A case of abdominal pain in the ER. And a surprising cause.

(Triage note: 45-year-old male, vomiting for two days. Abdominal pain.)

Dr. Stephen Cluff is like Yoda. Judging by body hair, he’s more like Chewbacca. But he’s short, wise, and with his white hair and arthritic limp, he may as well have green skin, poor sentence structure, and a Muppet’s voice. If I’m stumped on a case, I’ll ask him. If I’m pissed off about department politics, I’ll call him for advice. If I want to play a practical joke, like loosen the top of a coffee cup, I’ll pick someone else, because Cluffy might go ape-sh*t, like he does when we don’t pass the puck at Sunday hockey.

It’s six-thirty in the evening. He’s worked the early shift, and his first patient of the day, Frederick Johns (name changed), is the only one left on his list. It’s often like this: the first chart picked up is the last one that was skimmed over, then quietly stuffed back to the pile by the previous doctor.

“I don’t know what’s going on with this guy,” Cluff says bluntly.

This is a bad sign. If he doesn’t know, there’s little chance I’ll know. He’s been working 20 years longer than I have, and is constantly updating our group on  what he considers hot topics. Recently, he’d prepared a slide show on deer-tick identification for a dinner meeting, complete with a clever title “Tick Talk,” and quiz. As he flipped through slides, I closed my eyes and gave thanks for the woman who tapped my shoulder and asked if I’d like red or white.

Just leave me the bottle, lady. I’ll call a cab.

Mr. Johns has been having severe abdominal pain and vomiting for two days. There’s been no fever, no diarrhea (his poops are normal), and he’s tender “everywhere.” His appendix was removed years earlier, and other than that, his only medical problem is mild heartburn. Cluffy points to the patient and it’s the one I least want on my list — the middle-aged man in the tailored suit (a chartered accountant, he’d already missed a day and didn’t want to miss another) — writhing in pain, asking the nurse for more morphine.

Wait, I want to tell Stephen, are you kidding me? If you can’t figure him out, how the heck am I supposed to?

I scan the chart. His white count is up, but everything else — hemoglobin, liver function, pancreatic function, kidney function, electrolytes — they’re all normal. An ultrasound and x-ray of his belly are also unremarkable. His urine is clean: no sign of kidney stones. Maybe it’s just a bad flu? I look back at Mr. Johns and can’t help but worry that he’s going to go pulseless the moment Cluffy walks out of the department. That it’s his patient, however, reassures me; he’s too good to miss anything significant.

“I’m just waiting for the CT report,” my colleague says. “Hopefully, it shows something.” He mutters thanks, and limps away.

I only see four patients before a nurse tells me that Mr. Johns is ready for re-assessment. He’s been there all day, and I want to tell him that there’s something wrong — that there’s a segment of inflamed bowel, that his pancreas looks a little inflamed, that there’s a partial blockage — and that it can be fixed. Despite the medication, he’s still in pain, and as I approach, he spits bile into a kidney basin.

I introduce myself, and tell him that Dr. Cluff has told me his story, but that I’d like to hear it again. The illness has been ongoing for two days, almost three now. The pain has been across his abdomen, but is most severe at his stomach. I palpate, and he clutches my wrist when I push below his sternum. His bowel sounds are normal and his belly his soft. His heart and lungs are clear. His history is just as I’d heard from my colleague — a little reflux, and an appendectomy in his teens.  I apologize, and tell him that there is nothing abnormal on his CT scan. I go back to the story.

“When I asked if you’ve had this before,” I say, “you said ‘not like this.’ Does that mean you’ve had something similar to this before?”

He sits up. “It’s been over a year now,” he says. “Every couple of weeks I start vomiting, and sometimes there’s pain, but it’s never lasted this long. I’ve seen my family doctor. I’ve had ultrasounds, blood tests, and even a camera in my gut, but there’s nothing.”

“Does it just go away on it’s own?”

“Often,” he says, “I can sit down in a hot bath, and it settles.”

And immediately, I know what’s wrong with him. I stop him in mid-sentence and ask him a question I ask almost everyone. I don’t ask the elderly — maybe I should start — and I don’t ask little kids. And maybe, because of his suit, and his job, I’ve judged him, and left out the one question that will nail the diagnosis. I’m so sure I’m right, that if he says no, I won’t believe him.

“Do you use marijuana?”

He has nothing to hide. “Every day.”

“What if I told you that it’s likely the marijuana?”

“Marijuana helps nausea.”

“Has it helped you with this?”

He points to the IV in his arm.

Cannabinoid hyperemesis syndrome (CHS) was first described in 2004, four years after I graduated from medical school. It wasn’t in my textbooks, it wasn’t covered in lectures, and I didn’t have to know about it to graduate. I didn’t know much about it until 2014 when it was reviewed in Canadian Family Physician, under the title, “A Hot Mess.” CHS usually manifests after many years of daily marijuana use and is characterized by vomiting (sometimes for days), resolution of symptoms after marijuana cessation, abdominal pain, and a learned pattern of hot bathing. After I print the article and read it over with Mr. Johns, he agrees with me. It’s not always this easy.

“What if I told you that if you stopped using marijuana, these episodes would go away,” I told a young woman a week earlier.

“It’s not the marijuana,” she’d said.

“The only way to know is to stop using it.”

She walked away from me, then, ten minutes later, asked for her nurse. “What can I help you with?” the nurse asked.

“Can you tell the doctor he’s an asshole.”

Another patient with multiple episodes of nausea and vomiting was asked by one of my colleagues whether or not hot water soothed his symptoms.

“I know where you’re going with this,” he said, as he denied frequent bathing. “No, this isn’t from marijuana. It has to be something else.”

A month later, his parents called 9-1-1 after he’d been vomiting for four days. Paramedics had to extract him from a steaming shower.

In a 2011 literature review, it was reported that patient denial is often the biggest stumbling block for a physician to be able to make a proper diagnosis.

“I blew the diagnosis,” Cluffy told me several days later. “I didn’t even think of it.”

“He gave me the diagnosis,” I said. “He mentioned hot baths. I didn’t even ask. I got lucky.”

Marijuana use in North America is rampant. It is the most commonly used illicit drug on the continent. In 2015 Newsweek magazine issued a special edition entitled, “Weed Nation: Is America Ready for a Legalized Future.” Medical schools now teach about cannabinoid hyperemesis, as well other deleterious effects of marijuana use. I look forward to Cluffy’s next slide show.

Raj Waghmare is an emergency physician who blogs at the ERTales.com.

Image credit: Shutterstock.com

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