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BASICS

Description

  • Sudden involuntary repetitive contraction of inspiratory muscles, mainly diaphragm, with abrupt glottis closure.
  • Sound produced by air stoppage at glottis.
  • Duration-based classification:
  • Bouts: ≤48 hours
  • Persistent: >48 hours but <1 month
  • Intractable: >1 month
  • Systems affected: nervous, pulmonary.
  • Synonyms: hiccoughs, singultus.

Epidemiology

  • All ages including fetus.
  • Male predominance (4:1).
  • Incidence uncertain.
  • Self-limited hiccups very common, including perioperative.

Etiology & Pathophysiology

  • Stimulation of hiccup reflex arc: vagus nerve, phrenic nerve, central hiccup center in upper spinal cord/brain.

  • 90% organic cause in men; psychogenic causes more common in women.

  • Causes:
  • CNS: AV malformations, meningitis, encephalitis, brainstem mass, MS, hydrocephalus, PICA aneurysm, seizures.
  • Diaphragm irritation: tumors, pericarditis, eventration, splenomegaly, hepatomegaly, peritonitis.
  • Nerve irritation: pharyngitis, laryngitis, neck tumors.
  • Thoracic lesions: pneumonia, aortic aneurysm, TB, MI, lung cancer, rib exostoses.
  • Esophageal: reflux, achalasia, Candida, carcinoma, obstruction.
  • GI disorders: gastritis, GERD, PUD, distention, cancer.
  • Cardiovascular: MI, pericarditis.
  • Hepatic/pancreatic: hepatitis, hepatoma, pancreatitis, pseudocysts, cancer.
  • Other: IBD, cholelithiasis, cholecystitis, prostatic disorders, appendicitis, post-op.
  • Metabolic: uremia, hyponatremia, gout, diabetes.
  • Drug-induced: dexamethasone, steroids, benzodiazepines, methyldopa, propofol, chemotherapeutics.
  • Toxic: alcohol.
  • Psychogenic: anorexia, conversion, grief, malingering, schizophrenia, stress.
  • Idiopathic.

Risk Factors

  • Overeating.
  • Carbonated beverages.
  • Excess alcohol.
  • Excitement, emotional stress.
  • Ambient or GI temperature changes.

DIAGNOSIS

History

  • Duration and severity of hiccup episodes.
  • Associated medical conditions (GI, cardiac, neuro, pulmonary).
  • Recent surgery (especially genitourinary).
  • Behavioral/psych history.
  • Medication review.
  • Alcohol/drug use.

Physical Exam

  • Correlate with potential causes (e.g., rales in pneumonia, organomegaly).
  • Ear canal exam for foreign bodies.
  • Head and neck masses, lymphadenopathy.
  • Complete neurologic exam.

Differential Diagnosis

  • Rarely confused with burping (eructation).

Diagnostic Tests

  • Directed by suspected etiology.
  • Labs: CBC, electrolytes, BUN, creatinine, LFTs, amylase/lipase, metabolic panel, chest X-ray.
  • Fluoroscopy for diaphragm motion.
  • Imaging: upper endoscopy; CT/MRI brain, thorax, abdomen, pelvis.
  • MRI brain with contrast, lumbar puncture as indicated.

TREATMENT

General Measures

  • Evaluate and treat underlying cause.
  • Dilate esophageal strictures, treat ulcers/reflux.
  • Remove ear canal foreign bodies.
  • Address alcohol-induced hiccups with bitters.
  • Pharyngeal stimulation for postop hiccups.
  • Correct electrolytes.
  • Relieve gastric distention (lavage, NG aspiration).
  • Vagal nerve counterirritation (supraorbital pressure, carotid massage).
  • Respiratory stimulants (5% CO2 breathing).
  • Behavioral therapy (hypnosis, meditation).
  • Phrenic nerve block/stimulation.
  • Acupuncture.
  • Cardioversion (miscellaneous).

Physical Maneuvers (First Line)

  • Breath holding.
  • Valsalva maneuver.
  • Breathing into paper bag.
  • Fright.
  • Ice water gargles.
  • Swallow granulated sugar, hard bread, peanut butter.
  • Bite lemon.
  • Pull knees to chest.
  • Lean forward compressing chest.

Medications

  • Chlorpromazine (FDA-approved): 25-50 mg PO/IV TID.
  • Metoclopramide: 5-10 mg PO QID.
  • Baclofen: 5-10 mg PO TID.
  • Haloperidol: 2-5 mg PO/IM then 1-2 mg PO TID.
  • Phenytoin: 200-300 mg PO HS.
  • Nifedipine: 10-20 mg PO daily to TID.
  • Amitriptyline: 10 mg PO TID.
  • Viscous lidocaine 2%: 5 mL PO daily to TID.
  • Gabapentin: 300 mg PO HS (may increase to 1,800 mg/day divided).
  • Combination therapy: lansoprazole 15 mg daily, clonazepam 0.5 mg BID, dimenhydrinate 25 mg BID.
  • Contraindications and precautions apply.

ISSUES FOR REFERRAL

  • Acupuncture.
  • Phrenic nerve crush/block/electrostimulation.
  • Continuous cervical epidural block.
  • Cardioversion.

SURGERY/OTHER PROCEDURES

  • Phrenic nerve crush or transection.
  • Resection of rib exostoses.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Acupuncture promising for persistent/intractable hiccups, especially in cancer patients.

  • Home remedies often anecdotal and not universally effective.

ADMISSION & NURSING

  • Most cases outpatient.
  • Intractable cases may require IV meds, surgery, rehydration.

ONGOING CARE

  • Monitor until hiccups cease.

DIET

  • Avoid gastric distension from overeating, carbonation, aerophagia.

PATIENT EDUCATION

  • See general measures section.

PROGNOSIS

  • Most acute hiccups resolve spontaneously or with home remedies.
  • Intractable hiccups may last years or decades.
  • Cases persisted after bilateral phrenic nerve transection reported.

COMPLICATIONS

  • Inability to eat.
  • Weight loss.
  • Exhaustion.
  • Insomnia.
  • Cardiac arrhythmias.
  • Wound dehiscence.
  • Rarely death.

REFERENCES

  1. Leung AKC, Leung AAM, Wong AHC, et al. Hiccups: a non-systematic review. Curr Pediatr Rev. 2020;16(4):277-284.

  2. Thompson DF, Brooks KG. Gabapentin therapy of hiccups. Ann Pharmacother. 2013;47(6):897-903.

  3. Srinivasan M, Yadav G, Singh Y, et al. Comparison of efficacy of combination therapy with chlorpromazine and olanzapine with chlorpromazine alone for treatment of hiccups in traumatic brain injury patients—a randomised control trial. J Clin Diagn Res. 2022;16(9):28-31.