Few would argue that Gastroparesis (or, delayed gastric emptying) is in the pantheon of coolest topics in EM these days, and for good reason. Affecting diabetics, chronic marijuana users, long-term smokers, this disease causes the unpleasant combination of chronic nausea, frequent vomiting, and abdominal pain. It’s difficult to treat, often refractory to our most commonly given anti-emetic meds, and causes the patient to return to the ED again and again.
To recap the pathophysiology, the Vagus nerve helps oversee that our stomach is appropriately contracting and pushing digested food boluses into the small intestine. In diabetics (the group that we most often see this disease), many years of glycosylation will render the Vagus nerve unable to do its job. Food, even small amounts of it, will sit in the stomach and digestive tract of these patients for long periods of time, causing pain, nausea, and vomiting.
With increasing levels of abdominal pain in these patients, ED practitioners will sometimes resort to opiates, which in turn slow down motility and can paradoxically exacerbate the issue.
So, what to do for our patients?
That’s where HUGS (maybe) comes into play. HUGS stands for “Haloperidol Undermining Gastroparesis Symptoms.” This rad acronym come from Dr. Ramirez et al, who performed a small, retrospective case-matched observational study, where diabetics with a formal diagnosis of gastroparesis were treated with 5 mg IM Haldol, compared to previous visits where they were not treated with Haldol.
While only having 52 patients in the study, the findings showed that there was a statistically significant reduction in hospital admissions for the Haldol group (5/52 [10%]) vs. the non-Haldol group (14/52 [27%]).
In addition, while not statistically significant, there was a 14 hour (9.2 vs 25.4) difference in length of ED stay, with the Haldol group staying for a much shorter period of time. Also notable was the absence of any negative reactions, including dystonia, CV complications, or sedation requiring intervention.
Take Home Point: In addition to the usual anti-emetics at our disposal, a 5mg IM injection of Haldol in patients with known gastroparesis can be the treatment that finally turns them around. You may save your patient many unnecessary and unproductive hours spent in the ED, or even an admission. If you’re going to do this, make sure you still check that QTc interval first.
The legendary, most excellent Dr. Joe Pinero, who taught me about Haldol use for Gastroparesis when I was an intern.
Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. AJEM 2017.