Marijuana-Related Stomach Disorder on the Rise

A common condition is showing up more and more in our local Emergency Department: patients coming in with severe nausea and vomiting for several days. Often, they report having dealt with the same issue multiple times in the preceding months or even years. 

The symptoms often start as morning-time nausea and progress over time to episodes of unremitting pain in the upper abdomen, persistent nausea, and vomiting. One interesting feature is that often a hot shower or bath provides significant relief. The length of these symptoms is variable but can last for up to a week at a time and be completely disabling.

In the past, we had a poor understanding of what caused these symptoms and how to treat them, because they tended to be very resistant to even the most potent pain and nausea medications we have. We would direct our evaluation to pursue the most common and serious diagnoses, and often came up empty handed. We would test for problems with the stomach, liver, gall bladder, pancreas and bowels, test for pregnancy, and often even get CT scans in an effort to make a diagnosis. For years this problem was labeled as cyclical vomiting disorder, or sometimes mistaken for other problems such as irritable bowel, gastroparesis or gastritis due to our poor understanding of this disease entity. Patients would often have to come to the ER several times during an episode for hydration and electrolyte replacement due to the severity of the vomiting. The next step would be a referral to the gastroenterologist, although they usually had little success in diagnosing the problem.

Now, we understand that for many people presenting with this pattern of symptoms, the cause is related to cannabis use, or more specifically, high levels of the tetrahydrocannabinoid (THC) molecule in cannabis products.

The marijuana that we have access to today is not the same natural marijuana that people used decades ago. It has been highly modified and bred to have extraordinarily high levels of the psychoactive molecule, THC. Now legal for recreational use in many states, including Massachusetts and Vermont, it is perceived of as largely harmless for most casual users and, in years past, it may have been. Strains sold today can have up to 10 times the amount of THC as is found in the naturally occurring variant. THC is stored in our body fat, and can accumulate to very high levels there. We have receptors throughout our body for THC, known as the endocannabinoid system, which plays a role in our natural response to pain and stress. These receptors are concentrated in the brain and the stomach/intestines. When THC in therapeutic concentrations acts on brain receptors, it produces the pleasant effects that users expect. When THC fat stores are released, often during illness or fasting, and levels in the blood get too high, the effects on GI receptors tend to predominate and bad things can happen.

This newly understood condition can occur among people who use marijuana as little as once or twice a week. It’s called cannabinoid hyperemesis syndrome (CHS). It is characterized by these repeated episodes of severe nausea, abdominal pain, and vomiting that returns every few weeks or months.

CHS, first reported in 2004, is difficult to diagnose for many reasons. First of all, there is no test that can be used to make the diagnosis. Also, sometimes doctors are unfamiliar with it and do not know the right questions to ask, and patients may be reluctant to disclose marijuana use history. In addition, for reasons that are poorly understood, it doesn’t affect all chronic, long-term users. Moreover, longtime marijuana users don’t think to report their use of marijuana. They figure that they have used marijuana for years without any negative effects, but the onset of CHS typically doesn’t occur for a while after people have been using marijuana regularly.

The condition has three stages:

1. During the early stages, people typically experience morning nausea, urges to vomit, and stomach discomfort. Initially they often resolve throughout the day. These symptoms may last for hours to days and evolve over months or years. Knowing its anti-nausea effects, people sometimes increase their use of marijuana during this time.
2. The hyperemesis stage is characterized by episodes of intense pain and persistent nausea and vomiting. People in the hyperemesis stage have the urge to shower or bathe in hot water far more frequently, as it relieves the symptoms.
3. Finally, during the recovery stage, patients feel better, return to normal eating patterns, and resume a regular showering routine. Recovery can last from days to months before symptoms return. 

Clinical guidelines for the diagnosis, treatment, or management of CHS do not currently exist. The only way to confirm the diagnosis is to discover whether symptoms abate when the patient stops using marijuana. However, because THC can accumulate to high levels and is stored in our body fat, it can take weeks to months of complete abstinence to notice a difference. Many people resume use during this time because they do not fully appreciate this time-frame, feel that they need the marijuana to control the nausea, and resist the belief that marijuana can cause these symptoms.

If left untreated, severe prolonged vomiting can lead to dehydration and electrolyte imbalances in the blood, which can cause rare complications including confusion, muscle spasms or weakness, seizures, kidney failure, abnormal heart rhythms, and shock. Other conditions, like food poisoning, can cause very similar symptoms, although those are often accompanied by diarrhea, whereas CHS usually is not. It is critically important to understand that marijuana users, even those with known CHS, can have other serious causes of stomach pain and vomiting, and should always seek medical attention when those symptoms develop.

For help quitting marijuana, call the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-HELP (4357) or visit their online treatment locator findtreatment.samhsa.gov.

Adam Cohen, MD, is the director of Emergency Medicine and a board-certified Emergency Medicine physician at SVMC.