[size=6]A 14-year-old presents to the emergency room with several months of nausea and vomiting. They have a significant weight loss of over 20 lbs during this time. Workup included a CT of the abdomen/pelvis which showed pneumomediastinum which was confirmed on chest radiograph. The remainder of the CT was unremarkable. They note that the only time they have improvement of their symptoms is with taking hot showers. What is the next best study to obtain in this patient?

 

a Small bowel follow through

 

b Esophagram

 

c Urine drug screen

 

d CT chest

 

e Bronchoscopy[/size]

B

C

C

[size=6]A 14-year-old presents to the emergency room with several months of nausea and vomiting. They have a significant weight loss of over 20 lbs during this time. Workup included a CT of the abdomen/pelvis which showed pneumomediastinum which was confirmed on chest radiograph. The remainder of the CT was unremarkable. They note that the only time they have improvement of their symptoms is with taking hot showers. What is the next best study to obtain in this patient?

 

a Small bowel follow through

 

b Esophagram

 

c Urine drug screen

 

d CT chest

 

e Bronchoscopy[/size]

B

B

correct answer

c Urine drug screen

 

This patient presents with cannabinoid hyperemesis syndrome (CHS). This syndrome is characterized by cyclic vomiting due to chronic cannabis use. Due to multiple reasons, including legislative changes and increased medical indications for cannabis, the use of cannabis continues to increase. CHS is one of the more common side effects of daily high dose cannabis use and was first reported in 2004. Patients often present to multiple institutions with intractable nausea and vomiting and delays in diagnosis are common due to the under-reporting of cannabis use, failure of medical providers to recognize symptoms and the illegal status of cannabis in some states leading to a stigma with cannabis use. This can lead to significant health care expenditure with one study showing the median charge for ED visits and hospital admissions over a 2-year study period was $95,023 (IQR = 268,110). The exact mechanism for the hyperemesis syndrome is unknown and the symptoms can be vague including weight loss, abdominal pain, and cyclical vomiting. These symptoms may mimic surgical conditions. Many patients find relief with hot showers. Abstinence from cannabis is the only definitive treatment, however, capsaicin cream and haloperidol have been described for short term relief. Opiates should be avoided.