CASE  A 34 year old lady was admitted to the internal medicine ward 3 times over a course of 4 months because of episodes of vomiting and abdominal pain, lasting for few days  Her past medical history was normal. she had no history of surgery or drug allergies  Physical examination: - Vital signs : temp. 36.4 C , HR-100\min , BP- 110\80 mm hg , O2 sat. 100% - Mucous membrane is dry , CVS examination were normal, her chest was clear ,the abdomen was soft with diffuse tenderness with no rebound or guarding, CONTINUE…  CBC: WBC 13.30, Hb 14.9 Plt 277  Metabolic Panel: AST 23, ALT 38, ALP 36, GGT 12, Bil 0.52, Cr 0.55, BUN 11, Na 138, K 4, TSH 1.3., amyl 80  ABG, PT and INR are normal  Urine analysis was normal, pregnancy test results were negative  An abdominal x-ray was within normal limits CONTINUE…  During her admition she was treated with IV fluids and anti emetics with a steady improvement in her symptoms, then she was discharged home.  Two weeks later, she was readmitted because of the same symptoms  , the patient underwent an abdominal US which was normal  An abdominal pelvic CT scan was performed that yielded normal results  For further investigation an upper GI Endoscopy was performed and reveled a mild gastritis , urease test negative for HP  Eye fundus examination- normal ???? DD  Gastrointestinal: - Inflammation: gastritis, gastroenteritis, pancreatitis, cholecystitis, appendicitis… - Obstruction: pyloric stenosis ,small bowel obstruction, large bowel obstruction, illeus - Irritation: drugs, poisions DD  CNS: - Motion sickness - Menie’re’s disease - Migraine - Cerebral hemorrage - Brain tumor - Benign intracranial pressure - Head injury DD  Others: - Pregnancy: hyperemesis, morning sickness - Metabolic causes: hypercalcemia, uremia, adrenal insufficiency, hyperglycemia - Drug reactions: chemotherpy, opiods, SSRI, emetics - Eating disorder: bulimia nervosa, anorexia nervosa DD  Others: - Myocardial infarction - Severe pain - Postoperative nausea and vomiting - Coughing, hiccups or asthma - High dose of ionizing radiation - Rumination syndrome  The nurses observed that the patient spent many hours at the bathroom taking a shower BACK TO OUR PATIENT…  Upon further questioning the patient reported that she admitted to daily heavy tobacco and merijuana use for the past 16 years and denied any alcohol use  Urine toxicology test was positive to cannabinoid CANNABINOID HYPEREMESIS  Cannabinoid hyperemesis was first described by Allen in 2004 in Australia  More than 30 cases have described the association of chronic heavy cannabinoid use and cyclical vomiting with abdominal pain  A syndrome characterized by severe nausea and vomiting associated with chronic marijuana abuse and marked by compulsive hot bathing habits, which temporarily alleviate symptoms  Sometimes with polydipsia  Weight loss  Patients generally consider hot baths as a comforting maneuver to decrease the intensity of the nausea and vomiting  Abstinence from cannabis lead to resolution of the vomiting syndrome and the abdominal pain CANNABIS  Is the third most common used drug after tobacco use and alcohol  Marijuana is frequently used for the treatment of nausea, the mechanism of action of this effect is not preciesly known but it may be related to stimulation of the cannabinoid receptors in the brain Crude canabis is made of over 60 different compounds  The main active ingredient is delta-9tetrahydrocanabinol (THC)  i.v injection of crude marijuana extract causes acute toxicity and vomiting (paradoxical effect)  CANNABINOID RECEPTORS  Two types of cannabinoid receptors were been identified: - CB 1 receptor: present in brain areas that regulate HPA axis function and in enteric nerve plexus - CB2 receptor: present in nonneuronal tissues, but also present in microglia and has immmunomodulatory effect  Canabis decrease gastrointestinal motility and may overide the CNS mediated antiemetic effect,promoting emesis OTHER EFFECTS  Cannabinoids may also stimulate thirst  Cannabis may modulate the thermoregulatory system of the hypothalamus  This effect might arise from modulation of the HPA axis by cannabinoids THANK YOU