Cannabinoid hyperemesis syndrome

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Cannabinoid hyperemesis syndrome is characterized by recurrent nausea, vomiting and colicky abdominal pain. These symptoms have been reported to be alleviated temporarily by taking a hot shower or bath or more permanently by abstaining from the use of cannabis. The syndrome was described by Allen and colleagues (2004), and Sontineni and colleagues (2009) who offer simplified clinical diagnostic criteria.[1][2] A subsequent, larger study reported a case series of 98 subjects with cannabinoid hyperemesis syndrome, confirming the earlier reported findings.[3] This is only a proposed disorder as it is currently unlisted in the World Health Organisation International Classification of Diseases.[clarification needed]

Signs and symptoms[edit]

The long-term and short-term effects of cannabis use is associated with behavioural effects leading to a wide variety of effects on the body systems and physiologic states.[2] The phenomenon of cannabinoid hyperemesis and clinical diagnosis remained obscure until recently. In spite of these early reports, uncertainty remained among the doctors and scientists regarding the existence of the cannabinoid hyperemesis syndrome.[4] Sontineni and colleagues (2009) discuss the cannabinoid hyperemesis syndrome to offer guidelines for the clinical diagnosis.[2] The "suggested criteria for the diagnosis" are: Essential feature: 1) history of regular cannabis use for years; Major clinical features of syndrome: 2) severe nausea and vomiting, 3) vomiting that recurs in a cyclic pattern over months and 4) resolution of symptoms after stopping cannabis use. In addition diagnosis has supportive features of - 1) compulsive hot baths with symptom relief; 2) colicky abdominal pain; and 3) no evidence of gall bladder or pancreatic inflammation. Since the publication of these clinical guidelines, the syndrome is more easily recognized and treated. A series of 98 cases and review suggested modifications to original set of criteria that are listed below.

Sontineni et al. criteria for the diagnosis of "cannabinoid hyperemesis syndrome"[2]

Essential Cannabis use for years
Major Severe nausea and vomiting

Vomiting that recurs in a cyclic pattern over months

Resolution of symptoms after stopping cannabis use.

Supportive Compulsive hot baths with symptom relief

Colicky abdominal pain

No evidence of gall bladder or pancreatic inflammation

Modified criteria for the diagnosis of "cannabinoid hyperemesis syndrome"[3]

Essential Long-term cannabis use
Major Severe cyclic nausea and vomiting

Resolution with cannabis cessation

Relief of symptoms with hot showers or baths

Abdominal pain, epigastric or periumbilical

Weekly use of marijuana.

Supportive Age less than 50 y

Weight loss of >5 kg

Morning predominance of symptoms

Normal bowel habits

Negative laboratory, radiographic, and endoscopic test results

Individual attacks can lead to complications, such as acute kidney injury.[5]


Various pathogenic mechanistic theories attempting to explain symptoms have been put forward. These theories fall into two themes: 1) dose dependent buildup of cannabinoids and related effects of cannabinoid toxicity, and 2) the functionality of cannabinoid receptors in the brain and particularly in the hypothalamus (which regulates body temperature and the digestive system). But the mechanisms by which cannabis causes or controls nausea and the adverse consequences of long-term cannabis toxicity remain unknown and organic disease should not be ruled out as a possible cause.[6]

The neurobiology of the compound has led to the discovery of an endogenous cannabinoid system.[7] The therapeutic potential of cannabinoids has been recognized and these compounds are utilized as antiemetics. Several studies have demonstrated the therapeutic effects of cannabinoids for nausea and vomiting in the advanced stages of illnesses such as cancer and AIDS.[8]


Cannabinoid hyperemesis was first reported in the Adelaide Hills of South Australia.[1] Since then, several cases have been recognized worldwide.[9] Cannabis is by far the most widely cultivated, trafficked and used illicit substance. In the present decade, cannabis use has grown more rapidly than cocaine and opiate use. The most rapid growth in cannabis use since the 1960s has been in developed countries in North America, Western Europe and Australia. Cannabis has become more closely linked to youth culture and the age of initiation is usually lower than for other illicit drugs.[8]


  1. ^ a b Allen, J H; De Moore, GM; Heddle, R; Twartz, JC (2004). "Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse". Gut 53 (11): 1566–70. doi:10.1136/gut.2003.036350. PMC 1774264. PMID 15479672. 
  2. ^ a b c d Sontineni, Siva-P; Chaudhary, S; Sontineni, V; Lanspa, SJ (2009). "Cannabinoid hyperemesis syndrome: Clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse". World Journal of Gastroenterology 15 (10): 1264–6. doi:10.3748/wjg.15.1264. PMC 2658859. PMID 19291829. 
  3. ^ a b Simonetto, Douglas A.; Oxentenko, Amy S.; Herman, Margot L.; Szostek, Jason H. (2012). "Cannabinoid Hyperemesis: A Case Series of 98 Patients". Mayo Clinic Proceedings 87 (2): 114–9. doi:10.1016/j.mayocp.2011.10.005. PMC 3538402. PMID 22305024. 
  4. ^ Byrne, A; Hallinan, R; Wodak, A (2006). "'Cannabis hyperemesis' causation questioned". Gut 55 (1): 132; author reply 132. PMC 1856368. PMID 16344581. 
  5. ^ Habboushe J, Sedor J (June 2014). "Cannabinoid hyperemesis acute renal failure: a common sequela of cannabinoid hyperemesis syndrome". Am J Emerg Med 32 (6): 690.e1–2. doi:10.1016/j.ajem.2013.12.013. PMID 24418446. 
  6. ^ "NCPIC.Cannabinoid hyperemesis syndrome". Retrieved 2012-05-24. 
  7. ^ Davis, Mellar; Maida, Vincent; Daeninck, Paul; Pergolizzi, Joseph (2006). "The emerging role of cannabinoid neuromodulators in symptom management". Supportive Care in Cancer 15 (1): 63–71. doi:10.1007/s00520-006-0180-0. PMID 17139494. 
  8. ^ a b World health Organization, Cannabis - epidemiology.
  9. ^ Roche, E; Foster, PN (2005). "Cannabinoid hyperemesis: Not just a problem in Adelaide Hills". Gut 54 (5): 731. PMC 1774504. PMID 15831930. 

Further reading[edit]