What is the treatment for a patient with cannabis-induced hyperemesis (excessive vomiting) and esophagitis (inflammation of the esophagus)?

Treatment for Cannabis-Induced Hyperemesis and Esophagitis

The definitive treatment is complete and permanent cannabis cessation, which is the only intervention that leads to long-term resolution of symptoms, while acute management requires benzodiazepines (lorazepam) as first-line therapy, topical capsaicin 0.1% cream to the abdomen, and haloperidol as second-line, with the esophagitis managed as an epiphenomenon of vomiting using proton pump inhibitors. 1, 2, 3

Immediate Acute Management

First-Line Antiemetic Therapy

• Benzodiazepines, specifically lorazepam, are the most effective acute treatment for cannabis hyperemesis syndrome (CHS)-related nausea and vomiting, based on multiple case series and prospective studies showing superior efficacy compared to standard antiemetics. 1, 2, 3
• Lorazepam dosing: 0.5-2 mg every 4-6 hours during acute episodes, providing both antiemetic effects through sedation and anxiolytic properties that address the stress-mediated component of CHS. 4, 5

Second-Line and Adjunctive Therapies

• Haloperidol is the second-line agent for acute symptom control, with evidence showing it reduces hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014). 1, 3, 6
• Topical capsaicin 0.1% cream applied to the epigastric region activates transient receptor potential vanilloid type 1 (TRPV1) receptors and provides dramatic relief within 24 hours in many patients. 1, 2, 3, 7
• Alternative antipsychotics include promethazine (12.5-25 mg every 4-6 hours) or prochlorperazine (5-10 mg every 6-8 hours), though these are less effective than haloperidol. 4, 2

Critical Medications to Avoid

• Never use opioids in CHS patients as they worsen nausea, carry high addiction risk, and do not address the underlying pathophysiology. 1, 2, 3
• Ondansetron may be tried but often has limited efficacy compared to its use in other conditions. 1, 2

Management of Esophagitis

Understanding the Esophagitis Component

• The esophagitis in this clinical scenario is an epiphenomenon of recent retching and vomiting, not a causal factor, and should be recognized as secondary to the hyperemesis syndrome. 4
• When esophagogastroduodenoscopy is performed soon after a CHS episode, findings such as mild gastritis, erythematous streaking, Mallory-Weiss tears, or esophagitis are consequences of vomiting, not primary pathology. 4

Esophagitis Treatment

• Continue proton pump inhibitor therapy (such as pantoprazole) for symptomatic relief and healing of esophageal inflammation caused by repeated vomiting. 7
• The esophagitis will resolve with successful treatment of the hyperemesis and cannabis cessation. 7
• Repeated esophagogastroduodenoscopy should be avoided unless there are specific indications beyond the CHS diagnosis. 4

Supportive Care and Monitoring

Fluid and Electrolyte Management

• Provide intravenous fluids and electrolyte repletion for dehydration and electrolyte abnormalities commonly seen in CHS patients. 5, 8
• Monitor for complications of severe vomiting including metabolic alkalosis and hypokalemia. 5

Rule Out Life-Threatening Conditions First

• Before confirming CHS diagnosis, exclude acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction. 1, 2, 3
• Basic laboratory workup should include complete blood count, serum electrolytes and glucose, liver function testing, and lipase. 4

Definitive Long-Term Management

Cannabis Cessation: The Only Cure

• Complete and sustained cannabis abstinence is the only definitive treatment for CHS and must be strongly emphasized to the patient. 1, 2, 3
• Complete resolution of CHS symptoms requires at least 6 months of continuous cannabis abstinence, or abstinence duration equal to at least 3 typical vomiting cycles for that specific patient. 1, 2, 3
• Provide cannabis cessation counseling and consider referral to addiction medicine specialists or substance use specialists. 4, 1

Prophylactic Pharmacotherapy

• Tricyclic antidepressants, specifically amitriptyline, are the mainstay of long-term preventive therapy for CHS patients. 1, 2, 3
• Amitriptyline dosing: Start at 25 mg at bedtime and titrate weekly by 25 mg increments to reach the minimal effective dose of 75-100 mg. 1, 2, 3
• This prophylactic therapy can be initiated even while working toward cannabis cessation. 4

Psychological Support

• Assess for concurrent mental health disorders such as anxiety and depression, which are common comorbidities in cannabis users. 1
• Consider referral to psychiatry for patients with extensive psychiatric comorbidity or treatment resistance. 2
• Cognitive behavioral therapy or mindfulness meditation may improve overall quality of life. 4

Diagnostic Confirmation

CHS Diagnostic Criteria

• All three criteria must be met: stereotypical episodic vomiting occurring ≥3 times annually; cannabis use >1 year before symptom onset with frequency >4 times per week; and resolution of symptoms after 6+ months of abstinence or duration equal to 3 typical vomiting cycles. 1, 2
• Pathognomonic hot water bathing behavior (compulsive use of hot showers or baths for symptom relief) is present in 44-71% of CHS cases but is not required for diagnosis. 1, 3

Common Pitfalls to Avoid

• Do not pursue exhaustive investigations once CHS is suspected; focus on making an early diagnosis to facilitate treatment and avoid unnecessary testing and repeated hospitalizations. 1, 9
• Do not confuse CHS with cannabis withdrawal syndrome (CWS), which presents oppositely—CHS occurs during active cannabis use, while CWS occurs after stopping cannabis. 1
• Do not rely solely on hot water bathing behavior as a diagnostic criterion, as it also occurs in 44% of cyclic vomiting syndrome patients. 3
• Recognize that standard antiemetics (ondansetron, metoclopramide) are often ineffective in CHS, necessitating the use of benzodiazepines and antipsychotics. 6, 5