Cyclic Vomiting/AbdominalBull**** syndromes.

[RustedFox]

Not long ago, a poster on here (I honestly can't recall who) stated that s/he suspected that marijuana-induced hyperemesis or covert alcoholism was far more common than we all thought.

I think that poster was correct.

I've seen a good several of our bounceback belly-painers at my job sites over the past several shifts and I've really spent some time winning their cooperation, getting enablers out of the room, etc.

I'm going to report that over 80% of these patients will admit to either covert EtOH (once called out on their cues, habits, etc) or marijuana.

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[RustedFox]

Double-post. Sorry.

 

[LaBusqueda]

Seriously! It's a huge problem and seemingly getting much more common very quickly.
Since Inapsine is no more....Haldol is my go to and works well!!

Seems like there is also a good amount of enabling from the clinical side too. A whole lot of $$$$$$$$$$$ work ups and mention of them likely having "ATYPICAL" x, y, or z.
So many I see recently are in the midst of there multiple scopes, biopsies, referrals to Mayo/other ivory tower.

Not to say there are folks out there with porphyria or what not...but damn!

 

[RustedFox]

Seems like there is also a good amount of enabling from the clinical side too. A whole lot of $$$$$$$$$$$ work ups and mention of them likely having "ATYPICAL" x, y, or z.
So many I see recently are in the midst of there multiple scopes, biopsies, referrals to Mayo/other ivory tower.

Yeah; just yesterday morning, I saw "that" name come across the tracking board. Not the one that's there every goddamned day for belly pain, but that guy that you know you've seen before and given the benefit of the doubt to. I looked up his history. GI consult, scope, HIDA, et. al.

All it took was for me to give him a good stern look and say - "Dude, you smell like I used to feel in undergrad on a Sunday morning." He 'fessed up sharpish after some pressure.

Another guy (same day)... "I only had two drinks." Then, I leaned on him.

"Okay, my two drinks were two pint-glass sized drinks of vodka/tonic - with not much tonic."

After some more leaning:

"Well, I started with those two drinks. I can't remember how much after that."

Point being; this guy was slick enough to parlay his hangover thru an admission and a GI consult or two.

 

[Janders]

We've been seeing a steady rise in cyclical-vomiting-syndrome which seems VERY frequently to be cannabinoid hyperemesis (one of the FEW times UDS is useful to me...)

Unclear if it could be due to more potent MJ products, or lessening social stigma of HEAVY daily use. I've seen esophageal perfs, severe hyponatremia, and a lot of miserable admissions with tons of negative scopes and HIDAs just these past couple of months.

NEVER GIVE IT OPIATES. Just don't. Makes it worse.

I used to find a modified migraine-like cocktail was first line (reglan+benadryl+ativan+NS). But honestly it only worked occasionally. Lately I've started using Haldol with better relief for my patients.

 

[Zebra Hunter]

We've been seeing a steady rise in cyclical-vomiting-syndrome which seems VERY frequently to be cannabinoid hyperemesis (one of the FEW times UDS is useful to me...)

Unclear if it could be due to more potent MJ products, or lessening social stigma of HEAVY daily use. I've seen esophageal perfs, severe hyponatremia, and a lot of miserable admissions with tons of negative scopes and HIDAs just these past couple of months.

NEVER GIVE IT OPIATES. Just don't. Makes it worse.

I used to find a modified migraine-like cocktail was first line (reglan+benadryl+ativan+NS). But honestly it only worked occasionally. Lately I've started using Haldol with better relief for my patients.

Why would a UDS be useful if you could just ask the patient if they smoke and explain to them why you are asking? And even if the UDS is positive, it doesn't mean they are daily smokers. I'm not sure how a UDS would change your management even if it was able to determine with 100% certainty that someone was a daily user.

 

[VentJockey]

Why would a UDS be useful if you could just ask the patient if they smoke and explain to them why you are asking? And even if the UDS is positive, it doesn't mean they are daily smokers. I'm not sure how a UDS would change your management even if it was able to determine with 100% certainty that someone was a daily user.

UDS is useful because the majority of patients who smoke pot will also lie to you about it. When you have objective evidence that they smoke pot, they're more likely to open up and tell you the truth, since you've already "caught" them. I drug test a substantial portion of my patients, even ones who seem on the straight and narrow, and the UDS is positive very frequently. Drug abuse is a major problem, and is probably lurking as a reason for ER visits and hospital admission more frequently than we realize.

 

[Zebra Hunter]

UDS is useful because the majority of patients who smoke pot will also lie to you about it. When you have objective evidence that they smoke pot, they're more likely to open up and tell you the truth, since you've already "caught" them. I drug test a substantial portion of my patients, even ones who seem on the straight and narrow, and the UDS is positive very frequently. Drug abuse is a major problem, and is probably lurking as a reason for ER visits and hospital admission more frequently than we realize.

That has definitely not been my experience with pot smokers, as most don't see it as a big deal anymore. I'm surprised that even the under 18 crowd tends to be pretty open about smoking the ganja when their parents are out of the room. I'm sure patients lie quite frequently, but I still fail to see how that matters for the management of a hyperemetic patient and I fail to see how it is our job to catch drug users in a lie. Also, I don't think of marijuana use is a "major problem", but I'd rather not turn this political.

 

[VentJockey]

That has definitely not been my experience with pot smokers, as most don't see it as a big deal anymore. I'm surprised that even the under 18 crowd tends to be pretty open about smoking the ganja when their parents are out of the room. I'm sure patients lie quite frequently, but I still fail to see how that matters for the management of a hyperemetic patient and I fail to see how it is our job to catch drug users in a lie. Also, I don't think of marijuana use is a "major problem", but I'd rather not turn this political.

Maybe we work in places with a different culture, but for me those who abuse drugs tend to lie about it. You catch them on the UDS. Why should we care? In general, it is our job to know our patients, and one of the things we should know about them is what drugs they are using, since it materially affects their medical care. In the case of pot, as mentioned above, if we are consider marijuana hyperemesis syndrome, it helps to know if they smoke pot. Really helps a lot, actually.

In the grand scheme of things, marijuana abuse isn't necessarily a "major problem", I guess. Just a major nuisance. I'm all in favor of legalizing it, but if someone smokes pot, that is a strong predictor of other bad habits and it is going to influence my care. For example: do they want narcotics? Sorry, but if you're a pot head, I don't trust you with a big script for roxicet. You want something for anxiety? Well, since you're a pot head, you're not getting benzos out of me. Why? I percieve them as significantly more likely to either misuse or divert prescription drugs than someone who is, you know, not a drug user. In fact, looking back in the last year, I don't think I've ever issued an outpatient prescription for a controlled substance to someone who has a positive UDS not explained by something we gave them prior to the UDS. At the very least, I think frequent UDS on patient helps us be better stewards of controlled substances.

Also, by finding out they use drugs, you have the opportunity to counsel them against it. I know pot is considered "cool" these days, and pot heads tend to think there is nothing wrong with it, but at the very least, pot turns otherwise normal people into fat losers. We should advise them not to smoke it just like we advise people not to smoke cigarettes.

 

[Zebra Hunter]

Maybe we work in places with a different culture, but for me those who abuse drugs tend to lie about it. You catch them on the UDS. Why should we care? In general, it is our job to know our patients, and one of the things we should know about them is what drugs they are using, since it materially affects their medical care. In the case of pot, as mentioned above, if we are consider marijuana hyperemesis syndrome, it helps to know if they smoke pot. Really helps a lot, actually.

In the grand scheme of things, marijuana abuse isn't necessarily a "major problem", I guess. Just a major nuisance. I'm all in favor of legalizing it, but if someone smokes pot, that is a strong predictor of other bad habits and it is going to influence my care. For example: do they want narcotics? Sorry, but if you're a pot head, I don't trust you with a big script for roxicet. You want something for anxiety? Well, since you're a pot head, you're not getting benzos out of me. Why? I percieve them as significantly more likely to either misuse or divert prescription drugs than someone who is, you know, not a drug user. In fact, looking back in the last year, I don't think I've ever issued an outpatient prescription for a controlled substance to someone who has a positive UDS not explained by something we gave them prior to the UDS. At the very least, I think frequent UDS on patient helps us be better stewards of controlled substances.

Also, by finding out they use drugs, you have the opportunity to counsel them against it. I know pot is considered "cool" these days, and pot heads tend to think there is nothing wrong with it, but at the very least, pot turns otherwise normal people into fat losers. We should advise them not to smoke it just like we advise people not to smoke cigarettes.

Forgive me if I sound like a broken record, but I still don't see how it helps at all to know that they smoke pot in terms of management. Is cannabinoid hyperemesis syndrome a diagnosis that shouldn't be missed, or even matter if it is missed? Nope. You're still going to attempt to rule out serious pathology first, and while you are taking their social history you have the opportunity to educate them on the syndrome even if they are lying to you, so that even when you eventually "misdiagnose" them with cyclic vomiting syndrome or just plain ol' nausea, the patient has an answer to their problem even if they won't admit their drug use to you. So by not ordering that UDS you saved the patient and/or the taxpayers some money, were less confrontational than trying to catch them in a lie which means your press-ganey score won't take a nose dive, and there is absolutely no demonstrable change in management.

Also, I think you are painting with a very broad brush when you speak about pot heads. I don't smoke but it is very likely that several of your classmates in medical school were potheads, rather than just the "fat losers" you speak of.

 

[VentJockey]

Forgive me if I sound like a broken record, but I still don't see how it helps at all to know that they smoke pot in terms of management. Is cannabinoid hyperemesis syndrome a diagnosis that shouldn't be missed, or even matter if it is missed? Nope. You're still going to attempt to rule out serious pathology first, and while you are taking their social history you have the opportunity to educate them on the syndrome even if they are lying to you, so that even when you eventually "misdiagnose" them with cyclic vomiting syndrome or just plain ol' nausea, the patient has an answer to their problem even if they won't admit their drug use to you. So by not ordering that UDS you saved the patient and/or the taxpayers some money, were less confrontational than trying to catch them in a lie which means your press-ganey score won't take a nose dive, and there is absolutely no demonstrable change in management.

Also, I think you are painting with a very broad brush when you speak about pot heads. I don't smoke but it is very likely that several of your classmates in medical school were potheads, rather than just the "fat losers" you speak of.

I tend to think that if you strongly suspect cannainoid hyperemesis syndrome, you'd be doing the patient a favor by strongly counselling them to stop smoking pot. Kind of like when someone comes in with a COPD exacerbation, you're doing them a favor by telling them to knock off the marlboros. I realize that other parts of management won't change. But we really ought to be counselling our patients appropriately.

I do recall some people from medical school who smoked pot. They didn't pass Step 1. They may have spent some time and money in medical school, but they're not doctors now. I'm sure there are a few who made it. But my life expereience tells me pot heads don't tend to accomplish much of anything worthwhile. Maybe I'm just closed-minded. Who knows...

 

[Hercules]

my life expereience tells me pot heads don't tend to accomplish much of anything worthwhile. Maybe I'm just closed-minded. Who knows...

You are, but that's ok. I knew lots of potheads in college who made it to med school and I knew several in med school that did quite well. I had lots of friends in law school and it was even more prevalent there. There are lots of high achievers who smoke or smoked pot at some point. They probably just didn't discuss it with you based on your views on it. Now at some point most people wind up stopping. It's harder to pull that off with a full time job and family.

 

[docdragon]

How I miss droperidol.

I start them all on Haldol with some success. The actual QT risk is higher when mixing drugs, so I don't even try zofran first.

After the recent hints that capsaicin may be helpful, I've been applying capsaicin topically on the abdomen.

It may help with gastroparesis related pain as well - my last capsaicin treatment was for a patient with gastroparesis and MJ use, and said patient was quite complimentary and happy.

 

[TheBlueBlazer]

For those who have used haldol with success, what doses are you using?

And since it seems to be the panacea these days, anyone ever try ketamine, either low-dose or dissociative?

 

[WilcoWorld]

For those who have used haldol with success, what doses are you using?

And since it seems to be the panacea these days, anyone ever try ketamine, either low-dose or dissociative?

Doses as low as 0.5mg of haloperidol have been found effective for post-op N/V. As such, I start low and don't exceed doses of 2.5 mg in these cases.

I have not tried ketamine for this particular entity. Seems a little like poking a bear.

 

[WilcoWorld]

At the risk of seeming like an ivory tower academician/softy, I must point out the contradiction between the thread's title and it's content.

Here we are discussing diagnostic test utility, treatment options and dosages for a condition that we recognize, and even stipulate is increasing in incidence. That suggests it is a real-deal clinical entity. As such, we shouldn't call it "bulli****", as this suggests it is not real. We also shouldn't lump it in with other entities. It seems that this was NOT Rusted Fox's intention - he seems to actually be suggesting that this is real and we should be considering it more often. So I point this out, not to poop on RF. Rather, I'm trying to point out a possible misinterpretation resulting from the use of terms like "bulli****", and to caution us to be careful not to promote such misunderstandings.

 

[touchpause13]

I do recall some people from medical school who smoked pot. They didn't pass Step 1. They may have spent some time and money in medical school, but they're not doctors now. I'm sure there are a few who made it. But my life expereience tells me pot heads don't tend to accomplish much of anything worthwhile. Maybe I'm just closed-minded. Who knows...

I think your being closed minded and have a rather skewed sample size I know quite a few people who do or have smoked who are in the top of my class. The thing is, they don't tell most people about it. The people who are open about their drug use are high risk takers, and I think they are more likely to mess up. people who keep their business quiet... well I think they do just fine.

 

[WilcoWorld]

I think your being closed minded and have a rather skewed sample size I know quite a few people who do or have smoked who are in the top of my class. The thing is, they don't tell most people about it. The people who are open about their drug use are high risk takers, and I think they are more likely to mess up. people who keep their business quiet... well I think they do just fine.

I dunno, this graph proves that pot smokers are med school drop-outs. We all know that Orthopedics, Urology and Ophthalmology are "safety" specialties.

 

[RustedFox]

At the risk of seeming like an ivory tower academician/softy, I must point out the contradiction between the thread's title and it's content.

Here we are discussing diagnostic test utility, treatment options and dosages for a condition that we recognize, and even stipulate is increasing in incidence. That suggests it is a real-deal clinical entity. As such, we shouldn't call it "bulli****", as this suggests it is not real. We also shouldn't lump it in with other entities. It seems that this was NOT Rusted Fox's intention - he seems to actually be suggesting that this is real and we should be considering it more often. So I point this out, not to poop on RF. Rather, I'm trying to point out a possible misinterpretation resulting from the use of terms like "bulli****", and to caution us to be careful not to promote such misunderstandings.

Roger that; its not bull$hit because it doesn't exist; it's bull$hit because the majority of the patients will deny EtOH/THC, thus leading us rather intentionally down the wrong path. Furthermore; its this group of people who are histrionic, demanding, and abusive.... and frequent "customers", who divert time and energy away from places where it should be spent.

 

[DrDrummer]

It may help with gastroparesis related pain as well - my last capsaicin treatment was for a patient with gastroparesis and MJ use, and said patient was quite complimentary and happy.

You mentioned the topical capsaicin approach for this, as I first heard described here-- thought I'd throw a link in for those people who haven't heard of this. A buddy of mine tried this as a home remedy for himself after feeling a lot of nausea/vomiting post-indulging in marijuana (classic pothead med student, matched his top choice for plastics) and found it to be lacking in efficacy, but we'll let the results of the early case series speak for themselves.

I think that what people have said so far in the thread is generally true-- CVS is being increasingly recognized as one etiology of chronic abdominal pain/nausea, this syndrome is sometimes the product of THC usage, UDS are of low/questionable clinical utility and high cost in this setting, and capsaicin may have some efficacy in this setting. I don't think patients are likely to hide a history of cannabis use if approached in the right way, and I also think it's becoming a wastebasket diagnosis that risks overlooking serious pathology when people see N&V in someone who admits to smoking weed. Gotta be careful with that.

 

[GeneralVeers]

I don't delve too much into it. Young people with undifferentiated abdominal pain and negative workups go home. After their 2nd or 3rd visit they aren't going to get any more narcotics from me. The worst thing possible is to reinforce their behavior.....whatever the cause of their NON-EMERGENT pain is by giving them narcs each and every time they come in. If you've been worked up previously with every test imaginable, you're going to get toradol, fluids, and haldol. Once your lytes are normal you're getting a swift boot out the door.