Hiccups Disease

BASICS

DESCRIPTION

Sudden, involuntary, contraction of the inspiratory muscles (predominantly the diaphragm) terminated by abrupt closure of the glottis stopping the inflow of air and producing the characteristic sound.

System(s) affected: Pulmonary, nervous
Genetics: N/A
Incidence/Prevalence in USA: Self limited hiccups are extremely common; intractable hiccups are rare
Predominant age: All ages (including fetus)
Predominant sex: Male > Female (4:1)

SIGNS AND SYMPTOMS

Hiccup attacks usually occur at brief intervals and last only a few seconds or minutes. Bouts lasting more than 48 hours often imply an underlying physical or metabolic disorder. Intractable hiccups may occur continuously for months or years. Hiccups usually occur with a frequency of 4 to 60 per minute.

CAUSES

Pathophysiologic significance is unknown; hiccups have been associated with more than 100 underlying disorders.
Results from stimulation of one or more limbs of the hiccup reflex arc (vagus and phrenic nerves) with a "hiccup center" located in the upper spinal cord
In men greater than 90% have an organic basis while in women a psychogenic cause is more likely
Specific underlying causes include:
- Alcoholism
- CNS lesions (brainstem tumors, vascular lesions, Parkinson's disease)
- Diaphragmatic irritation (tumors, pericarditis, eventration, splenomegaly, hepatomegaly, peritonitis)
- Hair, insect or foreign body irritating tympanic membrane
- Pharyngitis, laryngitis
- Mediastinal and other thoracic lesions (pneumonia, aortic aneurysm, tuberculosis, myocardial infarction, lung cancer)
- Esophageal lesions (reflux esophagitis, achalasia, Candida esophagitis, carcinoma, obstruction)
- Gastric lesions (ulcer, distention, cancer)
- Hepatic lesions (hepatitis, hepatoma)
- Pancreatic lesions (pancreatitis, pseudocysts, cancer)
- Inflammatory bowel disease
- Cholelithiasis, cholecystitis
- Prostatic disorders
- Appendicitis
- Postoperative, abdominal procedures
- Toxic metabolic causes (uremia, hyponatremia, gout, diabetes)
- Drug induced (dexamethasone, methylprednisolone, benzodiazepines, alpha methyldopa)
- Psychogenic causes (hysterical neurosis, grief, malingering)
- Idiopathic

RISK FACTORS

General anesthesia
Postoperative state
Irritation of the vagus nerve branches
Structural, vascular, infectious or traumatic CNS lesions

DIAGNOSIS

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

Fluoroscopy is useful to determine if one hemidiaphragm is dominant

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient (usually)
Inpatient (if elderly, debilitated or intractable hiccups)

GENERAL MEASURES

Treat any specific underlying cause when identified.
- Dilate esophageal stricture or obstruction
- Remove hair or foreign body from ear canal
- Angostura bitters for alcohol induced hiccups
- Catheter stimulation of pharynx for operative and postoperative hiccups
- Antifungal treatment for Candida esophagitis
- Correct electrolyte imbalance
Simple home remedies
- Swallowing a spoonful of sugar
- Sucking on a hard candy or swallowing peanut butter
- Holding breath and increasing pressure on diaphragm (Valsalva maneuver)
- Tongue traction
- Lifting the uvula with a cold spoon
- Drinking from the far side of a glass
- Inducing fright
- Smelling salts
- Rebreathing into a paper (not plastic) bag
- Sipping ice water
Medical measures
- Relief of gastric distention (gastric lavage, nasogastric aspiration, induced vomiting)
- Counterirritation of the vagus nerve (supraorbital pressure, carotid sinus massage, digital rectal massage), to be used with caution
- Respiratory center stimulants (breathing 5% carbon dioxide)
- Phrenic nerve block of dominant hemidiaphragm; phrenic crush, transection
- Psychiatric (hypnosis, behavioral modification)
- Miscellaneous (cardioversion, acupuncture)

SURGICAL MEASURES

N/A

ACTIVITY

As tolerated

DIET

Avoid gastric distension from overeating, carbonated beverages, aerophagia

PATIENT EDUCATION

See General Measures

FOLLOW UP

PREVENTION/AVOIDANCE

Correct underlying cause
Maintenance drug therapy (e.g., baclofen 5-10 mg tid; phenytoin 100 mg qid; valproic acid 15 mg/kg undivided doses; nifedipine 10-20 mg qd-tid; metoclopramide 10 mg qid)

POSSIBLE COMPLICATIONS

Inability to eat
Weight loss
Exhaustion, debility
Insomnia
Cardiac arrhythmias
Wound dehiscence
Death (rare)

EXPECTED COURSE AND PROGNOSIS

Hiccups often cease during sleep
Most acute benign hiccups resolve with home remedies or spontaneously
Intractable hiccups may last for years and decades
Hiccups have persisted despite bilateral phrenic nerve transection

MISCELLANEOUS

ASSOCIATED CONDITIONS

See Causes

AGE-RELATED FACTORS

Pediatric: May persist from fetal state
Geriatric: Can be a serious problem among the elderly
Others: N/A

PREGNANCY

Fetal hiccups noted as rhythmic fetal movements (confirmed sonographically), fetal hiccups often recur in subsequent pregnancies

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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