Can marijuana use cause an ileus?

Marijuana and Ileus: Clinical Relationship and Management

Marijuana can contribute to intestinal dysmotility and potentially cause ileus through its effects on the endocannabinoid system, particularly in chronic, heavy users. 1, 2

Pathophysiological Mechanism

• Marijuana's main active ingredient (Δ9-THC) activates CB1 receptors located throughout the gut, primarily in myenteric and submucosal neurons, which can inhibit gastrointestinal motility 1
• Stimulation of CB1 receptors can lead to loss of negative feedback on the hypothalamic-pituitary-adrenal axis, resulting in increased vagal nerve discharges that affect gut motility 1
• Cannabis has been shown to inhibit gastric motility and emptying through activation of peripheral CB1 receptors 1, 2
• Research indicates that cannabinoids can contribute to paralytic ileus through their effects on intestinal motor function 2

Clinical Evidence

• A 2021 study found that cannabis use was an independent risk factor for intestinal obstruction in patients hospitalized with diverticulitis, suggesting a relationship between cannabis use and impaired gut motility 3
• The inhibition of gastrointestinal motility by cannabis may explain the increased risk of intestinal obstruction observed in cannabis users 3
• Chronic heavy cannabis use has been linked to recurrent episodes of severe nausea and intractable vomiting (cannabinoid hyperemesis syndrome), which can further complicate gut motility 4

Cannabinoid Hyperemesis Syndrome (CHS) and Gut Motility

• CHS is characterized by cyclic vomiting, nausea, and abdominal pain in chronic cannabis users 1, 5
• Clinical diagnostic criteria for CHS include:
  • Stereotypical episodic vomiting (≥3 times annually)
  • Cannabis use for more than 1 year before symptom onset
  • Cannabis use more than 4 times per week on average 1, 5
• The prevalence of CHS is rising with increased cannabis legalization and higher THC concentrations in modern cannabis products 1, 5
• CHS can lead to complications including dehydration, electrolyte abnormalities, and potentially contribute to ileus through effects on gut motility 1, 5

Management Considerations

• For patients with suspected cannabis-related ileus:

  • Cannabis cessation is the definitive treatment for cannabis-related gut motility disorders 1, 5
  • Correct dehydration and electrolyte abnormalities, particularly potassium and magnesium, which are crucial for intestinal motility 6
  • Consider nasogastric tube placement for decompression in patients with severe abdominal distention 6
  • Avoid medications that can worsen ileus, including opioids and anticholinergics 6, 5

• For patients with cannabinoid hyperemesis syndrome:

  • Topical capsaicin (0.1%) may improve symptoms through activation of transient receptor potential vanilloid type 1 receptors 1, 5
  • Consider benzodiazepines, haloperidol, promethazine, olanzapine, or ondansetron for acute symptom control 1, 5
  • For long-term management, tricyclic antidepressants such as amitriptyline (75-100mg at bedtime, starting at 25mg with weekly titration) may be effective 1

Clinical Pitfalls and Caveats

• Cannabis-related gut motility disorders are often underdiagnosed or misdiagnosed due to limited awareness among clinicians 5
• Patients may paradoxically report that cannabis helps relieve their gastrointestinal symptoms, leading to continued use and worsening of the underlying condition 1, 5
• Cannabis withdrawal syndrome can begin after 48 hours of abstinence and may include nausea and stomach pain, potentially complicating the clinical picture 5
• When evaluating patients with ileus, consider cannabis use in the differential diagnosis, especially in young adults with recurrent symptoms 1, 5
• Be aware that the prevalence of cannabis-related gut motility disorders is increasing with the rise in cannabis legalization and higher THC concentrations in modern cannabis products 1, 5