Version October 2024
| Clinical features |
| Abdominal pain, vomiting, and nausea that occurs in a cyclical pattern. The pain is intense and most often diffuse, periumbilical, or epigastric. Vomiting may be severe, with up to 30 episodes daily. |
| Hot showers or baths relieve symptoms in many patients, often resulting in compulsive bathing behavior. |
| Associated with regular (at least weekly, daily in many patients) cannabis use for over 1 year. Symptoms typically start within 24 hours of last cannabis use and can start at any time of day. |
| Diagnostic evaluation |
| CHS is a clinical diagnosis supported by the resolution of symptoms upon cannabis use cessation. |
| Evaluation is focused on excluding other etiologies for the symptoms and/or potential complications of excessive vomiting (eg, electrolyte disturbance, acute kidney injury, Boerhaave syndrome). |
| In a patient who has had multiple prior presentations with similar symptoms, a previous appropriate evaluation without an acute etiology identified, and a nonperitoneal abdominal examination, testing can be more focused and may not include abdominal imaging. |
| A negative result on a urine THC metabolite immunoassay (ie, drug screen) likely excludes CHS (unless the patient is only using synthetic cannabinoids, which do not cross-react with the standard urine THC immunoassay). |
| Management |
| Fluid repletion: IV isotonic saline or lactated Ringer (eg, 1L over 1 hour). |
| Dopamine antagonist: droperidol 0.625 or 1.25 mg IV or haloperidol 0.05 to 0.1 mg/kg, maximum single IV dose 2.5 mg. Dose related QT prolongation; when feasible, obtain ECG if risk factors for QT prolongation are present (eg, requiring repeated doses, electrolyte disorders, cardiovascular disease, other medicines that prolong QT). |
| Antiemetics: ondansetron (or others, such as metoclopramide) is often initially administered but is typically ineffective. |
Patient with persistent symptoms:
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| We discourage administering opioids given the risk of long-term adverse effects (eg, tolerance, dependence, opioid-induced hyperalgesia, opioid use disorder, and overdose), especially in patients with recurrent presentations for pain. |
| Long-term management: Cannabis abstinence will prevent recurrence. Offer mental health or substance use treatment referral. In a patient who cannot abruptly abstain, we advise use of products with decreased THC concentrations and reduced frequency of use with an ultimate goal of abstinence. |
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