Cyclic Vomiting Syndrome & Cannaboid Hyperemesis Syndrome & Hot Showers

[Guest guest]

Many of us have seen Cyclic Vomiting Syndrome over the years - see attached and below for a protocol that might work for these difficult to treat patients.

 

But even more intriguing is the possibility of Cannaboid Hyperemesis Syndrome in chronic marijuana users.

Even more out there is the hot bath/shower compulsion in these patients.

The mechanism of the CHS isn't clear, but one theory is below.

Some of the ER Docs at AVH feel there has been an uptick in patients presenting with Cyclic Vomiting Syndrome - but on further review - several of these patients were also chronic marijuana users -- and some even mentioned the onset of the vomiting after they got their marijuana card. So they are suspicious for CHS.

Maybe something to keep an outlook for.

 

Also, good ol' Cyclic Vomiting Syndrome is still out there - attached is an interesting protocol by a specialist in Missouri -- see below for his contact info.

 

Locke, MD

Locke Family Medicine

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Here is a google search on the issue...

 

     http://www.google.com/search?q=%22Cannabinoid+Hyperemesis+Syndrome#q=%22Cannabinoid+Hyperemesis+Syndrome

 

Here is the original 2004 article by ...

 

     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774264/

 

Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse

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One theory of the cause is...

 

http://www.jabfm.org/cgi/content/full/23/6/790

Cannabinoid hyperemesis was first described by 1 in Australia. He noted that patients habitually bathed in warm showers or baths with temporary relief of symptoms. More than 30 cases have described the association of chronic heavy cannabinoid use and cyclical vomiting with abdominal pain.2–11 Here we described 4 cases of cannabinoid hyperemesis in which cannabis abuse was confirmed after an exhaustive medical evaluation failed to reveal another cause of symptoms.

Marijuana is frequently used for the treatment of nausea. The mechanism of action of this effect is not precisely known, but it may be related to stimulation of the cannabinoid receptors in the brain. The paradoxical association between chronic cannabinoid use and cyclic vomiting has not been explained. Proposed mechanisms include prolonged cannabinoid half-life caused by fat solubility, delayed gastric emptying, and thermoregulatory disturbances via the limbic system.1 Cannabinoid receptor type 1 (CB1) receptors exert their neuromodulatory role in the central nervous system and the enteric plexus. Delta-9-tetrahydrocannabinol, also known as THC, acts on CB1 receptors in the brain that are also present in the gut.12 Chronic stimulation with this lipophilic compound may produce toxicity in sensitive patients.8 It is known that CB1 receptor stimulation by cannabinoids slows gastric emptying and peristalsis, but the mechanism of this action is uncertain and may be mediated by both the brain and the gut, with gut activity overriding brain CB1 activity in chronic users of THC.8,13,14

The most intriguing component of these cases is the compulsive bathing in hot water. Patient 1 had to be enticed to come out of his shower for evaluation; patient 4 spent 3 days standing in a warm shower while awake in an attempt to alleviate the symptoms. Compulsive hot-water bathing is present in nearly all cases of cannabinoid hyperemesis and has no explanation. Because the CB1 receptor is near the thermoregulatory center of the hypothalamus, chronic CB1 hypothalamic stimulation might be counteracted by warm bathing.8

We propose an alternate explanation, which relates the compulsive bathing in hot water to chronic stimulation of vascular CB1 receptors. It is well known that cannabinoid receptors in the splanchnic circulation cause vasodilation and are activated, for example, in sepsis and late-stage cirrhosis.15,16 We suggest that CB1 receptor–mediated vasodilation of the gut with chronic cannabinoid use may contribute to the symptoms.

A redistribution of blood flow from the splanchnic circulation to muscle has been demonstrated during exercise.17 We theorize that a temporary relief of symptoms may be related to a redistribution of blood flow from the gut to the skin with warm bathing. Such redistribution could be characterized as a " cutaneous steal syndrome " that brings relief to the patient.

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More info on the Hot Shower compulsion...snippets from the full article.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774264/

A novel finding was a “compulsive bathing” or washing behaviour noted in nine of 10 patients (X, Y, A, Q, R, J, K, E, and G). These patients would have multiple hot showers or baths on the ward. This ritual became the patients primary preoccupation, with them often waking at night to perform it.

Compulsive bathing behaviour

The compulsion to have multiple hot showers or baths was not part of a psychosis or obsessive-compulsive disorder. This was a learned behaviour which often did not present with the first few episodes of illness (as in L) but once established rapidly became a compulsion. The symptoms of nausea, vomiting, and abdominal pain would all settle within minutes in a hot bath or shower. Symptomatic relief was temperature dependent. The hotter the water, the better the effect. As the water cooled the symptoms returned. Two patients (X, Y) even scalded themselves in an attempt to have the water as hot as possible. These patients did not exhibit delusions or hallucinations which drove this behaviour, nor did they regard the showering as irrational and did not appear to resent it. Cessation of cannabis lead to cessation of the washing behaviour.

Patients exhibited odd behaviour: they repeatedly bathed in hot water to abate their illness; they vomited severely and uncontrollably; they lost and gained kilos of weight in the presence and absence of cannabis, respectively; and they displayed a spectrum of autonomic symptoms from sweating, flushing, thirst, and alteration in body temperature to colicky abdominal pain.

One logical explanation for this might lie with marijuana’s effect on the limbic system of the brain, particularly at the hippocampal-hypothalamic-pituitary level.17–19 Cannabis toxicity may disrupt the balanced equilibrium of satiety, thirst, digestive, and thermoregulatory systems of the hypothalamus and this disruption might settle with hot bathing or showering. A hypothalamic action is further supported by evidence that chronic cannabis use affects the secretion of pituitary hormones, suppressing growth hormone, follicle stimulating hormone, and luteinising hormone, with documented pubertal arrest.20,21 Cannabis cessation also results in these levels returning to normal with cessation of the disease state.20,21 Pure hypothalamic disruption, however, does not fully explain the entire autonomic overload, suggesting other mechanisms at play. Crude cannabis is made up of over 60 different compounds.22 Any one of these in toxic concentrations may be the culprit. The mechanism of action is equally complicated. It might be due to marijuana binding to CB1 receptor sites in the brain.23 Alternatively, anandamide, with its action on vallinoid receptor function and thermal control, may have a role here.23,24 The most recent research from Canada has shown that cannabidiol, in high concentrations, produces hyperemesis in house musk shrew models with lithium induced vomiting not acting through the CB1 receptor.25 Clearly, further research, using models capable of emesis, is needed to detect the exact mechanism of this apparent toxic effect.

 

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In regards to Cyclic Vomiting Syndrome...

Attached is a protocol by an expert out of Missiouri.

Here is his website...

http://www.ch.missouri.edu/fleisher/

R. Fleisher, M.D.Associate Professor of Child HealthPediatric GastroenterologyUniversity of Missouri Health Care

One Hospital DriveColumbia, MO  65212telephone: email: fleisherd@...

 

Curriculum Vitae 

 

Cyclic Vomiting Syndrome

Empiric Guidelines for the Management of Cyclic Vomiting Syndrome

  Cyclic Vomiting Syndrome in Adults   The Cyclic Vomiting Syndrome: A Report of 71 Cases and Literature Review

 

Cyclic Vomiting Syndrome in 41 Adults: the illness, the patients and problems of management

Management of Adult Cyclic Vomiting Syndrome, Including the Use of Opiates

 

Other Functional Vomiting Disorders

Functional Vomiting Patterns and Disorders in Infants, Children, and Adolescents

  Functional Vomiting Disorders in Infancy: Innocent Vomiting, Nervous Vomiting, and Infant Rumination Syndrome

  Regurgitation, Rumination and the Rumination Syndromes  Infant Rumination Syndrome  Comprehensive Management of Infants with Gastroesophageal Reflux and Failure to Thrive

 

2 of 2 File(s)

Cannaboid Hyperemesis Syndrome - Cyclic Vomiting Syndrome.pdf

Cyclic_Vomiting_Syndrome-Empiric_Guidelines_for_the_Management_of.pdf