Another Example of a frequently missed diagnosis: Cannabinoid Hyperemesis Syndrome

Kohn, Michael Michael.Kohn at UCSF.EDU
Tue Nov 26 23:08:35 UTC 2013

Dear Colleagues,

I thought most doctors who prescribe ACE inhibitors knew to expect (and warn the patient about) a cough initially that usually resolves.

Thanks to the case in Chapter One of Lisa Sanders's "Every Patient Tells a Story," I have diagnosed cannabinoid hyperemesis syndrome in several patients who previously had been misdiagnosed as having irritable bowel disease, cyclic vomiting syndrome, gluten intolerance, or something else.  One of them had previously been hospitalized for acute renal failure due to profound dehydration.

The characteristics are marijuana smoking, intractable vomiting, colicky abdominal pain, and relief of symptoms with hot showers or baths.  Warning: the patient will frequently disbelieve the diagnosis and keep smoking marijuana.  That's what happened in the Sanders book.

A computer-based decision aid that prompted us to review medications for an ACE inhibitor in a coughing patient or  ask about marijuana use in a vomiting patient might help us catch a few cases of ACE-inhibitor-related cough or cannabinoid hyperemesis syndrome, just as the computer's reading of the ECG can help us catch some subtle ST changes or atrial flutter that we might have missed on a busy shift.

The holy grail is to have the decision aid integrated into the EHR, but I'll believe it when I see it.  Although generalized diagnosis is several orders of magnitude more complex, the computerized ECG readings give me hope.

Michael A. Kohn, MD, MPP

Associate Professor

Epidemiology and Biostatistics


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