Saturday, June 15, 2024

Hiccups

Practice Essentials

Brief episodes of hiccups are a common part of life; however, prolonged attacks are a more serious phenomenon and have been associated with significant morbidity and even death. 

Signs and symptoms

No medical training is required to recognize hiccups. However, persistent and intractable hiccups frequently are associated with an underlying pathologic process, and efforts must be made to identify causes and effects. The history should address the following:

Surgical history

Comprehensive drug history

Indicators of psychogenic origin

Arrhythmia-induced syncope

Gastroesophageal reflux

Weight loss

Insomnia

Emotional distress

Alcoholism and acute alcohol ingestion

A complete and focused physical examination may yield evidence of the following:

Head – Foreign body or aberrant hair adjacent to tympanic membrane; glaucoma

Mouth – Pharyngitis

Neck – Inflammation; mass lesions; goiter; voice abnormalities; stiffness

Chest – Tumors; pneumonia; asthma

Cardiovascular system – Arrhythmias; myocardial infarction (MI); pericarditis; unequal pulses

Abdomen – Gastric atony; organomegaly; subphrenic abscess; cholecystitis; appendicitis; abdominal aortic aneurysm (AAA); pancreatitis; peritonitis

Rectum – Mass lesions

Nervous system – Focal lesions; disordered higher mental function; indications of multiple sclerosis

See Presentation for more detail.

Diagnosis

Laboratory testing is directed toward suspected abnormalities as follows:

Electrolytes – Hyponatremia, hypokalemia, hypocalcemia, and hyperglycemia

Renal function tests – Uremia

Liver function tests – Hepatitis

Amylase and lipase levels – Pancreatitis

White blood cell (WBC) count

Urine, sputum, or cerebrospinal fluid (CSF) – Infection

Imaging modalities that may be helpful in the workup include the following:

Chest radiography

Fluoroscopy of diaphragmatic movement

Computed tomography (CT) of the head, thorax, and abdomen

Magnetic resonance imaging (MRI)

Other studies that may be helpful include the following:

Electrocardiography (ECG)

Nerve conduction studies

Endoscopy or bronchoscopy

Esophageal acid perfusion test

See Workup for more detail.

Management

A definitive cure for hiccups has not yet been established. Treatment, if needed, may be pharmacologic or nonpharmacologic.

Pharmacologic therapies include the following:

Chlorpromazine (drug of choice)

Haloperidol

Metoclopramide

Phenytoin

Valproic acid

Carbamazepine

Gabapentin

Ketamine

Baclofen

Lidocaine

Other agents reported to be beneficial are as follows:

Muscle relaxants (not benzodiazepines, see Etiology)

Sedatives

Analgesics (eg, orphenadrine, amitriptyline, chloral hydrate, and morphine)

Stimulants (eg, ephedrine, methylphenidate, amphetamine, and nikethamide)

Miscellaneous agents (eg, edrophonium, dexamethasone, amantadine, and nifedipine)

Nonpharmacologic therapies include the following:

Techniques affecting components of the hiccup reflex – Stimulation of the nasopharynx; C3-5 dermatome stimulation; direct pharyngeal stimulation; direct uvular stimulation; removal of gastric contents

Techniques leading to vagal stimulation – Iced gastric lavage; Valsalva maneuver; carotid sinus massage; digital rectal massage; digital ocular globe pressure

Techniques interfering with normal respiratory function – Breath holding; hyperventilation; gasping; breathing into a paper bag; pulling the knees up to the chest and leaning forward; continuous positive airway pressure; rebreathing 5% carbon dioxide

Mental distraction

Behavioral conditioning

Hypnosis

Acupuncture

Phrenic nerve or diaphragmatic pacing

Prayer

Surgical intervention (typically a last resort) may include the following:

Phrenic nerve ablation (unilateral or bilateral as appropriate)

Microvascular decompression of the vagus nerve (according to case reports)

See Treatment and Medication for more detail.

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