How to manage acute gastroenteritis in a regular marijuana (cannabis) smoker?

Management of Acute Gastroenteritis in Regular Marijuana Smokers

For regular marijuana smokers with acute gastroenteritis, the most effective management includes standard rehydration therapy while ruling out cannabinoid hyperemesis syndrome (CHS) as a potential cause of symptoms. 1

Initial Assessment

• Consider cannabinoid hyperemesis syndrome (CHS) in the differential diagnosis for regular marijuana users presenting with nausea, vomiting, and abdominal pain 1
• Look for characteristic CHS features: stereotypical episodic vomiting (≥3 times annually), cannabis use >1 year before symptom onset, and use >4 times per week 1
• Note that hot water bathing behavior (long hot baths/showers for symptom relief) is commonly reported in 71% of CHS cases and can help distinguish it from other causes 1
• Evaluate for dehydration by assessing skin turgor, mucous membrane moisture, capillary refill, and mental status 1

Management Algorithm

For Standard Acute Gastroenteritis:

1. Rehydration Therapy

   • Oral rehydration is first-line treatment for mild to moderate dehydration 1
   • IV fluids may be necessary for severe dehydration or intractable vomiting 1

2. Antiemetic Considerations

   • Standard antiemetics may have limited effectiveness in marijuana users with CHS 1
   • Consider butyrophenones (haloperidol, droperidol) which have shown some success in CHS patients 1

3. Avoid Certain Medications

   • Avoid opioids as they can worsen nausea and have addiction risk, particularly in cannabis users 1
   • Nonspecific antidiarrheal agents (loperamide, kaolin-pectin) have limited evidence of effectiveness and may cause side effects 1

For Suspected Cannabinoid Hyperemesis Syndrome:

1. Acute Management

   • Topical capsaicin (0.1%) may improve symptoms through activation of transient receptor potential vanilloid type 1 receptors 1
   • Consider benzodiazepines, haloperidol, promethazine, olanzapine, or ondansetron for symptom control 1
   • Supportive care with IV fluids for dehydration 2

2. Long-term Management

   • Cannabis cessation is the definitive treatment for CHS 1
   • Consider tricyclic antidepressants (amitriptyline 75-100mg at bedtime, starting at 25mg with weekly titration) for prevention 1

Special Considerations for Cannabis Users

• Regular cannabis users may develop tolerance to certain medications, potentially requiring higher doses of analgesics 1
• Cannabis withdrawal syndrome (CWS) can begin after 48 hours of abstinence and may include nausea and stomach pain 1
• Supportive care for CWS may include gabapentin, nabilone, nabiximols, or dronabinol 1

Differential Diagnosis

• Rule out other causes of vomiting including acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction 1
• Consider other functional disorders such as cyclic vomiting syndrome, gastroparesis, rumination syndrome, and functional chronic nausea and vomiting syndrome 1

Pitfalls and Caveats

• CHS is often underdiagnosed or misdiagnosed due to limited awareness among clinicians 1
• Paradoxically, patients may report that cannabis helps relieve their symptoms, leading to continued use and worsening of the underlying condition 1
• Many patients remain uncertain about the role of cannabis in their symptoms and may attribute them to other factors like food, alcohol, stress, or pre-existing GI disorders 1
• The prevalence of CHS is increasing with the rise in cannabis legalization and higher THC concentrations in modern cannabis products 1, 3