Cannabinoid Hyperemesis Syndrome

Public Health Implications and a Novel Model Treatment Guideline

Jeff Lapoint, DO; Seth Meyer, MD; Charles K. Yu, MD; Kristi L. Koenig, MD; Roneet Lev, MD; Sayone Thihalolipavan, MD, MPH; Katherine Staats, MD; Christopher A. Kahn, MD, MPH


Western J Emerg Med. 2018;19(2):380-386. 

In This Article

Presentation and Diagnosis

A systematic review of CHS by Sorensen et al.[7] identified major diagnostic characteristics in patients with CHS as the following:

  • History of regular cannabis use for over a year (74.8%)

  • At least weekly cannabis use (97.4%)

  • Severe nausea and vomiting (100%)

  • Abdominal pain (85.1%)

  • Vomiting that recurs in a cyclic pattern over months (100%)

  • Resolution of symptoms after stopping cannabis (96.8%)

  • Compulsive hot baths/showers with symptom relief (92.3%)

  • Male predominance (72.9%)

Sorensen et al. identified seven diagnostic frameworks, with significant overlap among characteristics listed by the various authors; however, there was no specific mention of how many of the above features are required for diagnosis. Those with the highest sensitivity include at least weekly cannabis use for greater than one year, severe nausea and vomiting that recurs in cyclic patterns over months usually accompanied by abdominal pain, resolution of symptoms after cannabis cessation, and compulsive hot baths/showers with symptom relief. Clinicians should consider other causes of abdominal pain, nausea and vomiting to avoid misdiagnosis.

Abdominal pain is classically generalized and diffuse in nature. CHS is primarily associated with inhalation of cannabis, though it is independent of formulation and can be seen with incineration of plant matter (traditional smoking), vaporized formulations (e-cigarettes), waxes or oils, and synthetic cannabinoids. At the time of this writing, there have been no reported cases associated with edible marijuana. Episodes generally last 24–48 hours, but may last up to 7–10 days. Patients who endorse relief with very hot water will sometimes report spending hours in the shower.[11,12] Many of these patients will have had multiple presentations to the ED with previously negative workups, including laboratory examinations and advanced imaging.[10] Clinicians should assess for the presence of CHS in otherwise healthy, young, non-diabetic patients presenting with a previous diagnosis of gastroparesis.

Laboratory test results are frequently non-specific. If patients present after a protracted course of nausea and vomiting, there may be electrolyte derangements, ketonuria, or other signs of dehydration. Mild leukocytosis is common. If patients deny cannabis use but suspicion remains high, a urine drug screen should be considered. Imaging should be avoided, especially in the setting of a benign abdominal examination, as there are no specific radiological findings suggestive of the diagnosis.