Cannabinoid hyperemesis syndrome is not inherently life-threatening, but complications related to forced retching / vomiting or electrolyte abnormalities may potentially require urgent stabilization.
- Consider upper gastrointestinal (GI) bleeding if the patient develops coffee-ground emesis.
- Consider esophageal rupture if chest pain develops.
- An ECG may help evaluate for signs of significant electrolyte abnormalities such as hypokalemia with T wave abnormalities, prolonged QT/QTc, or prolonged QRS.
- Volume resuscitation may be necessary if tachycardia or hypotension are present.
Cannabinoid hyperemesis syndrome is characterized by recurring episodes of intractable nausea, abdominal pain, and vomiting in long-term cannabis users. Onset of the syndrome occurs after several years of chronic cannabis use and occurs more frequently in males. Most patients report long-term daily use. Each episode of hyperemesis typically lasts 24-48 hours. The term "scromiting" (a portmanteau of screaming and vomiting) has been adopted in some areas, as well as by the lay media, to describe the condition.
The provoking mechanism is uncertain. Prior to each episode, the user may experience a prodrome of autonomic symptoms such as agitation, sweating, flushing, thirst, and anxiety. Dehydration is common following episodic vomiting. Patients often continue to use cannabis, mistakenly believing that it will help when, in actuality, it prolongs the symptoms. Resulting complications may include gastritis, esophagitis, hypokalemia, and rarely acute renal failure. More significant complications can be related to continued forced vomiting and retching and can include esophageal rupture or pneumomediastinum.
Lack of knowledge of this syndrome may lead to delayed diagnosis, and misdiagnosis of cyclic vomiting syndrome may occur. A patient history of chronic use of marijuana and compulsive hot showers to alleviate symptoms of hyperemesis suggests cannabinoid hyperemesis syndrome.
Management should focus on the exclusion of more serious alternate etiologies through a thorough history taking and physical examination and the use of additional diagnostic testing if the diagnosis remains uncertain. Rehydration and symptomatic care are indicated. Antiemetics appear to have little or no effect in control of nausea and vomiting. Dopamine antagonists tend to be most effective for symptomatic management in the ED. Newer studies support the use of topical capsaicin cream over the abdominal wall as adjunctive therapy. Abstinence from cannabis use is the cornerstone of long-term management. If the patient resumes cannabis use, the hyperemesis syndrome typically returns.
Related topics: cannabis use disorder, synthetic cannabinoid adverse reaction
