Hiccups

Hiccups (singultus) are involuntary, intermittent, spasmodic contraction of diaphragm/intercostal muscles resulting in a sudden inspiration and ends with abrupt closure of glottis

  • "Hiccup bout" <48h
  • "Persistent hiccups" >48h-1 month
  • "Intractable hiccups >1 month

Causes

  • Central (CNS) vs. Peripheral (vagus/phrenic nerve irritation)

Risk

  • Older men
  • Vascular disease
  • Postoperative
  • CNS disease
  • Duodenal ulcer
  • Reflux esophagitis

History

  • Severity/duration
  • PMH
  • Surgery
  • Alcohol/drug
  • Medications
  • Persistence during sleep (organic)

Physical Exam

  • HEENT
    • Check TM for infection/foreign body
    • Thyroid and lymmpahdenopathy
  • Neurologic
  • Resp
  • Abdo

Investigations

  • Consider labs (CBC, lytes, LFTs, amylase/lipase)
    • r/o toxic/metabolic
  • Imaging/endoscopy if suspect abnormalities
    • r/o Resp/ENT/GI
    • r/o Neuro

Treatment

  • No RCT (just observational studies)
  • Empiric therapy with physical maneuvers
    • Interrupt normal respiratory function (breath holding/valsalva)
    • Stimulate nasopharynx/uvula (sipping cold water, gargling water, swallow a teaspoon of dry sugar)
    • Increase vagal stimulation (pressing on eyeballs)
    • Counteract irritation of the diaphragm (pulling knees to chest, leaning forward)
  • Drugs
    • Treat underlying cause
      • If on dexamethasone, consider switching to methylprednisolone which may improve hiccups
    • Consider empiric antacid/H2 blocker/PPI
    • Metoclopramide 10mg TID-QID
      • Risk of tardive dyskinesia with chronic/high doses
    • Baclofen
    • Gabapentin
    • If drug therapy works, consider stopping the day after cessation of hiccups
    • If does not work, consider switch after 7-10 days
  • Additional treatment options
    • Acupuncture
    • Hypnosis
    • Surgery (phrenic nerve block)