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hiccups (singultus)

Repetitive, sharp inspiratory sounds associated with spasm of the glottis, diaphragm & intercostal muscles. The term derives from the sound of the event. The medical term is singultus. [5] Classification: - hiccups lasting > 48 hours are considered persistent or protracted - hiccups lasting longer than 1 month are termed intractable Etiology: 1) irritation of the vagus nerve (most common) a) pharyngeal branches - pharyngitis - laughing - talking - eating - drinking b) auricular branches - hair or foreign body c) thoracic branches - pneumonia - pleuritis - thoracic aortic aneurysm - pericarditis - thoracic tumors - myocardial infarction - GERD with esophagitis - asthma - pacemaker lead complications d) abdominal branches - abdominal distension, gastric distension - gastritis - peptic ulcer disease - abdominal abscess - cholelithiasis - cholecystitis, pancreatitis, appendicitis, inflammatory bowel disease - abdominal tumors - abdominal aortic aneurysm e) meningeal branches - meningitis - glaucoma f) recurrent laryngeal nerve - neck mass - goiter - laryngitis 2) diaphragmatic irritation - gastric distension (most common) - hiatal hernia - GERD - splenomegaly - hepatomegaly - subphrenic abscess - pericarditis - myocardial ischemia 3) disorders that effect the central nervous system - structural lesions (congenital malformations) - brain & brainstem neoplasms - multiple sclerosis - syringomyelia - infection - meningitis - encephalitis - vascular disease - seizure - traumatic brain injury [5] 4) metabolic & drug-related etiologies a) alcohol b) uremia c) adverse reaction to pharmacologic agent - corticosteroid (dexamethosone) - benzodiazepine (low dose, may be useful for treatment at higher doses) [5] - Parkinsonian agent - short-acting barbiturates [5] - inhaled anesthetics [5] - donepezil [5] - ciplastin [5] - alpha-methyldopa [5] d) hyperglycemia, diabetes mellitus e) electrolyte imbalance (hyponatremia, hypokalemia, hypoocalcemia) f) hypocarbia [5] 5) infections - meningitis - encephalitis - neurosyphilis 6) postoperative etiologies - general anesthesia - stimulation of oropharynx or glottis - traction on viscera - gastric distension - neck extension 7) psychogenic - stress - conversion reaction - hysterical neurosis - malingering 8) prolonged immobilization [2] Epidemiology: - hiccups may occur at any age, even in utero, more common in adults, less frequent with advanced age [5] - no gender predilection except: - protracted & intractable hiccups more common in men [5] Pathology: - hiccups appear to serve no purpose in humans [5] Clinical manifestations: - spasms of the diaphragm muscle - a single hemidiaphragm may be involved, generally the left [5] - hiccups during sleep rule out a psychogenic cause [5] Laboratory: - arterial blood gas for mechanically-ventilated patients with hiccups Management: 1) physical maneuvers - swallowing - sip & swallow - a straw designed to cure hiccups (HiccAway) is available [5] - holding breath - Valsalva maneuver - breathing into bag - carotid sinus massage - ice water gargle - ocular compression 2) pharmacologic agents a) antipsychotics - chlorpromazine (Thorazine): - most common pharmacologic agent used for intractable hiccups (only FDA-approved agent) - 25 to 50 mg in 500 to 1000 mL of normal saline intravenously, infused slowly TID-QID - haloperidol (Haldol) - 2-5 mg IM initially - 1-4 mg PO TID (maintenance) b) local anesthetics - nerve blocks - lidocaine - bipivacaine c) muscle relaxants - cyclobenzaprine - baclofen - start 5 mg TID - titrate to 25 mg TID d) metoclopramide (Reglan) 10-20 mg every 6 hours e) amitriptyline (Elavil) f) anticonvulsants - phenytoin (Dilantin) - carbamazepine (Tegretol) - valproic acid (Depakote) - gabapentin (Neurontin) g) quinidine h) methylphenidate (Ritalin) 3) Other modalities - hypnosis - psychotherapy - acupuncture - direct pharngeal stimulation with a nasal or oral catheter (90% effective) [5] - direct stimulation of the uvula with a spoon or cotton-tip applicator [5] - induced emesis or gastric lavage [5] - phrenic nerve ligation (not first line option) [5]

General

sign/symptom

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 51-53
  2. Prescriber's Letter 9(11):66 2002
  3. Davis NJ, An experimental study of the hiccup. Brain 1970; 93:851 PMID: 5490279
  4. Stromberg BV. The hiccup Ear Nose Throat J 1979; 58:354 PMID: 387378
  5. Sinert RH Fast Five Quiz: Hiccups Medscsape. July 26, 2021 https://reference.medscape.com/viewarticle/955175
  6. Wilkes G, Dronen SC Hiccups Medscape. Dec 29, 2017 https://emedicine.medscape.com/article/775746-overview#showall