Baron/colitis/1990

Ulcerative Colitis and Marijuana

Annals of Internal Medicine, Volume 112, Number 6, 15 March, 1990, p. 471

To the Editor: The apparent protective effect of cigarette smoking on
ulcerative colitis (1) suggests that inhaled plant products might affect
the disease process. We report a case suggesting a relation between
ulcerative colitis and smoking marijuana.
In 1972, a 23-year-old woman developed abdominal pain, diarrhea,
and rectal bleeding. Sigmoidoscopy to 15 cm revealed diffuse cobblestone
ulcerations, and a single-contrast barium enema showed numerous small
marginal irregularities in the distal sigmoid and rectum. Ulcerative
colitis was diagnosed, and her symptoms waxed and waned despite treatment
with sulfasalazine, librax, and intermittent prednisone. Discouraged, she
stopped all medications in 1975. In 1976, she noted that smoking marijuana
resulted in fewer stools, more stable body weight, and fewer, milder
exacerbations . Her typical intake was a pipeful once or twice daily,
which she maintained despite her dislike for its euphoric effects.
Cessation repeatedly resulted in exacerbations within a few weeks;
resumption led to some improvement in a day or two, with maximal effect
after several weeks.
She was smoking marijuana daily when, after having 2 months of
symptoms, she was hospitalized at the Mary Hitchcock Memorial Hospital in
1983. She was febrile and had an erythrocyte sedimentation rate of 103
mm/h. Sigmoidoscopy to 16 cm showed diffuse small friable ulcerations with
granularity. A biopsy of the lower rectal fold showed marked chronic
inflammation extending into the submucosa without granulomas. She improved
promptly with prednisone. At home she resumed taking marijuana. Over 15
months her prednisone dose was tapered and sulfasalazine therapy begun.
Sigmoidoscopy to 20 cm was normal, and a single-contrast barium enema
showed a diffuse granular pattern with a "pipe-like" apearance, compatible
with inactive colitis.
In 1986 she stopped both sulfasalazine and marijuana but within 2
months became symptomatic. Sulfasalazine was resumed with minimal relief,
and 2 months later she resumed taking marijuana. Her symptoms improved
within about a week, and in 2 months she was again in remission through
1988. The patient had started smoking cigarettes before the onset of the
ulcerative colitis. She noted no relation to her symptoms and stopped
smoking in 1982 for "health reasons." She thought her symptoms worsened
with coffee or alcohol and rarely drank either beverage.
This case suggests marijuana may ameliorate ulcerative colitis,
although an alternative explanation is the natural variation in the
severity of its symptoms. It is not clear how tobacco or marijuana might
have a beneficial effect. Suggested mechanism for cigarettes include
enhanced catecholamine release, disturbed prostaglandin production, and
immunologic changes (1). Cigarettes increase colonic motility and
marijuana in large doses may cause diarrhea (2), although it is difficult
to relate these observations to ulcerative colitis. A few systemic effects
are similar for both drugs. Both have been associated with T-cell
suppression (3), but the relation of ulcerative colitis with immune
disturbances is weak (4). Interference with the pituitary-ovarian axis
can occur from either drug (2, 5); for tobacco, this interference seems
to cause relative estrogen deficiency in women (5). Through effects on
estrogen receptors in the colon or changes in bile composition, such
hormonal changes could conceivably affect the colon.
Although an ameliorative effect of marijuana smoking on ulcerative
colitis, if verified, would probably have little direct clinical relevance,
it might lead to new therapy and help elucidate the disease.

John A. Baron, MD, MS, MSc
Richard D. Folan, MD
Dartmouth-Hitchcock Medical Center
Hanover, NH 03756

References

1. Cope EF, Heatley RV, Kelleher J, Lee PN. Cigarette smoking and
inflammatory bowel disease: a review. Hum Toxicol. 1987; 6: 189-93.

2. Nahas GG. Toxicology and pharmacology. In: Nahas GG, ed. Marihuana
in Science and Medicine. New York: Raven Press; 1984.

3. Holt PG, Keast D. Environmentally induced changes in immunological
function: acute and chronic effect of inhalation of tobacco smoke and
other atmospheric contaminants in man and experimental animals. Bacteriol
Rev. 1977; 41: 205-16.

4. Kirsner JB, Shorter RG. Recent developments in nonspecific
inflammatory bowel disease, part 2. N Engl J Med. 1982; 305: 837-48.

5. Baron JA. Smoking and estrogen-related disease. Am J Epidemiol.
1984; 119: 9-22.

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