Howard University Hospital Washington, DC, United States
Natasha McMillan, MD1, Diena Abdelmaged, MD1, Farshad Aduli, MD2 1Howard University Hospital, Washington, DC; 2Howard University College of Medicine, Washington, DC
Introduction: The frequency of cannabis use has increased in the USA in the last few years. The prevalence of cannabis induced hyperemesis has also increased during this time. We present a case of presumed esophageal perforation in a patient with cannabis hyperemesis syndrome.
Case Description/Methods: A 26 year old female with daily inhaled cannabis use presents with nausea, vomiting and epigastric pain for 3 weeks. She denies chest pain or fever. She has been told in the past that she has Cannabis Hyperemesis Syndrome. Typically, her bouts last for one week and her symptoms improve with hot showers. On initial physical exam she was in moderate distress and tachycardic with tenderness over the epigastrium. Her WBC count was elevated at 18.53. She was also COVID-19 positive. CT of the abdomen performed in the ED noted free air surrounding the distal esophagus consistent with pneumomediastinum concerning for esophageal rupture. She was managed conservatively with close monitoring for a presumed esophageal perforation with spontaneous closure. She was made NPO and started on IV antibiotics. Over the next 48 hours, she developed crepitus in her neck and chest wall. Repeat imaging confirmed progression of pneumomediastinum. 48 hours later, she underwent a water-soluble esophagram negative for perforation and her diet was advanced. She was counseled on cannabis cessation and provided community resources for rehabilitation and discharged.
Discussion: Cannabis Hyperemesis Syndrome is a functional disorder marked by episodes of nausea and vomiting provoked by cannabis use. It is considered to be a variant of cyclical vomiting syndrome. These episodes of retching and vomiting can lead to complications including Mallory-Weiss tears and in rare cases esophageal rupture. The treatment for cannabis hyperemesis syndrome includes volume resuscitation, anti-emetics and cannabis cessation.
Esophageal perforations often present a diagnostic challenge due to the variability in presentation. This patient was fortunate to present early. She remained clinically stable without evidence of systemic inflammation or pleural or peritoneal collections and therefore was able to be managed conservatively.
With increasing legalization and popularity of cannabis use, it is important to recognize the potentially devastating complications of chronic marijuana use resulting in cannabinoid hyperemesis syndrome. Although esophageal perforation is rare, it has the potential for great morbidity.
Figure: Figure 1: CT Finding demonstrating concerning for esophageal rupture and progressing pneumomediastinum
Disclosures: Natasha McMillan indicated no relevant financial relationships. Diena Abdelmaged indicated no relevant financial relationships. Farshad Aduli indicated no relevant financial relationships.
Natasha McMillan, MD1, Diena Abdelmaged, MD1, Farshad Aduli, MD2. P0362 - Cannabis-Induced Esophageal Perforation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
