Review Article
Cannabinoid Hyperemesis Syndrome:
Literature Review and Proposed Diagnosis
and Treatment Algorithm
Erik A. Wallace, MD, Sarah E. Andrews, DO, MBA,
and Martina J. Jelley, MD, MSPH
Abstract: Cannabinoid hyperemesis syndrome (CHS) is character-
ized by cyclic vomiting and compulsive bathing behaviors in chronic
cannabis users. Patients are typically diagnosed with CHS only after
multiple and extensive medical evaluations, consequently without a
clear etiology of their symptoms or treatment plan leading to symp-
tomatic improvement. Increased healthcare provider awareness of CHS
as a cause of nausea, vomiting, and abdominal pain coupled with an
attentiveness to focused history takingVespecially noting symptomatic
improvement with prolonged exposure to hot showers or bathsVcan
lead to effective treatment through cannabis cessation. We propose a
diagnosis and treatment algorithm for physicians to follow when eval-
uating patients presenting with nausea, vomiting, and abdominal pain
who are suspected to suffer from CHS.
Key Words: cannabinoid hyperemesis, cannabis, compulsive bath-
ing, cyclic vomiting
C annabinoid hyperemesis syndrome (CHS) is character-
ized by cyclic vomiting and compulsive bathing behavior
in people who chronically use cannabis on a daily basis. The
syndrome was first reported in 2004 in 9 patients in Australia.1
Subsequently, 22 cases in Canada, Great Britain, Spain, the
Netherlands, New Zealand, and the United States have been
reported.2Y14 All patients were diagnosed with CHS after they
had suffered for years with symptoms and had presented
multiple times to healthcare facilities, receiving a variety of
diagnostic tests. While the antiemetic effects of cannabis are
widely known,15Y17 the paradoxical emetic effect from chronic
cannabis use is under-recognized by both healthcare providers
From the University of Oklahoma School of Community Medicine, Department
of Internal Medicine, Tulsa, OK.
Reprint requests to Erik A. Wallace, MD, University of Oklahoma School of
Community MedicineVTulsa, 4502 E. 41st St., Tulsa, OK 74135. Email:
erik-wallace@ouhsc.edu
The authors have no financial relationships to disclose and no conflicts of
interest to report.
Accepted June 1, 2011.
Copyright * 2011 by The Southern Medical Association
0038-4348/0Y2000/104-659
DOI: 10.1097/SMJ.0b013e3182297d57
Southern Medical Journal & Volume 104, Number 9, September 2011
Copyright © 2011 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.
Chad L. Garmany, MD,
and the public. Government- and nongovernment-sponsored
websites often list the benefits and harms of cannabis use but
fail to mention potential side effects of nausea, vomiting, or
abdominal pain associated with chronic cannabis use.18Y22 With
newfound awareness in 2010 of CHS as possible cause for
one of our patient’s nausea, vomiting, and compulsive bathing
behavior, we have since identified an additional 5 patients who
we believe suffer from CHS. Likely, a number of chronic can-
nabis users with similar symptoms are utilizing a significant
amount of healthcare resources for evaluation and treatment,
yet continue to use cannabis without symptom resolution.
In this article we discuss the epidemiology of cannabis
use and the number of people who are potentially at risk for
CHS; offer a review of previously published CHS cases; de-
scribe the pathophysiology of cannabis both as an antiemetic
and as a cause of cyclic vomiting; suggest how the patho-
physiology of compulsive bathing behavior may improve the
symptoms of CHS; and propose a diagnosis and treatment al-
gorithm for patients suspected of suffering from CHS. We also
examine areas of uncertainty and opportunities for potential
research.
Epidemiology
Cannabis is the most widely used illicit drug in the United
States among all age groups.23 In 2008, 2.2 million adolescents
aged 12 to 17 used marijuana for the first time, more than
any other illicit drug.24 While 42.6% of high school seniors
Key Points
& Compulsive hot water bathing that relieves the symptoms of
nausea and cyclic vomiting in patients who have been daily
cannabis users for more than one year should be considered
as a pathognomonic feature for cannabinoid hyperemesis
syndrome (CHS).
& Extensive medical testing should not be necessary in patients
with a high clinical suspicion for CHS based on history and
physical exam.
& Cannabis cessation and fluid replacement, if clinically indi-
cated, should lead to symptomatic improvement.
659
Wallace et al & Cannabinoid Hyperemesis Syndrome: Diagnosis and Treatment

reported using cannabis at least once in their lifetime, 5.4% use
cannabis on a daily basis.18 CHS has been almost exclusively
reported in people who began using cannabis daily in their
teenage years.2Y14 Therefore, chronic daily users of cannabis
may be at the highest risk for developing CHS. There are
presently 17.2 million students in the United States enrolled in
grades 9 through 12.25 If approximately 20% (3.4 million) are
enrolled in grade 12, then roughly 183,600 of current high
school seniors are potentially at risk of developing CHS within
the next few years if they continue to use cannabis daily. The
risk of developing CHS depends on multiple known and un-
known factors, including but not limited to how much cannabis
is used on a daily basis and the method of use, as well as other
confounding medical, psychiatric, ethnic, and socioeconomic
conditions. Fourteen US states and the District of Columbia
have legalized the use of medicinal cannabis,19 and other
countries have decriminalized the possession or use of can-
nabis. Increased availability and use by patients who become
chronic cannabis users as adults could result in a rise in the
number of people who develop CHS.
The relatively few number of published cases about
CHS could suggest that the diagnosis is uncommon; however,
we propose that because CHS was first described only 7 years
ago and the diagnostic symptoms are largely unknown

Table 1. Published cases of cannabinoid hyperemesis syndrome

Author Case Age, y Sex Compulsive bathing Agea Before vomitingb Before diagnosisc Symptomd
Allen et al1 1 23 M Yes 19 3 1.3 Improved
2 29 F Yes 17 3 9 Improved
3 44 M Yes 16 6 12 Improved
4 37 M Yes 17 17 3 Improved
5 21 M Yes 12 5 4 No cessation
6 38 M Yes 17 17 4 Improved
7 36 F Yes 12 2 3 Improved
8 21 M Yes 14 3 0.5 Improved
9 49 M No 18 14 6 No cessation
Boeckxstaens2 10 30 M Yes 14 V V V
Roche and Foster3 11 38 M Yes V V 2 Improved
Alfonso Moreno et al4 12 49 F Yes 18 2 29 Improved
Wallace et al5 13 30 M V 18 7 5 Improved
Chapyala and Olden6 14 38 M Yes 18 17 3 Improved
Singh and Coyle7 15 46 M Yes V V V Improved
Chang and Windish8 16 25 F Yes 19 5 1 Improved
Ochoa-Mangado et al9 17 25 M Yes 19 1 7 Improved
Sannarangappa and Tan10 18 34 M Yes 19 5 10 Improved
Sontinent et al11 19 22 M Yes 16 5 0.2 Improved
Watts12 20 32 M Yes 16 13 3 Improved
Donnino et al13 21 22 M Yes V V 2.1 Improved
22 23 M Yes 20 1 1.7 Improved
23 51 M Yes V V 2 Improved
Soriano-Co et al14 24 34 M Yes 20 19 1 Improved
25 34 F Yes 13 19 2 No cessation
26 26 M Yes 14 9 5 Improved
27 34 M Yes 10 21 3 Improved
28 38 F Yes 15 15 8 Improved
29 27 M Yes 9 19 0 No cessation
30 35 M Yes 15 20 0 No cessation
31 31 F Yes 13 16 2 Not improved
Mean (SD) 32 (9) 15.9 (3.0) 10.2 (7.1) 4.5 (5.6)
a
Age at onset of regular cannabis use in years.
b
Duration of daily cannabis use before cyclical vomiting in years.
c
Duration of illness before CHS diagnosis in years.
d
Symptom result.
M, male; F, female.

660 * 2011 Southern Medical Association

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throughout the medical profession and among cannabis users,
a significant number of cases might be unrecognized. Patients
with CHS have often been diagnosed only after undergoing
extensive and repeated testing for their symptoms over a period
of several years with no previously identified, clear etiology.
An extensive review of the literature was required for us to
recognize that chronic cannabis use could be the cause of their
patients’ paradoxical nausea and vomiting.
Summary of Case Reports
Thirty-one previously published cases of CHS are de-
scribed in Table 1. Seventy-seven percent of patients reported
were men. Most patients began chronic, daily cannabis use
as teenagers (mean 15.9 years; SD 3.0; range 9Y20), and
symptoms of CHS developed after years of chronic daily
use (mean 10.2 years; SD 7.1, range 1Y21). Diagnosis of CHS
did not occur until several years after the initial onset of
symptoms (mean 4.5 years, SD 5.6; range 0Y29). Use of
cannabis multiple times daily was specified in all reports ex-
cept for three cases where amount used was not specified.
Amounts were described in terms of ‘‘cones,’’ ‘‘joints,’’
‘‘bongs,’’ or ‘‘bags’’ per day or by frequency of inhalation in
hours. Prior to diagnosis, all patients presented multiple times
to healthcare facilities with similar symptoms and received
multiple diagnostic imaging and invasive procedures without a
clear diagnosis and treatment plan resulting in symptomatic
improvement. Reported tests included abdominal x-ray, ab-
dominal computerized tomography (CT), abdominal ultra-
sound, esophagogastroduodenoscopy (EGD), colonoscopy,
head CT, gastric emptying studies, upper GI with barium with
or without small bowel follow through, capsule endoscopy,
hepatobiliary iminodiacetic acid (HIDA) scan, and magnetic
resonance cholangiopancreatography (MRCP). One patient
received a neurology consultation9 and 2 patients received
psychiatric consultations.5,9
Previous reports described improvement in cyclic vomit-
ing within 12 to 48 hours of hospital admission and adminis-
tration of intravenous fluids.8,12,13 A recent case series of eight
patients reported a significant decline in daily vomiting one
Table 2. Differential diagnosis of cyclic vomiting
Diagnoses to consider with cyclic vomiting
Cannabinoid hyperemesis syndrome
Cyclic vomiting syndrome
Hyperemesis gravidarum
Psychogenic vomiting
Bulimia
Addison disease
Migraine headaches
Southern Medical Journal & Volume 104, Number 9, September 2011
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Review Article
week, on average, after cannabis cessation.14 Antiemetics, in-
cluding metoclopramide, ondansetron, prochlorperazine, and
promethazine, have not been effective in relieving nausea and
vomiting at presentation.8,10,14 Significant symptom resolu-
tion following cannabis cessation was reported in cases where
follow-up information was reported. Given the small number
of cases reported and lack of clinical trials, it remains un-
clear whether intravenous hydration or cannabis cessation alone
leads to symptom resolution and which, if any, antiemetics ef-
fectively improve symptoms.
Cyclic Vomiting
The pathophysiology of cannabis as a cause of cyclic
vomiting is not completely understood. Several theories have
emerged based on current understanding of the endogenous
cannabinoid system. Delta-9-tetrahydrocannabinol (THC) is
the principle active cannabinoid in marijuana; it binds to
cannabinoid type 1 (CB1) and type 2 (CB2) receptors in
human tissues.26 CB2 receptors are located mostly in immune
tissue and thus may not have a role in emesis due to cannabis
use. CB1 receptors are located in the central nervous system
and enteric plexus. It is likely they mediate the anti-emetic
effects of cannabinoids.1,8 However, chronic stimulation of
these receptors may produce a paradoxical emetic response
in susceptible individuals. THC has been shown to slow gas-
trointestinal motility in a dose-dependent manner and could
induce symptoms via this neuromodulatory effect.27 One study
demonstrated that nausea and vomiting can be provoked with
a large intravenous dose of crude marijuana extract.28
Diagnoses to consider when evaluating patients with cy-
clic vomiting include CHS, migraine headaches, hyperemesis
gravidarum, Addison’s disease, psychogenic vomiting, bu-
limia, and cyclic vomiting syndrome (CVS).29 Unique char-
acteristics of these diagnoses are listed in Table 2. The causes
of CVS and psychogenic vomiting remain unclear and are the
most confounding differentials when establishing a diagnosis
of CHS. Unique to CVS is a family history of migraine
headaches and psychological stressors, which are not associ-
ated with CHS. However, compulsive bathing behaviors and
Associated disease components and symptoms
Chronic cannabis use, compulsive bathing behaviors
Family history of migraines, psychological stressors
Pregnancy
Typically associated with conversion disorder or major
depression
Binging/purging behavior to prevent weight gain
Fatigue, weight loss, hyperpigmentation, hypotension,
hyponatremia, hyperkalemia
Unilateral headache with/without aura, photophobia
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Wallace et al & Cannabinoid Hyperemesis Syndrome: Diagnosis and Treatment

chronic cannabis use are distinctive to CHS, unlike other di-

agnoses associated with cyclic vomiting.

Compulsive Bathing
Compulsive bathing behaviors were described in all but
2 reported cases. Though not clearly defined, compulsive
bathing is suggested when patients take multiple hot showers
or baths daily or take a single bath or shower lasting several
hours. Patients diagnosed with CHS report temporary relief
of nausea and vomiting with prolonged and repeated exposure
to hot water through baths or showers. Bathing duration was
reported in one case series to last from 3 to 6 hours at a time7,8
with a mean of 5 hours daily.14 One patient spent ‘‘all day’’ in
the bathtub ‘‘300 out of 365’’ days during the past year5; 1 ran
out of hot water at home; and 1 used a shower in an adjacent
hospital room when the hot water in his room ran out.8 Another
patient reported taking ‘‘20 lengthy showers each day’’ and
applying hot water bottles to his abdomen to help relieve
symptoms.10
Compulsive hot water bathing is thought to relieve nau-
sea and cyclic vomiting through either brain response to core
body temperature changes resulting from hypothermic effects
of THC or activation of CB1 receptors in the hypothalamus,
which regulates body temperature.8 Cannabinoids may also
exert an anxiolytic effect by reducing the psychological stress
from persistent nausea and vomiting.14 Regardless of the
mechanism, other clinical conditions have not been identi-
fied in the literature where consistent relief of nausea and
Fig. 1 Diagnosis and treatment algorithm for cannabinoid
vomiting is achieved with hot water exposure. Since com- hyperemesis syndrome. Diagnoses to consider when a patient
pulsive bathing and symptom relief were clearly described in presents with nausea include, but not are not limited, to acute
nearly all CHS patients, the relief of cyclic vomiting with hot hepatitis, adrenal insufficiency, bowel perforation, bowel obstruc-
water exposure in chronic cannabis users should be consid- tion, cholangitis, cholecystitis, diverticulitis, ectopic pregnancy,
ered a pathognomonic feature of CHS. gastroparesis, myocardial infarction, nephrolithiasis, pancreatitis,
pelvic inflammatory disease, pregnancy, and ruptured or dissecting
aortic aneurysm.
Diagnosis and Treatment
Increased healthcare provider awareness of CHS and fo-
cused history takingVespecially noting symptomatic im- a hot shower or bath. Such inquiry prior to questions about
provement with prolonged exposure to hot showers or baths in cannabis use is warranted, as patients may be reluctant to offer
chronic cannabis users presenting with cyclical vomitingVcan an accurate drug use history or may deny that cannabis use
lead to effective treatment through cannabis cessation. Clini- is contributing to their symptoms. If patients report relief from
cal characteristics for the diagnosis of CHS have been pro- their symptoms with hot water exposure, it is important to
posed.11,14,30 However, we encourage clinicians to use the determine the extent to which bathing activity is compulsive
diagnosis and treatment algorithm shown in Figure 1 for by asking how long and how often they take a hot shower
patients with suspected CHS to help reduce unnecessary testing or bath. Patients with CHS often take hot baths or showers
and utilization of healthcare resources. Initially, physical ex- lasting up to several hours and/or multiple times each day. If
amination and history taking is recommended for patients pre- compulsive bathing behavior in hot water is confirmed, the
senting with nausea, vomiting, and abdominal pain to rule out clinician should ask the patient about their use of cannabis
life-threatening causes or diagnoses that confer significant products.
potential morbidity to the patient. Prompt and appropriate di- Since discussing substance use can be a sensitive topic
agnostic testing and treatment should be pursued for patients for patients, healthcare providers are advised to describe a
with suspected conditions noted in Figure 1. possible relationship between cannabis use and the patient’s
If life-threatening diagnoses are not suspected, we sug- symptoms before inquiring about cannabis use. Informed
gest the healthcare provider ask the patient if symptoms of patients may be more likely to accurately detail their cannabis
nausea, vomiting, and abdominal pain improve after taking use if they understand that cannabis may be the cause of

662 * 2011 Southern Medical Association

Copyright © 2011 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.

symptoms that lead them to seek medical assistance and that
cessation of cannabis may lead to symptom improvement.
Clinicians should elicit details as to when cannabis use first
began, how often and how much it is used, and when symp-
toms of nausea, vomiting, and abdominal pain were first ex-
perienced. If symptoms began at least 1 year after chronic daily
cannabis use began, a diagnosis of CHS is likely. Furthermore,
if symptoms previously improved during cannabis cessation
and reoccurred after resuming cannabis use, the diagnosis is
further supported. It is advised that clinicians initially avoid
unnecessary laboratory testing and imaging unless otherwise
clinically indicated. If a patient denies cannabis use yet states
that bathing in hot water relieves nausea and vomiting symp-
toms, a urine drug screen for THC is suggested. Patients
testing positive should be informed of the test results, and then
re-questioned.
Once a presumptive diagnosis of CHS has been made,
patients should be evaluated for signs and symptoms of vol-
ume depletion. If so evident, a patient may require intravenous
hydration in a clinic, an emergency department, or hospital,
depending on symptom severity. Continuous observation and
treatment should not be necessary for more than 48 hours
given that symptoms improve and cannabis use has ceased. Be
aware that cyclic vomiting may be refractory to antiemetics.
Intravenous hydration may not be required provided that
the presumptive CHS diagnosis is accepted, the patient is com-
pliant with cannabis cessation, symptoms are mild, and oral
liquids can be tolerated. If symptoms resolve, additional coun-
seling and resources to assist with continued cessation of can-
nabis use should be provided. Clinicians might consider a urine
drug screen after symptom resolution to confirm the absence
of THC, which would further support a CHS diagnosis. How-
ever, clinical management would not change if the patient’s
symptoms have resolved with reported cannabis cessation. Thus,
a repeat urine drug screen might not be clinically useful.
If symptoms do not improve, healthcare providers are
encouraged to ask the patient about continued cannabis use
and secondhand exposure to cannabis. If confirmed, the pro-
vider should offer additional information resources and en-
courage the patient to cease cannabis use or secondhand
exposure. If the patient denies use, a re-evaluation and urine
drug screen is warranted to identify other possible causes for
their symptoms.
Summary
CHS is characterized by chronic cannabis use, cyclic vom-
iting, and compulsive bathing behavior. As a potentially under-
recognized cause of nausea, vomiting, and abdominal pain,
the effects of CHS on undiagnosed patients can lead to de-
creased quality of life and productivity and result in repeated
and unnecessary overuse of healthcare resources. Patients have
typically been diagnosed with CHS only after receiving mul-
tiple and extensive medical evaluations over the course of
months to years without a clear diagnosis. Earlier recognition
Southern Medical Journal & Volume 104, Number 9, September 2011
Copyright © 2011 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.
Review Article
and subsequent cannabis cessation can lead to symptom re-
solution and fewer trips to emergency departments or phy-
sician offices where additional testing and expense is likely
to occur.
We suggest that focused history taking and physical ex-
amination with minimal testing can assist in eliminating other
causes of nausea and vomiting while identifying CHS as a
possible diagnosis. Primary care, emergency room, hospital
physicians, and other healthcare providers are encouraged to
ask patients presenting with nausea, vomiting, and abdominal
pain if symptoms improve after taking hot showers or baths,
and if so, to then inquire about cannabis useVthe amount used
and length of use. For patients who have used cannabis on a
daily basis for more than one year; whose history suggests
improvement of cyclic vomiting with compulsive hot water
bathing; and who show no signs or symptoms of dehydration
requiring intravenous fluids, we recommend cannabis cessa-
tion and primary care follow-up. Providers should be aware
that patients might deny cannabis use as cause of their
symptoms and, therefore, are at risk of continuing cannabis
use. Some patients may doubt the presumed diagnosis and
fail to follow up or might seek other medical opinions. This
could result in repeated testing in other healthcare settings
without identification of a clear diagnosis or provision of a
treatment plan to alleviate symptoms. A lack of available in-
formation detailing side effects from chronic cannabis use
warrants that government and non-government Internet sites
related to cannabis use enumerate and update the published
side effects of cannabis to include cyclic vomiting associated
with chronic use. We also suggest that cannabis dispensaries
provide CHS information to their customers, advising them
to discuss an appropriate diagnosis and treatment plan with
their physician.
Future studies are needed to better estimate the prevalence
of CHS. Given the projected increased use of legalized me-
dicinal cannabis in the United States, we suggest the number of
CHS cases could increase, especially in states where patients
have more consistent access to cannabis that can be used on a
daily basis. Additionally, studies are needed to determine the
risk factors for developing CHS, e.g., underlying medical,
psychiatric, ethnic, or socioeconomic conditions as well as
specific species, amount, potency, and method of inhalation
of cannabis.
Acknowledgment
The authors would like to thank Michelle C. Farabough,
MSKM, for technical assistance and manuscript preparation.
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