User:LukeC98/Cannabinoid Hyperemesis Syndrome

Treatment via hot water, sometimes for hours at a time, relieves symptoms for many patients, which can result in compulsive bathing or showering. People have described the hot water relief as "temperature-dependent," meaning that hotter temperatures provide greater relief. While this relationship has been widely documented, some studies have found that as little as 11.2% of their participants reported this finding. Although the presence of compulsive bathing may reinforce the diagnosis of CHS, the absence of compulsive bathing does not exclude it.

Two deaths were reported as complications of associated kidney failure and electrolyte disorders secondary to dehydration due to persistent vomiting.

The prodromal phase is characterized by mild symptoms of CHS, including nausea, anxiety associated with vomiting, and mild abdominal discomfort, sweating, and increased thirst; symptoms are often more severe in the morning. During this phase, treatment with compulsive bathing is rarely reported, and some patients may attempt to treat their symptoms with cannabis use Prior to the use of compensatory exposure to hot water to treat symptoms, people sometimes increase their intake of cannabinoids in an effort to treat the persistent nausea they experience. This phase can last for months or even to years.

The diagnostic criteria for CHS were ill-defined prior to the establishment of the Rome IV criteria of 2016. Per the Rome IV criteria, all 3 of the following must be met to be diagnosed with CHS. They must be present for at least the last three months and the beginning of symptoms must have began 6 months prior to the diagnosis. The criteria specify symptoms which resemble cyclic vomiting syndrome and which occur after long-term cannabis use, but which cease after cannabis use is halted.

1. Episodic nausea and vomiting that appears similar to cyclic vomiting syndrome
2. Symptom onset occurs after prolonged, weekly cannabis use
3. Resolution of symptoms with sustained abstinence from cannabis use

Treatment:

The relationship between compulsive bathing and CHSWhile this relationship has been widely documented, some studies have found that as little as 11.2% of their participants reported this finding. Although the presence of compulsive bathing may reinforce the diagnosis of CHS, the absence of compulsive bathing does not exclude it.

Many traditional medications for nausea and vomiting are ineffective. Treatment is otherwise supportive and focuses on stopping cannabis use. Proper patient education includes informing patients that their symptoms are due to their use of cannabis/cannabinoids, and that exposure to cannabinoids in the future are likely to cause their symptoms to return. Clinical pharmacists can play a role in administering this education, as well as encouraging patients to seek the assistance of mental health providers. Abstinence from cannabinoids currently remains the only definitive treatment. Cognitive behavioral therapy and motivational enhancement therapy are evidence-based outpatient treatment options for patients with cannabis use disorder.

Symptomatic relief is noted with exposure to hot water (greater than 41°C, 106°F), which is mediated by TRPV–the capsaicin receptor. Assessing for dehydration due to vomiting and hot showers is important as it can lead to acute kidney failure, and this is easily treated with IV fluids.^{[citation needed]} If dehydration is severe, hospitalization may be required. Based on the mechanism of the effect, some clinicians have used topical capsaicin cream applied to the periumbilical area in the treatment of acute CHS. The use of capsaicin as first-line treatment for CHS has been well tolerated, and it has been demonstrated that capsaicin cream has decreased the need of other medications for symptom management during an emergency department stay, and patient's receiving capsaicin cream were discharged from the emergency department sooner. Capsaicin cream has also been shown to be particularly beneficial in patients who were resistant to other antiemetic therapies during their hospital stay. The use of hot water showers in the emergency department setting has been advocated in situations where topical capsaicin cream is unavailable, though the same precautions to hot water use (dehydration, burn injury) are required.

The use of antipsychotics, such as haloperidol and olanzapine, have provided partial relief of symptoms in case-reports. The evidence for the use of benzodiazepines, such as lorazepam, has shown mixed results. Other drug treatments that have been tried, with unclear efficacy, include neurokinin-1 receptor antagonists, first-generation antihistamines (e.g. diphenhydramine), 5-HT₃ receptor antagonists (e.g. ondansetron), and non-antipsychotic antidopaminergics (e.g. metoclopramide).

Acetaminophen has shown some benefit in case reports for alleviating headaches associated with CHS. Opioids can provide some relief of abdominal pain, but their use is discouraged due to the risk of worsening nausea and vomiting.

Epidemiology

The exact proportion of the population affected by this syndrome is difficult to conclude because there has not always been a specific criteria to diagnose this syndrome, there are no diagnostic tests to confirm it, and cannabis use may not always be reported truthfully. A 2015 study that surveyed patients from an urban emergency department found that 32.9% of people who reported cannabis use of at least 20 days per month

Differential Diagnosis:

There are an overwhelming amount of conditions that are characterized by abdominal pain and associated nausea and vomiting. When a patient

Diagnosis:

People with the symptoms described above often go through extensive workups and testing before the diagnosis of cannabinoid hyperemesis syndrome is made. Testing may consist of

Cannabinoid hyperemesis syndrome (CHS) is recurrent nausea, vomiting, and cramping abdominal pain that can occur due to prolonged, high-dose cannabis use. These symptoms may be relieved temporarily by taking a hot shower or bath. Complications are related to persistent vomiting and dehydration which may lead to kidney failure and electrolyte problems.

Weekly cannabis use is generally required for the syndrome to occur; synthetic cannabinoids can also cause CHS. The underlying mechanism is unclear, with several possibilities proposed. Diagnosis is based on the symptoms, as well as the history of cannabis use (including a urine screen test if necessary). The condition is typically present for some time before the diagnosis is made.

The only known curative treatment for CHS is to stop using cannabis. Two weeks (or possibly up to 3 months) may be required to see a benefit. Treatments during an episode of vomiting are generally supportive in nature (e.g., hydration). There is tentative evidence for the use of capsaicin cream on the abdomen during an acute episode.

Another condition that presents similarly is cyclic vomiting syndrome (CVS). The primary differentiation between CHS and CVS is that cessation of cannabis use only resolves CHS. CVS does not resolve with the cessation of cannabis use. Another key difference is that CVS symptoms typically begin during the early morning; predominant morning symptoms are not characteristic of CHS. Distinguishing the two can be difficult since many people with CVS use cannabis, possibly to relieve their symptoms.

The syndrome was first described in 2004, and simplified diagnostic criteria were published in 2009.

DIAGNOSIS SECTION EDITS:

The diagnostic criteria for CHS were ill-defined prior to the establishment of the Rome IV criteria of 2016. Per the Rome IV criteria, all 3 of the following must be met to be diagnosed with CHS. They must be present for at least the last three months and the beginning of symptoms must be at least 6 months prior to the diagnosis being made.

1. Episodic nausea and vomiting that appears similar to cyclic vomiting syndrome
2. Symptom onset occurs after prolonged cannabis use
3. Resolution of symptoms with sustained abstinence from cannabis use

Various diagnostic frameworks for CHS have been proposed. As of 2015, the modified criteria by Simonetto et al. are the most frequently used.^{[needs update]} One of the most important features for establishing a diagnosis of CHS is a history of cannabinoid use, the denial of which can delay proper diagnosis.

A complete history of the person's use of cannabinoids is important in establishing the correct diagnosis. CHS has often been undiagnosed, sometimes for years. This may be due to reluctance on behalf of patients to fully disclose their use of cannabis to healthcare professionals, especially when another person is accompanying the patient to an appointment or emergency department visit. Identifying the correct diagnosis saves money for the healthcare system and reduces morbidity associated with the condition.

A urine drug screen can be useful for objectively determining the presence of cannabinoids in a person's system. Cannabinoid metabolites (specifically 11-nor-Δ9-carboxylic acid) can be detected in urine for about 2 to 8 days with short-term use, and for 14–42 days of chronic use.

Other commonly used diagnostic tests include laboratory blood tests (complete blood count, blood glucose, basic metabolic panel, pancreatic and liver enzymes), pregnancy test, urinalysis, and imaging (X-ray and CT scan). These are used to rule out other causes of abdominal pain, such as pregnancy, pancreatitis, hepatitis or infection.

Differential Diagnoses

Prior to diagnosing and treating for a presumed CHS, more serious medical conditions need to be ruled out. The differential diagnoses include, but are not limited to, cyclic vomiting syndrome, bowel perforation or obstruction, gastroparesis, cholangitis, pancreatitis, nephrolithiasis, cholecystitis, diverticulitis, ectopic pregnancy, pelvic inflammatory disease, heart attack, acute hepatitis, adrenal insufficiency, and ruptured aortic aneurysm. However, if simple laboratory tests and imaging have excluded more serious conditions, it is reasonable to monitor for a worsening of the patient's status to prevent the unnecessary application of more invasive, and potentially dangerous, diagnostic procedures (e.g., exploratory surgery). In general, CHS is most often misdiagnosed as cyclic vomiting syndrome.

unedited Diagnosis sect

The diagnostic criteria for CHS were ill-defined prior to the establishment of the Rome IV criteria of 2016. The criteria specify symptoms which resemble cyclic vomiting syndrome and which occur after long-term cannabis use, but which cease after cannabis use is halted.

Various diagnostic frameworks for CHS have been proposed. As of 2015, the modified criteria by Simonetto et al. are the most frequently used.^{[needs update]} The most important feature is detecting a history of cannabinoid use, the denial of which can delay proper diagnosis. A urine drug screen can be useful for objectively determining the presence of cannabinoids in a person's system. Cannabinoid metabolites (specifically 11-nor-Δ9-carboxylic acid) can be detected in urine for about 2 to 8 days with short-term use, and for 14–42 days of chronic use.

Other commonly used diagnostic tests include laboratory blood tests (complete blood count and differential, blood glucose, basic metabolic panel, pancreatic and liver enzymes), pregnancy test, urinalysis, and plain flat radiographic series. These are used to rule out unrelated conditions, such as pregnancy or infection.

Prior to diagnosing and treating for a presumed CHS, more serious medical conditions need to be ruled out. Medical conditions that may present similarly to CHS include cyclic vomiting syndrome, bowel perforation or obstruction, gastroparesis, cholangitis, pancreatitis, nephrolithiasis, cholecystitis, diverticulitis, ectopic pregnancy, pelvic inflammatory disease, heart attack, acute hepatitis, adrenal insufficiency, and ruptured aortic aneurysm. However, if simple laboratory tests and imaging have excluded more serious conditions, it is reasonable to monitor for a worsening of the patient's status to prevent the unnecessary application of more invasive, and potentially dangerous, diagnostic procedures (e.g., exploratory surgery). In general, CHS is most often misdiagnosed as cyclic vomiting syndrome.

A complete history of the person's use of cannabinoids is important in establishing the correct diagnosis. CHS has often been undiagnosed, even for years. This may be due to reluctance on behalf of patients to fully disclose their use of cannabis to healthcare professionals, especially when another person is accompanying the patient to an appointment or emergency department visit. Identifying the correct diagnosis saves money for the healthcare system and reduces morbidity associated with the condition.