Cyclic Vomiting Syndrome Versus Cannabinoid Hyperemesis Syndrome
Internal medicine, Henry Ford Allegiance, Jackson, MI, USA
Government Medical College, Kala Mala Chowk, Amritsar, India
Article notes
Untitled section
Issue date 2025 Jul 30.
Introduction
Cyclic vomiting syndrome (CVS) can be defined by episodes of intense nausea and vomiting, which occur multiple times in a year in a characteristic fashion with asymptomatic intervals in between. Cannabinoid hyperemesis syndrome (CHS), in contrast, is linked to prolonged cannabinoid use and presents with cyclical episodes of severe nausea and vomiting. Individuals affected by CHS often find temporary relief in hot showers or baths.
This detailed case shows the difficulty of diagnosing such gastrointestinal disorders and differentiating between conditions with overlapping symptoms.
Case Report
A 57-year-old male presented with severe, intractable nausea and vomiting for 3 days. Physical examination and CT were negative for any abnormality. Despite aggressive initial hydration, electrolyte replacement, and anti-emetics, including ondansetron, metoclopramide, and even aprepitant, the patient continued to experience persistent symptoms. He was found to take multiple warm showers multiple times a day, which provided some relief. The patient reported the onset of symptoms at age 21, indicating a chronic course. The episodes would last 4-5 days, and then the patient would improve with milder symptoms on and off before the subsequent episode. He would get one such episode every 2-3 months. CHS had been speculated in the past; the patient quit smoking for 18 months without relief. He insisted that symptoms predated his cannabis use and that cannabis use was prompted by initial symptom relief. By Rome IV criteria, a diagnosis of CVS was established.
Discussion
Hot Showering Behavior Dilemma
As evidenced by the case, it is tough to differentiate between CHS and CVS. The patient’s initial diagnosis was highly influenced by hot showering behavior and ongoing cannabis use. Upon a review of the literature, we found this to be a common practice. In a study, one-third of patients were diagnosed with CHS based on marijuana use and intractable vomiting.1 Up to 10% of CHS patients did not demonstrate showering behavior, whereas in another, 48% of patients with CVS had similar behavior compared to 72% with cannabis use.2,3 This possible overlap suggests a correlation and possibly shared pathophysiology as explained by the endocannabinoid system later.
Diagnostic Criterion
CHS has a Rome IV criterion including CVS-like episodes, prolonged cannabinoid use, and improvement with cessation for diagnosis, and a separate, more refined criterion proposed by Venkatesan et al4 as shown in Table which includes duration and quantity of cannabis use and further duration of discontinuation. CVS, like in our patient, is diagnosed with its own Rome IV criterion including acute episodes lasting a week, asymptomatic intervals, with three episodes in last year with 2 in 6 months, at least a week apart. Hot showers were supportive in CHS and migraines in CVS as per respective criteria. CVS is often associated with migraines, autonomic dysfunction, and psychiatric illness.
| Clinical features | Stereotypical episodic vomiting resembling CVS in terms of onset, and frequency ≥ 3 episodes a year |
| Cannabis-use patterns | Duration; > 1 year , Frequency of use > 4 times/week |
| Cannabis cessation | Resolution of symptoms should follow a period of cessation from cannabis for a minimum of 6 months |
Pathophysiology
The odds of cannabinoid use in CVS are 2.9 since the legalization of cannabis use.5 This loosely suggests a spectrum of CVS and CHS. The patient stated that he had started smoking marijuana as a measure of relief from the vomiting. This can be partially explained by the underlying pathophysiology of the cannabinoid system. Stimulation of the endocannabinoid receptor with cannabinoids, in vagal nuclei, decreases emesis. Emetic effects come from a bimodal effect of marijuana and developing tolerance with downregulation of cannabinoid receptor 1 at increasing doses.4
Treatment
For prophylactic treatment, anti-epileptics, most notably amitriptyline,6 which Hejazi et al7 demonstrated an improvement in the number of CVS episodes, and Topiramate in studies has shown 81% remission.8 Co-enzyme Q10, showed 68% response, in a retrospective internet survey in patients with CVS.9
For abortive purposes, Venkatesan et al4 recommend ondansetron as a first-choice and aprepitant as a potentially effective second-choice agent.10 The efficacy of Sumatriptan seen in studies suggests that CVS is an abdominal migraine-like entity. Lastly, meditation, exercise, and good sleep hygiene may reduce the frequency of CVS episodes.
Our patient was treated with Co-enzyme Q10 and as needed triptan with good response.
Conclusion
In patients with CVS/CHS, the Rome IV criterion is the backbone for diagnosis. Despite the problem with the diagnosis, the pathophysiology, and medical therapy of CVS and CHS are similar. Cannabis cessation is always recommended even in patients who claim to have started it for improvement.
Footnotes
Footnote Group
References
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References
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