Case Study: Atypical Cyclical Vomiting in a Young Woman with Chronic Cannabis Use

Case at a Glance

A 23-year-old female with a history of anxiety, depression, ADHD, and a prior cholecystectomy presents with a one-year history of debilitating, recurrent episodes of vomiting and epigastric pain. Despite a normal endoscopy and PPI therapy, her symptoms persist, prompting investigation into less common etiologies, including Cannabinoid Hyperemesis Syndrome (CHS).

Patient's Story

The patient is a 23-year-old female with a complex medical history who reports a significant decline in her gastrointestinal health over the past year. The episodes, which she initially described as a 'stomach flu,' began occurring unpredictably. Each episode lasts several days and is characterized by intractable vomiting and profound fatigue, rendering her unable to eat or function. Her past medical history is notable for a cholecystectomy. She does not consume alcohol or use tobacco but reports regular daily use of marijuana. Her current medications include zopiclone, lamotrigine, effexor, vyvanse, and an oral contraceptive.

Initial Assessment

On presentation between episodes, the patient reports daily symptoms, including a gnawing epigastric and chest pain, most prominent in the morning or when her stomach is empty. She describes a unique and distressing symptom: a sensation of building pressure in her chest that culminates in a painful, high-pitched 'squeal' or 'yawn,' which she feels is a form of unproductive belching. During acute episodes, her emesis consists primarily of bile, and she notes the presence of bile and mucus in her stool. She also experiences significant shakiness. The pattern is cyclical: nausea leads to an inability to eat, which triggers vomiting, which is then exacerbated by any attempt to eat, until the episode spontaneously resolves.

The Diagnostic Journey

The patient's initial workup included an upper endoscopy, which revealed no abnormalities. Her history of a cholecystectomy ruled out gallbladder-related pathology. A trial of a proton pump inhibitor (dexlansoprazole) was initiated but provided no relief. Given the constellation of cyclical vomiting and chronic cannabis use, Cannabinoid Hyperemesis Syndrome (CHS) was high on the differential diagnosis. Clinicians specifically inquired about the pathognomonic feature of CHS: the compulsion to take hot showers or baths for symptom relief. The patient adamantly denied this, stating that hot showers offered no improvement and that any form of movement tended to worsen her nausea and vomiting. This atypical feature complicated the clinical picture, though it did not entirely rule out CHS. Other considerations included Cyclical Vomiting Syndrome (CVS) and an underlying motility disorder.

Final Diagnosis

Presumptive Cannabinoid Hyperemesis Syndrome (CHS), Atypical Presentation. The diagnosis was made clinically based on the triad of chronic cannabis use, a cyclical vomiting pattern, and the exclusion of other upper GI pathology. The absence of relief with hot showers was noted as an atypical feature of her presentation.

Treatment Plan

The cornerstone of the treatment plan was counseling on the likely diagnosis of CHS and the recommendation for complete cessation of cannabis use as both a diagnostic and therapeutic intervention. For management of acute episodes, the plan included supportive care with IV hydration and antiemetics. The patient was educated that a definitive diagnosis could only be confirmed by the resolution of symptoms following a sustained period of cannabis abstinence.

Outcome and Follow-up

The patient was initially resistant to the diagnosis due to her atypical symptoms and the role of cannabis in her daily life. However, she agreed to a trial of cessation. A follow-up was scheduled for six weeks to monitor for symptom resolution. It was explained that if her symptoms did not improve with complete cannabis abstinence, further investigations into other causes of cyclical vomiting, such as formal gastric motility studies, would be initiated.