Management of Hiccups in the ED

A hiccup, or singultus, is an involuntary spasm of the inspiratory muscles resulting in sudden inspiration and subsequent closure of the glottis. The reflex arc involves the afferent limb of the phrenic and vagus nerve, a CNS mediator such as the medulla oblongata, and the efferent limb of the phrenic nerve to the inspiratory muscles and glottis. They are classified as benign (<48h), persistent (48h-1month) and intractable (>1month).

Benign hiccups result from carbonated beverages, gastric distension, changes in temperature or aerophagia caused by excessive smoking. Alcohol ingestion can also precipitate hiccups.

Intractable hiccups, however, may be the sign of more serious, underlying disease. Think of the reflex arc when considering possible etiologies. CNS disorders such as vascular malformations, infections, and lesions can disturb the reflex arc by releasing normal inhibitory signals. Intractable hiccups can also result from local irritation of the phrenic nerve or vagus nerves caused by goiters, mediastinal or chest masses, or diaphragmatic abnormalities.  Foreign bodies in the ear may also irritate the auricular branch of the vagus nerve.

An ample history and physical exam can help elucidate the cause of hiccups. Hiccups that are reported to abate at night may point to a psychogenic cause. Check the ear canal for a foreign body. A chest X-ray should be ordered to evaluate for possible intrathoracic etiology. Further evaluation can be based on patient symptoms and risk factors. A chest CT may be necessary if there is dyspnea and endoscopy, or abdominal CT may be useful if there are GI findings. Neurological findings may require MRI brain to evaluate for lesions or an LP to evaluate for infection. Depending on the clinical status of the patient, extensive workup may be initiated outpatient rather than from the emergency department.

The exact underlying cause of hiccups cannot always be elucidated, and sometimes all we can do is initiate symptomatic treatment. Physical maneuvers may be attempted first and are thought to interrupt the reflex arc, though the exact mechanism is not well understood. Drinking water quickly, sipping ice water, swallowing a teaspoon of sugar, holding one’s breath, and vagal stimulation such as pressing one’s eyeballs are some examples. There are even case reports of intractable hiccups ceasing after sexual intercourse¹ or digital rectal exams². Typical medical management includes chlorpromazine and metoclopramide whose onset of effect is approximately 30 minutes. Haloperidol, nifedipine, baclofen, gabapentin, and valproate are other options if hiccups remain refractory to treatment. There are reports of benzodiazepines and steroids both causing hiccups, and in other cases, stopping hiccups. If all else fails, alternative therapy such as hypnosis and acupuncture have been attempted.

Sources:

1. Pelag and Pelag. Case report: sexual intercourse as potential treatment for intractable hiccups. Can Fam Physician. 2000 Aug;46:1631-2.

2. Odeh M., Bassan H. and A. Oliven. Termination of intractable hiccups with digital rectal massage. J Inter Med. 1990 Feb;227(2):145-6.

3. Sarko J. and J. Stapczynski. “Chapter 62. Respiratory Distress.”Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2015. n. pag. AccessMedicine.Web. 8 Nov. 2016.

4. Lembo, A. Overview of Hiccups. In: UpToDate, UpToDate, Waltham, MA. (Accessed on March 18, 2017.)

 

Thank you to Dr. deSouza.