Cannabinoid Hyperemesis Syndrome

1. Cannabinoid Hyperemesis Syndrome By Amanda Day RN,BSN

2. Chief Complaint&History of Present Illness • Brought in today by EMS for abdominal pain vomiting x 4 days. Pt reports that he has been nauseated and unable to eat or drink anything x 4 days since he ate a calzone and salad at Olive Garden with friends the other day. His only relieving factor is a hot bath. He states he has intense diffuse abdominal pains which are stabbing and burning in nature, and nausea, which is worsened by PO intake. He states he drank a red Gatorade today and is now having red vomitus which is watery without consistency as he has not eaten. He also reports his last BM was 4 days ago, hard and dark black in color.

3. Past Medical History • Pt reports a long history of gastritis GERD secondary to gastritis. He states that he has been in the ER multiple times for this in the past. He recently moved to the area and has not established primary care here locally. Pt has PMH of gastritis since age 18. He reports that he has been seen and treated in the ER with multiple diagnostic tests but all tests are always negative. He does not currently have a PCP as he recently moved here from San Antonio and has not established care with a PCP yet.

4. Past Medical History Surgical History • Pt denies any surgeries in the past including circumcision Family History • His mother is deceased at age 56 due to complications from Hep C and also had epilepsy. Father also Hep C positive. Pt reports all tests for him have been negative.

5. Past Medical History Social History • Drinks socially (4-6 beers and/or drinks of liquor 1-2 night per week) • Smokes 1/2 ppd cigs x 5 years • Smokes marijuana daily Medications • He currently takes Zantac 150mg PO BID • Denies other meds • Has NKDA.

6. Review of Symptoms • General: Pt denies significant weight changes in the past 6 months and states that his weight has remained within 5lb range. He reports decreased appetite due to N/V. He also reports increased sleeping and fatigue and states that the abd pains frequently wake him up at night. Denies fever or diaphoresis, but positive for chills. Reports generalized body aches and weakness. He states he feels that he is in fair health but that the nausea and vomiting and abd pains are interfering with his work and social life. • Skin: Denies rashes, skin lesions/breakdown, moles, hair loss, dryness, change in nails, sores, or pruritis • HEENT: Denies visual changes, HA, head trauma, dizziness, diplopia, otalgia, otorrhea, hearing changes, rhinorrhea, epistaxis, sinusitis, hoarseness, tinnitus, vertigo, gingival bleeding, or neck/throat masses. Reports sore throat due to vomiting. • Respiratory: Denies cough or sputum, hemoptysis, dyspnea, SOB, adventitious breath sounds, stridor, occupational exposures, TB exposure, asthma, bronchitis, recent infections, pleuritic pain, sleep apnea, or tachypnea. • Cardiovascular: Denies hypertensions, orthopnea, edema, angina, arrhythmia, nocturnal dyspnea, cyanosis, ascites, claudication, varicose veins, DVT, cramping, Raynaud’s syndrome

7. Review of Symptoms Cont.. • GI: Reports nausea and vomiting intermittently since age 18 with most recent episode occurring x 4 days now. Reports decreased appetite, denies weight changes, Reports hx of GERD, and chronic gastritis. Denies hematemesis, although his vomitus was bright red in color after drinking a red Gatorade. Denies jaundice. Reports stools are black in color and hard. Last BM 4 days ago. History of chronic constipation. Denies known PUD. Denies belching or flatulence. Positive indigestion. . Denies hematochezia/melena/ or pruritus. • GU: Denies urinary pain, frequency, burning, hesitancy, urgency, or incontinence. Denies hematuria or flank pain. Reports that urine is clear and yellow and he has not noticed any odor. Denies hx of STD/UTIs/or renal stones. Reports decrease in libido. • MSK/Neuro: Denies edema/varicosities/numbness/tingling/parasthesias. Denies cyanosis/vertigo/sudden loss of consciousness/loss of sensation/unsteady gait. Denies any hxof seizures/loss of memory/syncope • Hematologic: Denies bleeding, pallor, bruising, enlarged lymph nodes. Denies hx of anemia, or chronic infections. Denies night sweats/fever. Reports intermittent chills, in addition to increased fatigue and weakness. • Psych/Neuro: Denies history of anxiety/depression. Reports recent sleep disturbances due to nausea/vomiting and increased abd pain.. Reports irritability with pain/N/V. Denies apathy/mood swings/suicidal or homicidal thoughts.

8. Physical Exam Findings • General: Pt moaning and yelling loudly in pain, facial grimacing noted. BP 131/78 ; HR 72; Temp 99.0; Resp22; O2 sats99% on RA; Pt A&Ox4. Pt is well nourished/hydrated. Appears to be having increased SOB with conversation but not in respiratory distress at this time. Well developed. Smooth gait and posture. Nail beds pale and smooth, clean, without clubbing./cyanosis. Capillary refill < 3 seconds. Skin pink and warm, no cyanosis/petechiae noted. Good turgor. • ENT: Head normocephalic, symmetric, holds erect and midline. PERRLA, conjuctiva and lacrimal system are without discharge or erythema; Sclera white; no ptosis; no periorbital edema present; all extraocular movements are present without nystagmus or fasciculation’s. No ictera noted. Ears are nontender, without erythema/lesions/discharge/abnormal growths. External cartilage is firm without any palpable indurations. External auditory canals are clear. Bilateral tympanic membranes are patent and appear pearly gray with a present light reflex, bony landmarks noted in both ears; no bulging or erythema noted. Nose is midline, no lesions noted on exterior surface; no nasal flaring or narrowing. Nares are patent. Nasal Cartilage is firm and non-tender. Septum is intact without perforations; no crusting, lesions, or polyps noted. Turbinatesare nonedematous/nonerythematous. Dentation intact. Oral mucosa pink and moist. No lesions of mouth noted. Normal pink and moist pharynx. Uvula rises evenly, gag reflex intact. Neck supple, nontender, no masses or nodules, trachea midline, no goiter. Thyroid rises evenly and symmetrical. No cervical lymphadenopathy noted.

9. Physical Exam Findings Cont.. • Cardiac: Neck vein distention present, rate and rhythm regular and normal, S1 and S2 present, no rub/gallop/murmur/clicks auscultated. No thrill or heaves noted. No edema. Pulses +2 and symmetric throughout. Extremities pink and temp warm to touch. • Respiratory: Respiratory rate and rhythm even and unlabored, no use of sternocleidomastoid muscle or intercostal retractions noted. No audible wheezes, rales, crackles auscultated. All lung fields clear to auscultation. No pursed lipped breathing noted. Normal fremitus. No dullness. • GI: Pt with diffuse abd tenderness and guarding with light palpation. RUQ and LUQ abd rebound tenderness. Abdomen soft, nondistended. Bowel sounds normoactivex 4. No ascites present. No rebound tenderness/nodularities, or enlargement of liver or spleen noted. No hernias. No protrusions. Umbilicus is midline and inverted. Last BM 02/06/14.Murphy's sign/obturator/merkle signs all negative. • GU: Denies flank pain or CVA tenderness, no bladder distention and nonpalpable. • Skin: color is consistent throughout, no lesions/masses/discolorations/rashes/ecchymosis. • MSK: Gait is smooth and rhythmic. Musculature is symmetrical. Full active and passive range of motion noted in all extremities. No tenderness noted on palpation of joints. Strength is a 5/5 in all muscle groups. • Physch/Neuro: Pt with rapid speech and flight of ideas. Increased anxiety and restlessness throughout questioning. Judgment and insight intact. Intact memory for recent and remote events. Reflexes are intact. CN’s intact.

10. Differential Diagnoses • Acute Gastroenteritis • Cholelithiasis • Cyclic Vomiting Syndrome • Appendicitis • Intestinal Obstruction • Diverticululitis

11. Diagnostics Ordered • CBC(to determine possible blood loss or infection) • CMP (liver enzymes, electrolyte imbalances) • Amylase/Lipase (determine possible pancreatic involvement) • Guiac Stool (possible GI hemorrhage/ulcer) • UA (determine renal involvement, urine drug screen) • Abdominal U/S: gallbladder/renal stones, bowel obstruction • Will order CT with contrast if suspected appendicitis/pancreatitis or GI infection (such as diverticulitis) or GI obstruction; or if elevated WBC count/bilirubin/ or intestines appears to be blocked)

12. Diagnostic Results • Abd ultrasound negative for fluid in morrisons pouch or murphy's sign today. Gallbladder without wall thickening, sludge, or pericholecysticfluid. Occult stool negative. Labs including CMP, CBC, and pancreatic enzymes all within expected range today.

13. Cannabinoid Hyperemesis Syndrome (CHS) • Newly described in 2004 • characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and the learned behavior of hot bathing which occurs by an unknown mechanism • Very similar to many of the same symptoms as cyclic vomiting syndrome • Frequent hot bathing produces temporary relief from nausea and abdominal pain

14. Cannabinoid Hyperemesis Syndrome (CHS) • Tetrahydrocannabinol, cannabidiol, and cannabigerol are three cannabinoids found in the marijuana plant and have an oppsing effect on the GI and CNS systems and actually activate the emetic response system

15. Treatment and Follow Up • Treatment is supportive therapy; including antiemetics, fluid volume replacement, and abdominal/visceral pain management • Pt given the following meds upon at this time: maalox, ketorlac, and lidocaine for GI pain (known as a GI Cocktail). Pt also given zofran for nausea and vomiting prior to leaving ER. • Pt given scripts today for ultramfor abd pain and phenerganfor nausea. • Pt given referral today for GI and psych. Studies indicate pts may have varying degree of gastritis or esophagitis and acid suppression therapy should be initiated such as PPIs, in addition to monitoring via endoscopy for progression of varying disease. Also, pt’s have a learned behavior of compulsive bathing in addition to their illicit drug use for which psychiatric evaluation and treatment may prove to be beneficial. Pt instructed on importance smoking and marijuana cessation as buildup of THC is causing pt's discomfort. Pt also given handout today on dx and smoking cessation.

16. References Galli, J. A., Sawaya, R. A., Friedenburg, F. K., (2013). Cannabinoid hyperemesis syndrome. Current Drug Abuse Reviews, 4(4), 241-249. Sullivan, S. (2010). Cannbinoid hyperemesis. Canadian Journal of Gastroenterology, 24(5), 284-285.