Can vomiting and diarrhea be side effects of marijuana use?

Can Vomiting and Diarrhea Manifest with Marijuana Use?

Yes, marijuana use can paradoxically cause severe vomiting and, to a lesser extent, diarrhea through two distinct mechanisms: Cannabinoid Hyperemesis Syndrome (CHS) during active chronic use, and Cannabis Withdrawal Syndrome (CWS) after cessation.

Understanding the Paradox

Despite marijuana's well-known antiemetic properties, chronic heavy use leads to a paradoxical syndrome where the endocannabinoid system becomes dysregulated, causing severe gastrointestinal symptoms rather than relieving them 1, 2. This represents a critical diagnostic pitfall, as patients and clinicians often assume marijuana is treating rather than causing the symptoms 1.

Two Distinct Clinical Presentations

Cannabinoid Hyperemesis Syndrome (CHS) - Vomiting During Active Use

CHS occurs during ongoing chronic marijuana use and is characterized by:

• Stereotypical episodic vomiting (≥3 episodes annually) in patients using cannabis >1 year with frequency >4 times per week 1
• Pathognomonic hot water bathing behavior (compulsive hot showers/baths for symptom relief) reported in 71% of cases 1
• Abdominal pain accompanying the vomiting episodes 3, 2
• Symptoms that resolve only with cannabis cessation, requiring 6+ months of abstinence for definitive resolution 4

Key diagnostic criteria include:

• Cannabis use >1.5 g/day of inhaled product, >20 mg/day THC oil, or >300 mg/day CBD oil 3, 1
• Patients using cannabis products with unknown THC/CBD content more than 2-3 times daily are also at high risk 3, 1

Cannabis Withdrawal Syndrome (CWS) - Symptoms After Cessation

CWS develops 24-72 hours after stopping marijuana and includes:

• Nausea and stomach pain as prominent features 3, 4
• Gastrointestinal distress including diarrhea 4
• Anxiety, irritability, insomnia, and decreased appetite 4
• Symptoms peak between days 2-6 and generally last 1-2 weeks 4
• Approximately 47% of regular cannabis users experience withdrawal symptoms 4

Critical Diagnostic Algorithm

When evaluating a marijuana user with vomiting/diarrhea, determine:

1. Is the patient actively using cannabis or recently stopped?

   • Active use → suspect CHS 1, 2
   • Stopped 24-72 hours ago → suspect CWS 3, 4

2. Look for the pathognomonic hot water bathing behavior

   • Present in 71% of CHS cases and helps distinguish from other causes 1
   • Patients report hot showers prevent vomiting and relieve abdominal pain 5

3. Rule out life-threatening conditions first

   • Acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, myocardial infarction must be excluded before attributing symptoms to cannabis 1, 2

Management Approach

For CHS (Active Use):

• Standard antiemetics are often ineffective 3, 1
• Butyrophenones (haloperidol 5 mg IV or droperidol) are most effective, reducing hospital length of stay by nearly 50% 1, 2
• Topical capsaicin 0.1% applied to the abdomen activates TRPV1 receptors and provides consistent benefit 1, 2
• Benzodiazepines (lorazepam 2 mg IV) for anxiolysis and enhanced symptom control 1
• Alternative options: promethazine 12.5-25 mg IV, olanzapine 5-10 mg PO daily, or ondansetron (though less effective) 1
• Avoid opioids entirely - they worsen nausea, carry high addiction risk, and do not address the underlying pathophysiology 1, 4, 2
• Cannabis cessation is the only definitive cure 3, 1, 2

For CWS (After Cessation):

• Supportive care with gabapentin, nabilone, nabiximols, or dronabinol may be beneficial 3, 4
• Loperamide for diarrhea and gastrointestinal distress 4
• Ondansetron may be tried for nausea, though efficacy is often limited 4
• Avoid opioids for the same reasons as in CHS 4

Common Pitfalls and Caveats

• CHS is frequently underdiagnosed or misdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing 1, 2
• Patients often 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 and may attribute symptoms to other factors like food, alcohol, stress, or pre-existing GI disorders 1
• The prevalence of CHS is increasing with cannabis legalization and higher THC concentrations in modern products 1
• Both CHS and Cyclic Vomiting Syndrome (CVS) present identically - only complete symptom resolution after 6 months of cannabis abstinence reliably distinguishes CHS from CVS 2
• Diarrhea is more commonly associated with withdrawal rather than active use, though gastrointestinal distress can occur in both scenarios 4

Long-Term Prevention

• For CHS prevention: Amitriptyline 25 mg at bedtime, titrating weekly to 75-100 mg, is the mainstay of preventive therapy 1, 2
• For CWS: Cannabis cessation counseling and psychological support are essential, as anxiety is a prominent feature 4
• Referral to psychiatry or addiction medicine specialists for patients with significant withdrawal symptoms who were consuming high amounts of cannabis 4