(P06) Hyperemesis Cannabis Syndrome Gone Wrong

Chief Complaint : 19-year-old female presents to the ER for nausea and vomiting.

History of Present Illness : The patient is a 19-year-old female with no significant past medical history who presents to the emergency department for evaluation of nausea and daily emesis for the past month. Patient reports that on the day her symptoms began, she went to a different emergency room for evaluation, and subsequently followed up at that hospital’s clinic and was prescribed trimethoprim-sulfamethoxazole, metoclopramide, and famotidine without alleviation of symptoms. She was diagnosed with cannabinoid hyperemesis syndrome (CHS) and was told to stop her daily marijuana use, which she complied with. Since then, she had been unable to tolerate her medication due to emesis. Additionally she endorsed experiencing decreased frequency of urination, 15-20 lbs weight loss, increased fatigue, and intermittent chills. She did have transient symptom improvement after hot showers.

She denied current abdominal pain, diarrhea, constipation, dizziness, fever, cough, chest pain, shortness of breath, vision changes, and headaches.

Pertinent Physical Exam: Patient is tachycardic to 120 beats per minute lying in a stretcher, with body mass index of 15.4kg/m2. She appears dehydrated, cachectic and malnourished. She has normoactive bowel sounds and a soft, non-tender abdomen. Patient has no murmurs, rubs or gallops. Patient has no other apparent relevant physical exam findings.

Pertinent Laboratory Data: Pt has no gross abnormalities on labs. The patient received a CAT scan of the abdomen and pelvis to rule out mass, which indicated distention of the stomach with dilatation of the duodenum and narrow zone of transition at the ligament of Treitz, interpreted by reading radiologist to represent underlying superior mesenteric artery (SMA) syndrome.
During hospital admission, the patient had CTA which showed an SMA-aortic angle of 10 degrees with proximal dilation, consistent with SMA syndrome.

Case Discussion: SMA syndrome is a rare condition characterized by compression of the third portion of the duodenum between the SMA and the aorta, leading to upper gastrointestinal obstruction. The incidence of SMA syndrome is estimated to be 0.013%-0.3% based on autopsy studies, and it has been reported more commonly in females (aged 10-39) and young adults. Symptoms include nausea, vomiting, and postprandial epigastric abdominal pain, often with associated weight loss.
The etiology of SMA syndrome is multifactorial, and several predisposing factors have been identified, such as rapid weight loss, scoliosis, lordosis, and traumatic injuries. The diagnosis of SMA syndrome can be challenging due to the non-specific nature of the symptoms.
The most significant risk factor is severe weight loss.Any etiology that decreases the angle between the SMA and the aorta can be causative, including rapid loss of mesenteric and retroperitoneal fat, congenital or postoperative anatomic abnormalities, and local pathology. In this case, the most likely contributing factor to weight loss was CHS, which likely depleted the mesenteric fat and subsequently became a self-perpetuating cycle.
The challenge here specifically was that SMA syndrome is a rare diagnosis, and the patient already had a known diagnosis of CHS that explained her symptoms. The patient had a soft abdomen and was non toxic appearing. CHS is increasing in incidence with the expanded marijuana legality in the United States, which may lead to increased prevalence of SMA syndrome in the future. In the emergency department, the key is to correct electrolytes and suspect SMA syndrome if high risk, such as status post scoliosis surgery or rapid weight loss, as treatment is often conservative.
Our patient was treated conservatively in the hospital and was tolerating liquid at time of discharge and was told to follow up with surgery in two weeks.

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