Can cannabis hyperemesis syndrome (CHS) cause pancreatitis with elevated lipase levels?

Cannabis Hyperemesis Syndrome and Pancreatitis

Cannabis hyperemesis syndrome (CHS) can potentially cause pancreatitis with elevated lipase levels, although this is not a common manifestation of the condition. Case reports have documented instances of cannabis-induced pancreatitis, but the evidence remains limited and the exact mechanism is not well established 1.

Relationship Between CHS and Pancreatitis

Cannabis hyperemesis syndrome is characterized by:

• Stereotypical episodic vomiting in patients using cannabis for >1 year
• Cannabis use frequency >4 times per week
• Relief from hot showers/baths
• Resolution of symptoms after cannabis cessation 2

The connection to pancreatitis appears to manifest in several ways:

1. Case Evidence: There are approximately 26 reported cases of acute pancreatitis associated with cannabis use 1. These cases typically present with:

   • Intractable nausea and vomiting
   • Epigastric pain
   • Elevated lipase levels (>3 times upper limit of normal)
   • No other identifiable causes (alcohol, biliary, autoimmune, etc.)

2. Prevalence: Cannabis use was found in about 10% of acute pancreatitis cases in one study, and in 9% of previously labeled "idiopathic" pancreatitis cases, suggesting cannabis could account for approximately 2% of all acute pancreatitis cases 3.

3. Recurrence Pattern: Cannabis-induced pancreatitis can be recurrent, with symptoms resolving upon cannabis cessation and returning with resumed use 4.

Potential Mechanisms

The exact mechanism by which cannabis or CHS might cause pancreatitis is not fully understood, but several theories exist:

• Endocannabinoid System Dysregulation: Prolonged high-dose THC exposure can disrupt normal endocannabinoid system functioning 5
• Genetic Factors: Mutations in genes affecting cannabinoid metabolism may play a role, particularly in:
  • COMT (catechol-O-methyltransferase)
  • TRPV1 (transient receptor potential vanilloid receptor 1)
  • CYP2C9 (cytochrome P450 enzyme involved in cannabinoid metabolism)
  • DRD2 (dopamine-2 receptor)
  • ABCA1 (ATP-binding cassette transporter gene) 6

Clinical Implications

When evaluating patients with unexplained pancreatitis and elevated lipase:

• Screen for cannabis use: Particularly heavy, long-term use (>1 year, >4 times weekly)
• Look for CHS symptoms: Cyclical vomiting, abdominal pain, relief with hot showers
• Rule out other causes: Alcohol, gallstones, medications, autoimmune disorders
• Management approach:
  1. Complete cannabis cessation for at least 3-6 months 2
  2. IV fluid rehydration
  3. Symptom management with dopamine receptor antagonists (e.g., haloperidol 0.5-2 mg IV or PO every 4-6 hours) 2
  4. Hot showers/baths and topical capsaicin cream for symptomatic relief 2

Important Caveats

• Cannabis use does not appear to independently impact the severity or mortality of acute pancreatitis 3
• Typical antiemetic drugs are often ineffective for CHS symptoms 5
• The only definitive treatment for cannabis-induced pancreatitis is complete abstinence from cannabis 1, 4
• CHS is often misdiagnosed due to overlap with other conditions and limited awareness among healthcare providers 5

When evaluating patients with unexplained pancreatitis, particularly young adults with recurrent episodes, cannabis use should be considered as a potential etiology, especially when other common causes have been ruled out.