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Nausea and vomiting with stomach pain and cramping often co-occur in many health issues, such as food poisoning and stomach flu. However, some people may continue having cyclical vomiting syndrome (CVS), where they experience repeated episodes of severe vomiting preceded by nausea without any indication of an ongoing illness or infection.
Also known as psychogenic vomiting, CVS is very common in adults and children and sometimes indicates an underlying behavioral problem. Some research also suggests it as a sign of abdominal migraine or headaches. However, in 2004, scientists first associated it with marijuana use. Following more research, this association was termed cannabinoid hyperemesis syndrome (CHS). Despite being under investigation for nearly two decades, scientists are yet to know more about Cannabinoid Hyperemesis Syndrome. Due to a lack of awareness, the condition may go unnoticed and undiagnosed, wrecking the quality of life for many.
What is Cannabinoid Hyperemesis Syndrome and What Causes it?
Cannabinoid Hyperemesis Syndrome describes a series of constant vomiting episodes secondary to marijuana use. [1] While experts still do not know what causes this condition, several theories are under study, none of which has strong evidence-backed research. Some of these theories include the following:
Genetics
Some people might be more susceptible to acquiring CHS than others due to genetic variations.
Dysregulation of specific receptors
So far, two receptors called CB1 and CB2 are known to bind marijuana in the human body. These receptors are found in the brain, immune system, and gastrointestinal tract and can respond to specific environmental changes or stimuli. CB1 receptors, in particular, can regulate the marijuana effects in the gut, and their long-term activation due to marijuana use can cause nausea and vomiting associated with CHS.
Disrupted temperature control
Cannabis use can alter a person’s ability to regulate their temperature, naturally triggering CHS symptoms.
Slowed digestion
Stimulation of the cannabis receptors in the brain may slow the digestive processes, causing vomiting and nausea.
Stress response
Chronic use of marijuana can mess with the hypothalamic-pituitary-adrenal axis and the consequent stress response this axis controls. As a result, the symptoms of CHS may prevail.
Toxin Buildup
People who use marijuana, in the long run, can lead to a buildup of cannabinoids in the fatty tissues of the brain and the rest of the body. This toxic effect can also be potentially responsible for the symptoms of CHS.
Enlargement of the blood vessels
Marijuana can dilate the blood vessels in the gut, which may be another cause of Cannabinoid Hyperemesis Syndrome.
CHS Syndrome: Common Symptoms and Stages
People with an underlying CHS may experience repeated bouts of vomiting while remaining symptom-free between these episodes. In general, experts divide CHS symptoms into the following three stages: [2]
Prodromal Phase
This phase includes CHS early symptoms, such as early morning nausea and abdominal pain. Some individuals may also develop an intense fear of vomiting but can eat and drink normally. Others may try to use more marijuana, believing it will help with nausea. The prodromal phase may persist for months or even years.
Hyperemetic phase
Some common symptoms of the hyperemetic phase include the following:
- Ongoing nausea
- Belly ache
- Signs of excessive fluid loss or dehydration, such as dry lips and skin, sunken eyes, etc.
- Repeated episodes of vomiting
- Decreased food intake and weight loss
Vomiting may become intense and extremely overwhelming during this phase, forcing people to take lots of hot showers to ease their nausea by regulating the hypothalamus, an area of the brain that regulates body temperature and vomiting. The hyperemetic stage can sometimes become so severe that people often seek medical care. This stage usually persists as long as a person keeps using cannabis.
Recovery phase
The last phase of CHS, i.e., the recovery phase, begins when a person gives up cannabis. The usual CHS symptoms slowly disappear during this phase, making it easier to resume normal eating once again. The recovery phase can last months or years, but the symptoms can return if a person uses marijuana again.
Diagnosing Cannabinoid Hyperemesis Syndrome
Multiple health problems can lead to persistent nausea and vomiting. To differentiate CHS from these conditions, a healthcare professional will detail the ongoing symptoms while correlating them with past health. The diagnostic assessment also involves a physical exam emphasizing the abdomen. Sometimes, an expert may request additional tests to rule out other potential causes of vomiting, especially the ones considered medical emergencies. These tests may include one or more of the following:
- Blood tests to check infection or anemia
- Tests to check liver enzymes and pancreatic sufficiency
- Tests for electrolytes
- A CT scan of the abdomen to check for health problems that potentially require surgery
- Pregnancy test
- Drug screen to rule out any drug-related causes of vomiting
- Urine analysis to detect any infection or other urinary issues
- X-rays of the abdomen to confirm if there is any blockage
- A CT scan of the head to rule out any neural cause of persistent vomiting
- Upper endoscopy to closely view the stomach and food pipe
Because CHS is a relatively newer condition, some healthcare professionals may not fully know about it and miss the diagnosis for months or years. Others may confuse it with cyclical vomiting disorder, which leads to similar symptoms. A health specialist trained to deal with digestive tract issues, also known as a gastroenterologist, is usually the one to diagnose Cannabinoid Hyperemesis Syndrome.
In general, a person may be a suspect of CHS if they exhibit all of the following:
- Belly pain
- Persistent vomiting and nausea
- Long-term frequent marijuana use
- Alleviation of ongoing nausea and vomiting by hot showers
Unfortunately, no single test can confirm or negate the diagnosis of CHS at this moment. Improvement in the symptoms after stopping the ongoing marijuana use is the only way to confirm the diagnosis. [3]
Cannabinoid Hyperemesis Syndrome Treatment
Following are some treatments that can help people get past CHS as quickly as comfortably as possible:
Hot Showers/Heat Packs
Many people report feeling better after taking hot showers. Alternatively, a heat pack or a hot water bottle can relieve nausea, vomiting, and stomach pain. While you follow this technique, ensure that you do not overheat the water, or it may cause burns.
Capsaicin Cream
Some experts believe that capsaicin cream provides some relief against the common CHS symptoms. [4] While researchers are still unsure about the ideal strength, most recommend going for 0.025 to 0.1 percent of capsaicin cream. The product is available over the counter and is easy to apply directly to the stomach in a thin layer as needed.
If the remedies mentioned above are unsuccessful at relieving the symptoms, it is better to seek medical care. Urgent help is also advised if the severe CHS symptoms make it difficult to keep fluids down and cause dehydration. For such people with severe CHS, experts recommend the following treatment modalities:
IV Fluids
Fluids given intravenously can replace electrolytes and water lost due to constant vomiting. This continuous infusion can replenish hydration levels and prevent potentially life-threatening symptoms.
Antinausea Medications
Several antinausea medications are available to relieve the common symptoms of CHS readily. These medications may include metoclopramide and ondansetron, both available as pills. People who can tolerate oral feeding can use them orally at home. However, remember that these medications may not work for everyone, and sometimes, alternatives may be needed.
While the abovementioned treatments can improve the CHS symptoms and stop the persistent vomiting, they cannot cure cannabinoid hyperemesis syndrome. The condition only truly goes away when a person stops using cannabis and is likely to return once they restart using it. Hence, complete abstinence is the only way to stop its reoccurrence once and for all.
Can CHS Cause Complications?
Persistent vomiting is CHS’s biggest symptom, which can trigger dehydration and cause an imbalance in electrolytes. If medical help is not sought, many complications may arise, such as the following:
- Seizures
- Problems with the heart rhythm
- Kidney failure
- Shock
- Muscle weakness and spasms
- Brain swelling or cerebral edema
In addition to dehydration, excessive vomiting can also lead to the following complications:
- Inflammation of the esophagus, a condition called esophagitis
- Tooth decay
- Malnutrition
- Low phosphorus levels in the body, a condition called hypophosphatemia
- Low potassium in the body, a condition known as hypokalemia
- Pneumomediastinum, a condition where the air gets trained between the lungs in the chest cavity
- Tears in the esophageal muscles, a condition called Mallory-Weiss syndrome
- Aspiration pneumonia is a condition where the vomitus gets into the lungs and airway, causing choking
To prevent the abovementioned complications, a healthcare professional must act quickly to fix the underlying dehydration and rebalance electrolytes.
FAQs
When should I call my doctor for CHS?
If CHS is causing severe nausea and vomiting and you cannot eat or drink anything, call a doctor immediately before complications develop.
Who is at risk of developing cannabinoid hyperemesis syndrome?
Not every individual who uses marijuana will develop cannabinoid hyperemesis syndrome. The risk is particularly high in people who use cannabis more frequently, such as daily or weekly, for at least one year. Using the drug in high doses can also increase the possibility of experiencing CHS. Because the condition is relatively new, experts still require additional evidence to understand it better and identify the possible factors contributing to the overall risk. For now, some risk factors may include the potency of cannabis a person is using, a history of co-occurring mental or physical issues, socioeconomic status, ethnicity, age, gender, and environmental factors.
How common is cannabinoid hyperemesis syndrome?
Experts have only come to know about CHS as a medical condition. So far, the condition reportedly affects a small number of cannabis users, particularly prevalent in heavy abusers. However, some fear the condition is highly underdiagnosed, and many cases are routinely missed. One study found that up to 6 percent of people who attended the emergency room for persistent vomiting were diagnosed with a case of CHS.
How long does it take to recover from cannabinoid hyperemesis syndrome?
Once you stop taking marijuana, CHS symptoms may persist for a few days to weeks before subsiding completely. The exact duration to complete recovery may vary depending on how long you abused marijuana and in what quantities.
Is it possible to treat CHS at home?
It is possible to manage mild symptoms of CHS at home with remedies, such as regular hot baths. However, remember that too many hot baths may increase the risk of dehydration as they may trigger sweating. Sometimes, over-the-counter medications, such as ibuprofen, diphenhydramine, and capsaicin cream may also help. For patients with anxiety or restlessness, some physicians may prescribe antipsychotic medications like haloperidol to calm them down and help them transition into recovery.
Can I smoke weed if I have cannabinoid hyperemesis syndrome?
Experts strictly advise not to use cannabis in any form if they have a history of CHS, as the risk of a relapse is very high.
Is it possible to prevent cannabinoid hyperemesis syndrome?
The only guaranteed way to prevent developing CHS is by completely avoiding the use of cannabis. In addition to reducing the risk of complications, abstaining from cannabis can increase sleep quality, improve lung functions, lower the risk of anxiety and depression, and improve thinking and memory skills.
References
[1] Chu F, Cascella M. Cannabinoid hyperemesis syndrome.
[2] Russo EB, Spooner C, May L, Leslie R, Whiteley VL. Cannabinoid hyperemesis syndrome survey and genomic investigation. Cannabis and Cannabinoid Research. 2022 Jun 1;7(3):336-44.
[3] Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid hyperemesis syndrome: diagnosis, pathophysiology, and treatment—a systematic review. Journal of Medical Toxicology. 2017 Mar;13:71-87.
[4] Stumpf JL, Williams LD. Management of cannabinoid hyperemesis syndrome: focus on capsaicin. Journal of Pharmacy Practice. 2021 Oct;34(5):786-93.
