Cannabinoid Hyperemesis and Compulsive Bathing: A Case Series and Paradoxical Pathophysiological Explanation

Patient 1

A 20-year-old African-American man presented to the emergency department (ED); he had been having frequent episodes of nausea and vomiting for 8 months and indicated that warm baths provided relief of his symptoms. He denied any medical or surgical history. His only medication was promethazine. An abdominal ultrasound and computerized tomography (CT) scans of his abdomen and pelvis with and without contrast were negative; his vital signs were normal, and his abdomen was soft and was not tender. He admitted to smoking marijuana daily and smoking 5 cigars per day for at least the past 4 years. Laboratory data included a white blood cell count of 11,700 cells/μL with normal complete blood count (CBC), basic metabolic profile (BMP), hepatic profile, and lipase. Urine drug screen revealed only cannabinoids. The patient was admitted for rehydration, antiemetics, and evaluation. Upper endoscopy showed very mild esophagitis and gastritis with negative biopsies for Heliobacter pylori. During the patient's hospitalization, he took long showers multiple times each day; furthermore, it was difficult for the physicians to convince the patient to exit the shower for examination.

The physician stressed complete abstinence from marijuana, and the patient was placed on a short course of omeprazole. The patient was contacted 2 months after discharge and reported improvement in symptoms since marijuana cessation. However, soon after the telephone interview, he was readmitted to the hospital with a recurrence of his symptoms after resuming marijuana use.

Patient 2

A 27-year-old white man presented with a 2-day history of nausea, vomiting, and abdominal pain. He had recurrent visits to the ED and admissions to hospitals for similar symptoms since the age of 18. The patient reported that he took up to 4 baths per day during his episodes, indicating that the baths provided relief of his symptoms. His previous evaluations included 3 abdominopelvic CT scans, one abdominal ultrasound, and one upper endoscopy. All imaging tests were normal. The esophagogastroduodenoscopy showed gastritis, which was treated with omeprazole. Biopsy for H. pylori was negative. Medical history was significant for previous cholecystectomy. He denied taking any medications other than antiemetics. The patient admitted to daily heavy marijuana use for the past 10 years and denied any recent alcohol or tobacco use.

His vital signs were within normal limits. Physical examination was notable for dry mucous membranes and a soft, diffusely tender abdomen without guarding and normal bowel sounds. His white blood cell count was 11,100 cells/μL, potassium was 3.2 meq/L, blood urea nitrogen was 27 mg/dL, and creatinine was 1.4 mg/dL. His urine drug screen was positive only for cannabinoids. Liver function tests, urinalysis, lipase, and hemoglobin were unremarkable. The patient was admitted for rehydration therapy and potassium repletion. A small-bowel follow-through study was normal.

The patient was advised to discontinue all marijuana use. He had a symptom-free period with the cessation of marijuana use. However, he relapsed and his symptoms returned. The patient recognizes an association between marijuana use and his symptoms but is unable to stop smoking marijuana.

Patient 3

A 31-year-old man presented to the ED with nausea, vomiting, and diffuse crampy abdominal pain that had lasted for several days and had been present intermittently for years. The patient noted that his symptoms improved when he took multiple daily hot baths and showers. Four previous ED visits during the past 5 years with extensive workups at other hospitals had failed to reveal a source of his symptoms. He has smoked 3 to 5 “blunts” (marijuana and tobacco cigars) per day and 8 to 9 on weekends for the past 16 years. He denied alcohol abuse. The physical examination revealed normal vital signs, dry oral mucosa, and diffuse mild tenderness of a soft abdomen. Because of the classic nature of his symptoms and his desire to control the expense of his visit, the physician did not order laboratory tests or radiologic imaging. Previous ED visits revealed normal CBC, BMP, lipase, and urinalysis. The patient was treated with intravenous hydration and antiemetics and was discharged with a diagnosis of cannabinoid hyperemesis. Phone follow-up revealed that after a brief symptom-free interval the patient resumed smoking marijuana and suffers periodic episodes of cyclical vomiting.

Patient 4

A 43-year-old white man presented to his primary physician with a 4-year history of unexplained cyclic vomiting and vague recurrent abdominal pain. He was evaluated during frequent hospitalizations and found to have normal CBC, BMP, and lipase levels. Prior CT scans and ultrasounds of the abdomen as well as esophagogastroduodenoscopy and colonoscopy were normal. The patient also had a left colectomy for presumed diverticulitis, which did not improve his symptoms. Aware of the association between chronic marijuana use and paradoxical hyperemesis, the physician questioned the patient in her office regarding the use of marijuana. The patient admitted to smoking an average of 0.5 to 1 g per day since age 15 and noted temporary relief of his symptoms with multiple hot showers. The patient recalled on one occasion spending most of 3 days in a hot shower in an attempt to alleviate the symptoms. He noted that he gradually improved over 2 to 3 weeks with cessation of marijuana use; however, when he resumed regular marijuana use his symptoms returned. When the association was suggested to the patient, he stopped using marijuana and has been symptom free for 1 year, the longest period since his cyclic vomiting began 5 years earlier.