Cannabinoid hyperemesis syndrome

reference

Habboushe J, Rubin A, Liu H, Hoffman RS. The prevalence of the Cannabinoid hyperemesis syndrome for regular marijuana smokers in a city public hospital [Published Online Ahead of Print January 12, 2018]. Basic Clin Pharmacol toxicol .

objective

to collect data about the prevalence of the cannabinoid hyperemesis syndrome (CHS) in regular marijuana users.

draft

prospective observation study

participant

patients (aged 18 to 49) who presented themselves in the emergency room of a city public hospital; Out of 2,127 patients who were written to participate, 155 fulfilled the criteria for the frequency of marijuana consumption, i.e. h. Smoking marijuana on at least 20 days a month.

study parameters evaluated

Patients who presented themselves in the emergency room was administered (by a trained research assistant) a questionnaire. The survey included questions about CHS symptoms (nausea and vomiting) and rankings on the Likert scale for 11 methods for relieving symptoms, including "hot showers".

Primary result measurements

patients were classified as a phenomenon that was agreed with CHS if they had to have smoked marijuana at least 20 days a month, and also "hot showers" on the 10-point Likert scale for nausea and vomiting with 5 or more.

important knowledge

The respondents were 32.9 % (95 % confidence interval [CI]: 25.5 %-40.3 %) met the criteria for CHS experience.

practice implications

The Cannabinoid hyperemesis syndrome is a unique entity that is only associated with the use of cannabinoids. The patients typically imagine with cyclical vomiting, diffuse abdominal pain and (interestingly) relief through hot showers. Patients with CHS can repeatedly imagine in the emergency room and undergo extensive examinations, including laboratory tests, imaging and in some cases of unnecessary procedures. They are often treated with a number of pharmacological interventions, including opioids, for which it is not only lacking evidence that support their use in this context, but which can also be harmful.

Cecilia Sorensen is a doctor in the emergency room (ED) at the University of Colorado Hospital on the Annial Protection Medical Campus, which examined the syndrome. Sorensen, in a recent interview with the New York Times reported that the number of cases of cyclical vomiting, which were observed in their emergency, doubled after marijuana was legalized in Colorado, and believed that many of these cases probably related to the consumption of marijuana.

We have to keep marijuana on our differential list as a possible cause of a number of GI symptoms, including nausea, vomiting, anorexia, weight loss and chronic pain.

In March 2017, Sorensen and colleagues published a systematic literature overview of CHS. 3 In their search in medical literature, 1,253 abstracts were spotted and 183 articles were finally included in their analysis. Diagnostic characteristics of CHS were identified, and the frequency of the main features was as follows:

• history of regular cannabis for any period (100 %)
• Cyclical nausea and vomiting (100 %)
• Disconnecting the symptoms after stopping cannabis (96.8 %)
• compulsive hot baths with relief of the symptoms (92.3 %)
• male dominance (72.9 %)
• abdominal pain (85.1 %)
• weekly cannabis consumption (97.4 %).

episodes of CHS typically last 24 to 48 hours, but can take a week or more. Cannabic cessation seems to be the best treatment. A review of Khattar and Routsolias from September 2017 reported about similar symptoms as the review of Sorensen.

The symptoms of CHS are in a way paradoxical to the long -recognized anti -metal effects of cannabinoids. Many of our cancer patients use marijuana in the hope of reducing nausea and vomiting that occur after chemotherapy. At least in some cases, patients can incorrectly attribute the symptoms of CHS to cancer treatments they receive, and not the cannabinoids they take. This can be difficult to distinguish, apart from the special symptom that CHS is relieved by heat, typically very hot showers.

There are 2 main cannabinoid receptors: CB1 and CB2. The CB1 receptors are mainly in the central nervous system, while the CB2 receptors can be found mainly in the peripheral system, including gastrointestinal tract (GI). The Cannabinoid receptors regulate and optimize the release of neurotransmitters. The severe vomiting triggered at CHS can be secondary to brain stem effects or enteric neurone effects. A chronic exposure to cannabinoids leads to the end of the endocannabinoid receptors in animal models. The triggering of the peripheral receptors in the enter the enteric nerves can slow the gastric motility.

The transient receptor potential Vanilloid-1 (TRPV-1) is a G-protein-coupled receptor, which is known that it interacts with the endocannabinoid system. This receptor seems to play an important role in regulating body temperature, ^{5 and is activated by heat (temperature above 41 ° C). This can explain the clinical relief of CHS symptoms through hot showers/bathrooms.}

The TRPV-1 receptors could also explain another strange phenomenon: the symptoms of CHS can be temporarily reduced by topical use of capsaicin. Capsaicin also activates TRPV-1 receptors. In January 2018, Andrew Moon and colleagues reported that topical capsaicin in a patient with difficult CHS caused a significant, albeit temporary relief of the symptoms. They suggested that the long-term intake of cannabis can reduce the TRPV-1 signaling and impair gastric motility.

Moon was not the first to report on the use of capsaicin for the treatment of CHS. Khattar et al listed Capsaicin as a possible treatment for CHS in their review of 2017, 6 and in 2014 Lapoint and colleagues reported a complete disappearance of nausea and vomiting in a series of 5 patients after applying capsaicin cream on the stomach. reports. 8 The only known receptor in the body that interacts with capsaicin is trpv-1. In a publication from 2017, DEFIEKECK et al. 13 case stories of patients in emergency rooms in Massachusetts and Illinois, the symptoms of which were relieved by topical capsaicin.

guidelines published in March 2018 in the Western Journal for Emergency Medicine describe how capsaicin is used to treat CHS:

capsaicin 0.075 % can be applied to the stomach or the back of the arms. If the patients can identify regions of their body in which hot water relieves the symptoms, these areas should be prioritized for the use of capsaicin. The patients should be advised that capsaicin can initially be uncomfortable, but then quickly imitate the relief that they get through hot showers.

Therefore, CHS's current theory is that chronic cannabinoid exposure inactors inactors, which leads to nausea and vomiting due to central effects and vagal afferences. And the TRPV-1 inactivation changes gastric motility. Capsaicin, both warmth and skin, seem to alleviate the symptoms; It is possible that heat and capsaicin trpv-1 reactivate to normalize motility and at least temporarily reduce vomiting.

The effects of cannabis on the digestive tract are complex. Endogenic circulating cannabinoids can have a protective effect on the gastrointestinal tract, and their receptors could prove to be a therapeutic goal for the treatment of some gastrointestinal diseases, especially in inflammatory bowel diseases. However, we have to keep marijuana on our differential list as a possible cause of a number of GI symptoms, including nausea, vomiting, anorexia, weight loss and chronic pain.

In view of the fact that about 1 of 3 regular marijuana consumers in this study had symptoms of CHS, and taking into account the sub -group of patients who choose a naturopathic treatment, it is possible that a significant number of our patients suffer from CHS, but is not diagnosed.