabis Use: A Case Report

Abstract

Intussusception is a rare finding in adults presenting with abdominal pain. In the absence of obstruction, environmental factors should be investigated. Cannabinoid Hyperemesis Syndrome (CHS) and its relationship to intussusception in adults has not been established but should be considered if the clinical course matches the criteria and an obstruction has been ruled out. A recent article in The New York Times identified the syndrome as a commonly missed diagnosis that may affect an estimated 2.7 million Americans that are known to smoke marijuana. Patients present to the emergency department (ED) an average of 7 times before a diagnosis is made, expending up to $100,000 in medical resources. With the recent legalization of marijuana by many states, more patients are suspected to present with this syndrome. This case represents an example of how a delay in making a clinical diagnosis correlates to overtesting and rising medical costs. A 30-year-old female with a history of inhaled cannabis use since adolescence presented to the ED with abdominal pain, nausea, and vomiting. She has a history of multiple visits with similar symptoms in the last 3 years. Symptomatic relief at home was previously achieved with hot showers. The patient was managed for nausea and discharged home. The following day, she returned to the ED with severe abdominal pain and intractable vomiting. Abdominal CT revealed 3 jejunal intussusceptions:1 on the right and 2 on the left. Previous imaging on past presentations showed multiple intussusceptions along the small bowel, but a pathological lead point was never identified. She was admitted to the surgical unit and managed conservatively. On day 3, the abdominal pain subsided and repeat imaging showed resolution of all intussusceptions. Cannabinoid Hyperemesis Syndrome (CHS) is a phenomenon associated with long-term cannabis use. It can be diagnosed clinically by the following criteria: cannabis use, abdominal pain, nausea and vomiting, and symptom relief with hot showers and cannabis cessation. Our patient meets all of the criteria but the correlation to CHS was not previously considered, leading to repeat diagnostic testing and unnecessary hospital admission. In an economy where healthcare costs account for 17.9% of the GDP, reducing medical interventions that add low value to healthcare outcome is critical for the financial sustainability of our health systems. One solution lies in restoring the confidence of making a clinical judgment.3072_A Figure 1. Axial contrast enhanced CT scan of the abdomen showing a target-like mass in the small bowel, pathognomonic of intussusception.3072_B Figure 2. Ring-like configurations in the right and left mid abdomen showing evidence of additional intussusceptions (arrow).3072_C Figure 3. Sagittal contrast enhanced CT scan of the abdomen demonstrating a sausage-like mass, typical of a small bowel intussusception. No obstruction or lead point is identified.