C ASE

CASE

A 34 year old lady was admitted to the internal medicine ward 3 times over
a course of 4 months because of episodes of vomiting and abdominal pain,
lasting for few days

Her past medical history was normal. she had no history of surgery or drug
allergies

Physical examination:
- Vital signs : temp. 36.4 C , HR-100\min , BP- 110\80 mm hg , O2 sat. 100%
- Mucous membrane is dry , CVS examination were normal, her chest was clear
,the abdomen was soft with diffuse tenderness with no rebound or
guarding,
CONTINUE…

CBC: WBC 13.30, Hb 14.9 Plt 277

Metabolic Panel: AST 23, ALT 38, ALP 36, GGT 12, Bil
0.52, Cr 0.55, BUN 11, Na 138, K 4, TSH 1.3., amyl 80

ABG, PT and INR are normal

Urine analysis was normal, pregnancy test results were
negative

An abdominal x-ray was within normal limits
CONTINUE…

During her admition she was treated with IV fluids
and anti emetics with a steady improvement in her
symptoms, then she was discharged home.

Two weeks later, she was readmitted because of
the same symptoms

, the patient underwent an abdominal US which
was normal

An abdominal pelvic CT scan was performed that
yielded normal results

For further investigation an upper GI Endoscopy
was performed and reveled a mild gastritis ,
urease test negative for HP

Eye fundus examination- normal
????
DD

Gastrointestinal:
- Inflammation: gastritis, gastroenteritis,
pancreatitis, cholecystitis, appendicitis…
- Obstruction: pyloric stenosis ,small bowel
obstruction, large bowel obstruction, illeus
- Irritation: drugs, poisions
DD

CNS:
- Motion sickness
- Menie’re’s disease
- Migraine
- Cerebral hemorrage
- Brain tumor
- Benign intracranial pressure
- Head injury
DD

Others:
- Pregnancy: hyperemesis, morning sickness
- Metabolic causes: hypercalcemia, uremia, adrenal
insufficiency, hyperglycemia
- Drug reactions: chemotherpy, opiods, SSRI, emetics
- Eating disorder: bulimia nervosa, anorexia nervosa
DD

Others:
- Myocardial infarction
- Severe pain
- Postoperative nausea and vomiting
- Coughing, hiccups or asthma
- High dose of ionizing radiation
- Rumination syndrome

The nurses observed that the patient spent many
hours at the bathroom taking a shower
BACK TO OUR PATIENT…

Upon further questioning the patient reported
that she admitted to daily heavy tobacco and
merijuana use for the past 16 years and denied
any alcohol use

Urine toxicology test was positive to cannabinoid
CANNABINOID HYPEREMESIS

Cannabinoid hyperemesis was first described by Allen in 2004 in
Australia

More than 30 cases have described the association of chronic heavy
cannabinoid use and cyclical vomiting with abdominal pain

A syndrome characterized by severe nausea and vomiting associated
with chronic marijuana abuse and marked by compulsive hot bathing
habits, which temporarily alleviate symptoms

Sometimes with polydipsia

Weight loss

Patients generally consider hot baths as a
comforting maneuver to decrease the intensity
of the nausea and vomiting

Abstinence from cannabis lead to resolution of
the vomiting syndrome and the abdominal pain
CANNABIS

Is the third most common used drug after
tobacco use and alcohol

Marijuana is frequently used for the treatment
of nausea, the mechanism of action of this
effect is not preciesly known but it may be
related to stimulation of the cannabinoid
receptors in the brain
Crude canabis is made of over 60 different
compounds
 The main active ingredient is delta-9tetrahydrocanabinol (THC)
 i.v injection of crude marijuana extract causes
acute toxicity and vomiting (paradoxical effect)

CANNABINOID RECEPTORS

Two types of cannabinoid receptors were been
identified:
-
CB 1 receptor: present in brain areas that
regulate HPA axis function and in enteric nerve
plexus
-
CB2 receptor: present in nonneuronal tissues,
but also present in microglia and has
immmunomodulatory effect

Canabis decrease gastrointestinal motility and
may overide the CNS mediated antiemetic
effect,promoting emesis
OTHER EFFECTS

Cannabinoids may also stimulate thirst

Cannabis may modulate the thermoregulatory
system of the hypothalamus

This effect might arise from modulation of the
HPA axis by cannabinoids
THANK YOU
`