Just another drug seeker?

by Adam Herbstritt

A female in her 20s has had recurrent presentations over the years, usually in clusters every 6 months or so.
Her only proven PMH is a previous OGD showing a small healed ulcer.  She has been labeled as ‘seeking opiates’ on HAS…

HPC: vomiting+++ hourly for days. 
She was admitted under general surgery with similar symptoms last week but self discharged on symptoms resolution. No clear cause had been identified.  She now represents as symptoms returned+++ over 24 hours.

Has been making periodic trips to the water fountain in ED, and appears to be inducing emesis back in the cubicle. Vitals all normal, exam unremarkable other than some upper ado tenderness without guarding.

Bloods awaited.

Thoughts?

How about if you asked about cannabis use…

Cannabis Hyperemesis Syndrome
Cannabinoid hyperemesis syndrome (CHS) is a cluster of symptoms characterised by cyclical nausea & vomiting with abdominal pain without an obvious organic cause and associated compulsive hot water bathing induced by long-term cannabis  use (more than 1 year).  One patient was reported spending all day in the bathtub for 300 days one year. 

Australian researchers described the first series in 2004, reviewing nine patients. Subsequent literature is fairly abundant with case reports and series, the largest of which was 98 cases by Simonetto in 2012. They propose the clinical criteria for CHS shown in the table.

Mechanisms aren’t clear but may include:

• Excessive levels of cannabis metabolites that promote emesis 
• THC to accumulate in cerebral fat cuasing toxicity
• Slowed GI transit
  
• Central effects of long-term use on the HPA axis with an imbalance between satiety, thirst, digestion, and thermoregulatory systems
  

Bathing may help through activation of hypothalamic cannabinoid receptors regulating body temperature. 
Compulsive bathing behaviours and long term cannabis use should flag suspicion.

For the ED;

• Rule out significant underlying acute medical and surgical conditions — such as pancreatitis
• IV fluids if dehydrated. 
  
• Treat pain as appropriate, including opiates where necessary.
  
• Lorazepam has specifically been found beneficial in a number of cases, perhaps due to its antiemetic, amnestic, and anxiolytic properties - although I’ve never tried, it may work better than anything else.  A short course (<1 week) can be considered if found beneficial in ED.
• Symptoms will gradually resolve once cannabis use stops.  Getting patients to accept cannabis as a cause of symptoms can be challenging

I think CHS is a reminder that repeat presenters can easily be mislabelled and receive inadequate care simply because there’s still an awful lot in medicine we just don’t understand.  

She self discharged from CDU after apparent benefit from prolonged showering.

Interested to know more? see this and this review.

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