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
Causes
- Central (CNS) vs. Peripheral (vagus/phrenic nerve irritation)
Risk
Risk
- Older men
- Vascular disease
- Postoperative
- CNS disease
- Duodenal ulcer
- Reflux esophagitis
History
History
- Severity/duration
- PMH
- Surgery
- Alcohol/drug
- Medications
- Persistence during sleep (organic)
Physical Exam
Physical Exam
- HEENT
- Check TM for infection/foreign body
- Thyroid and lymmpahdenopathy
- Neurologic
- Resp
- Abdo
Investigations
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
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
- Treat underlying cause
- Additional treatment options
- Acupuncture
- Hypnosis
- Surgery (phrenic nerve block)
References:
- AP&T 2015. http://onlinelibrary.wiley.com/doi/10.1111/apt.13374/abstract
- Scottish Palliative Care Guidelines 2015. http://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Hiccups.aspx
- Cochrane 2013. http://www.cochrane.org/CD008768/SYMPT_interventions-treating-persistent-and-intractable-hiccups-adults
- CFP 2011. http://www.cfp.ca/content/57/6/672