SPONTANEOUS HEMOPERITONEUM AS A COMPLICATION OF CANNABINOID HYPEREMESIS SYNDROME
Peter Fahim*1, Gitanjali Lobo1, Robert W. Isfort2
1Internal medicine, Good Samaritan Hospital Trihealth, Cincinnati, OH; 2Gastroenterology, TriHealth Digestive Institute, Cincinnati, OH
Introduction
Spontaneous hemoperitoneum is intra-abdominal bleeding due to a non-traumatic and non-iatrogenic cause. Here, we present a case of spontaneous hemoperitoneum caused by vascular avulsion in an otherwise healthy young male suffering from cannabinoid hyperemesis syndrome (CHS).
Case Presentation
A 28-year-old Caucasian male presented to the Emergency Department complaining of several hours of sharp, constant, and severe left upper quadrant abdominal pain after an episode of forceful retching. He denied trauma or strenuous physical activities. History was notable for chronic abdominal pain with vomiting occurring nearly every morning before eating. Esophagogastroduodenoscopy and colonoscopy performed for evaluation of these symptoms identified a small hiatal hernia, mild Helicobacter pylori-negative gastritis, and colonic redundancy, but no other pathology.
The patient was diaphoretic and in severe pain. Heart rate was 103 bpm with a blood pressure of 124/80 mm Hg. Physical examination was only remarkable for abdominal tenderness with guarding, localized to the left upper quadrant. Hemoglobin was 15.1 g/dL. Fecal occult blood testing was negative. Lipase and complete metabolic panel were normal. CT of the abdomen and pelvis with intravenous contrast revealed a 7 cm ill-defined soft tissue mass which was consistent with a clot in the left upper quadrant separate from the spleen and colon. There was extensive free fluid in the abdomen and pelvis representing blood due to an active area of hemorrhage. After surgical consultation, mesenteric angiography was performed for embolization, but no actively bleeding vessel was identified.
The patient remained hemodynamically stable overnight with hemoglobin of 11.7 g/dL the following morning. MRI of the abdomen showed a collection of hematomas in the lesser sac and along the gastrosplenic ligament. The study was negative for gastric wall or other solid organ mass. On further inquiry, the consulting gastroenterologist discovered that the patient had used marijuana daily for over 13 years. A diagnosis of CHS was suspected and the patient was advised to avoid further use of marijuana. Given his clinical stability and stable hemoglobin on serial evaluation, exploratory laparotomy was not pursued. He was discharged from the hospital.
CT angiography of the abdomen and pelvis performerd two months later revealed near complete resolution of hemoperitoneum. The patient stopped using marijuana and his chronic vomiting completely ceased within three weeks.
Discussion
This is the first case to demonstrate hemoperitoneum as a complication of CHS. Forceful retching likely resulted in transient gastric intussusception or volvulus, putting a shearing force on the short gastric arteries which led to bleeding into the lesser sac. Blood reached the peritoneal cavity through the foramen of Winslow.
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