So Bored I Hiccup’ed

It is 4 AM in the morning and a 50 year-old male is next to be seen in the emergency department. You think to yourself, what can possibly compel this patient to leave the warm comforts of his bed to come to the ED in the dead of night? Chest pain? Belly pain and vomiting? Either way, you have your treatment algorithm ready in your head until he throws you a curveball. “Hey doc, I got these hiccups I just cannot get rid of…”

How are hiccups defined?

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).

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

 

What are more serious causes?
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.

 

What is the workup in the emergency department?
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.

 

What is the treatment for hiccups?
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.

 

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