he young woman was hunched over a large pink basin when Dr. Amy
Hsia, a resident in her first year of training, entered the patient's cu-
bicle in the Emergency Department. The girl looked up at the doctor. Tears
streamed down her face. "l don't know if I can take this any longer," twenty-
two-year-old Maria Rogers sobbed. Since arriving at the emergency room
early that morning, she'd already been given two medicines to stop the vom-
iting that had brought her there—medicines that clearly had not worked.
"l feel like I've spent most of the last nine months in a hospital or a doc-
tor's office," Maria told the doctor quietly. And now, here she was again,
back in the hospital. She'd been perfectly healthy until just after last Christ-
mas. She'd come home from college to see her family and hang out with her
friends, and as she prepared to head back to school this strange queasiness
had come over her. She couldn't eat. Any odor—especially food—made her
feel as if she might vomit. But she didn't. Not at first.
The next day, on the drive back up to school, she'd suddenly broken
into a cold sweat and had to pull over to vomit. And once she got started,
it seemed like she would never stop. "l don't know how I made it to school
because it seems like I had to get out of the car to throw up every few min-
utes.
Back at school she spent the first few days of the semester in bed. Once
she was back in class her friends joked that she was just trying to get rid of
the extra pounds from the holidays. But she felt fine and she wasn't going
to worry about it.
Until it happened again. And again. And again.
The attacks were always the same. She'd get that queasy feeling for a
few hours, and then the vomiting would start and wouldn't let up for days.
There was never any fever or diarrhea; no cramps or even any real pain.
She tried everything she could find in the drugstore: Tums, Pepcid, PeptoBismol, Prilosec, Maalox. Nothing helped. Knowing that another attack
could start at any moment, without warning, gnawed insistently in the back
of her mind.
She went to the infirmary with each attack. The doctor there would get a
She went to the infirmary with each attack. The doctor there would get a
pregnancy test and when it was negative, as it always was, he'd give her some
intravenous fluids, a few doses of Compazine (a medicine to control nau-
sea), and, after a day or two, send her back to the dorm. Halfway through
the semester she withdrew from school and came home.
Maria went to see her regular doctor. He was stumped. So he sent her
to a gastroenterologist, who ordered an upper endoscopy, a colonoscopy,
a barium swallow, a CT scan of her abdomen, and another of her brain.
She'd had her blood tested for liver disease, kidney disease, and a handful of
strange inherited diseases she'd never heard of. Nothing was abnormal.
Another specialist thought these might be abdominal migraines. Migraine
headaches are caused by abnormal blood flow to the brain. Less commonly,
the same kind of abnormal blood flow to the gut can cause nausea
and vomiting—a gastrointestinal equivalent of a migraine headache. That
doctor gave Maria a medicine to prevent these abdominal "headaches" and
another one to take if an attack came anyway. When those didn't help, he
tried another regimen. When that one failed, she didn't go back.
The weird thing was, she told Hsia, the only time she felt even close to
normal during these attacks was when she was standing in a hot shower.
Couldn't be a cold shower; even a warm shower didn't quite do it. But if she
could stand under a stream of water that was as hot as she could tolerate,
The weird thing was, she told Hsia, the only time she felt even close to
normal during these attacks was when she was standing in a hot shower.
Couldn't be a cold shower; even a warm shower didn't quite do it. But if she
could stand under a stream of water that was as hot as she could tolerate,
the vomiting would stop and the nausea would slowly recede. A couple of
times she had come to the hospital only because shed run out of hot water
at home.
Recently, a friend suggested that maybe this was a food allerw, so she
gave up just about everything but ginger ale and saltines. And that seemed
to work—for a while. But two days ago she'd woken up with that same bil-
ious feeling. She'd been vomiting nonstop since yesterday.
Maria Rogers was a small woman, a little overweight with a mass of long
brown hair now pinned back in a barrette. Her olive skin was clear though
pale. Her eyes were puffy from crying and fatigue. She looked sick, and was
clearly distressed, Hsia thought, but not chronically ill.
How often did she get these bouts of nausea? she asked the girl. Maybe
once a month, she told her. Are they linked to your periods? Hsia offered
hopefully. The girl grimaced and shook her head. Are they more common
just after you eat? Or when you're hungry? Or tired? Or stressed? NO, no,
no, and no. She had no other medical problems, took no medicines. She was
a social smoker—a pack of cigarettes might last a week, sometimes more.
She drank—mostly beer, mostly on the weekends when she went out with
Recently, a friend suggested that maybe this was a food allergy, so she
gave up just about everything but ginger ale and saltines. And that seemed
to work—for a while. But two days ago she'd woken up with that same bilious
feeling. She'd been vomiting nonstop since yesterday.
Maria Rogers was a small woman, a little overweight with a mass of long
brown hair now pinned back in a barrette. Her olive skin was clear though
pale. Her eyes were puffy from crying and fatigue. She looked sick, and was
clearly distressed, Hsia thought, but not chronically ill.
How often did she get these bouts of nausea? she asked the girl. Maybe
once a month, she told her. Are they linked to your periods? Hsia offered
hopefully. The girl grimaced and shook her head. Are they more common
just after you eat? Or when you're hungry? Or tired? Or stressed? NO, no,
no, and no. She had no other medical problems, took no medicines. She was
a social smoker—a pack of cigarettes might last a week, sometimes more.
She drank—mostly beer, mostly on the weekends when she went out with
More Than Just the facts
Dr. Hsia was a resident in Yale's Primary Care Internal Medicine residency
training program, where I now teach. She told me about Maria Rogers be-
cause she knew I collected interesting cases and sometimes wrote about
Ste hit the enter Key and a second later the screen 'led
her to a disease Hsia had never heard Of cannabinoid hyperemesis—
persistent and excessive vomiting (hypereremesis) associated with chronic cannabis use.
Hsia, a resident in her first year of training, entered the patient's cu-
bicle in the Emergency Department. The girl looked up at the doctor. Tears
streamed down her face. "l don't know if I can take this any longer," twenty-
two-year-old Maria Rogers sobbed. Since arriving at the emergency room
early that morning, she'd already been given two medicines to stop the vom-
iting that had brought her there—medicines that clearly had not worked.
"l feel like I've spent most of the last nine months in a hospital or a doc-
tor's office," Maria told the doctor quietly. And now, here she was again,
back in the hospital. She'd been perfectly healthy until just after last Christ-
mas. She'd come home from college to see her family and hang out with her
friends, and as she prepared to head back to school this strange queasiness
had come over her. She couldn't eat. Any odor—especially food—made her
feel as if she might vomit. But she didn't. Not at first.
The next day, on the drive back up to school, she'd suddenly broken
into a cold sweat and had to pull over to vomit. And once she got started,
it seemed like she would never stop. "l don't know how I made it to school
because it seems like I had to get out of the car to throw up every few min-
utes.
Back at school she spent the first few days of the semester in bed. Once
she was back in class her friends joked that she was just trying to get rid of
the extra pounds from the holidays. But she felt fine and she wasn't going
to worry about it.
Until it happened again. And again. And again.
The attacks were always the same. She'd get that queasy feeling for a
few hours, and then the vomiting would start and wouldn't let up for days.
There was never any fever or diarrhea; no cramps or even any real pain.
She tried everything she could find in the drugstore: Tums, Pepcid, PeptoBismol, Prilosec, Maalox. Nothing helped. Knowing that another attack
could start at any moment, without warning, gnawed insistently in the back
of her mind.
She went to the infirmary with each attack. The doctor there would get a
She went to the infirmary with each attack. The doctor there would get a
pregnancy test and when it was negative, as it always was, he'd give her some
intravenous fluids, a few doses of Compazine (a medicine to control nau-
sea), and, after a day or two, send her back to the dorm. Halfway through
the semester she withdrew from school and came home.
Maria went to see her regular doctor. He was stumped. So he sent her
to a gastroenterologist, who ordered an upper endoscopy, a colonoscopy,
a barium swallow, a CT scan of her abdomen, and another of her brain.
She'd had her blood tested for liver disease, kidney disease, and a handful of
strange inherited diseases she'd never heard of. Nothing was abnormal.
Another specialist thought these might be abdominal migraines. Migraine
headaches are caused by abnormal blood flow to the brain. Less commonly,
the same kind of abnormal blood flow to the gut can cause nausea
and vomiting—a gastrointestinal equivalent of a migraine headache. That
doctor gave Maria a medicine to prevent these abdominal "headaches" and
another one to take if an attack came anyway. When those didn't help, he
tried another regimen. When that one failed, she didn't go back.
The weird thing was, she told Hsia, the only time she felt even close to
normal during these attacks was when she was standing in a hot shower.
Couldn't be a cold shower; even a warm shower didn't quite do it. But if she
could stand under a stream of water that was as hot as she could tolerate,
The weird thing was, she told Hsia, the only time she felt even close to
normal during these attacks was when she was standing in a hot shower.
Couldn't be a cold shower; even a warm shower didn't quite do it. But if she
could stand under a stream of water that was as hot as she could tolerate,
the vomiting would stop and the nausea would slowly recede. A couple of
times she had come to the hospital only because shed run out of hot water
at home.
Recently, a friend suggested that maybe this was a food allerw, so she
gave up just about everything but ginger ale and saltines. And that seemed
to work—for a while. But two days ago she'd woken up with that same bil-
ious feeling. She'd been vomiting nonstop since yesterday.
Maria Rogers was a small woman, a little overweight with a mass of long
brown hair now pinned back in a barrette. Her olive skin was clear though
pale. Her eyes were puffy from crying and fatigue. She looked sick, and was
clearly distressed, Hsia thought, but not chronically ill.
How often did she get these bouts of nausea? she asked the girl. Maybe
once a month, she told her. Are they linked to your periods? Hsia offered
hopefully. The girl grimaced and shook her head. Are they more common
just after you eat? Or when you're hungry? Or tired? Or stressed? NO, no,
no, and no. She had no other medical problems, took no medicines. She was
a social smoker—a pack of cigarettes might last a week, sometimes more.
She drank—mostly beer, mostly on the weekends when she went out with
Recently, a friend suggested that maybe this was a food allergy, so she
gave up just about everything but ginger ale and saltines. And that seemed
to work—for a while. But two days ago she'd woken up with that same bilious
feeling. She'd been vomiting nonstop since yesterday.
Maria Rogers was a small woman, a little overweight with a mass of long
brown hair now pinned back in a barrette. Her olive skin was clear though
pale. Her eyes were puffy from crying and fatigue. She looked sick, and was
clearly distressed, Hsia thought, but not chronically ill.
How often did she get these bouts of nausea? she asked the girl. Maybe
once a month, she told her. Are they linked to your periods? Hsia offered
hopefully. The girl grimaced and shook her head. Are they more common
just after you eat? Or when you're hungry? Or tired? Or stressed? NO, no,
no, and no. She had no other medical problems, took no medicines. She was
a social smoker—a pack of cigarettes might last a week, sometimes more.
She drank—mostly beer, mostly on the weekends when she went out with
More Than Just the facts
Dr. Hsia was a resident in Yale's Primary Care Internal Medicine residency
training program, where I now teach. She told me about Maria Rogers be-
cause she knew I collected interesting cases and sometimes wrote about
Ste hit the enter Key and a second later the screen 'led
her to a disease Hsia had never heard Of cannabinoid hyperemesis—
persistent and excessive vomiting (hypereremesis) associated with chronic cannabis use.
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