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)