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Emergency And Acute Medicine – Hiccups
Basics
Description
Hiccups are sudden, involuntary contractions of the diaphragm (usually unilateral) and other inspiratory muscles, abruptly terminated by closure of the glottis. The medical term is singultus. Episodes typically occur at a frequency of 4–60 per minute and result from stimulation of the hiccup reflex arc involving irritation of the vagus and phrenic nerves. The hiccup center is believed to be located in the upper spinal cord or brainstem.
Classification includes hiccup bouts lasting less than 48 hours, persistent hiccups lasting 48 hours to 1 month, and intractable hiccups persisting longer than 1 month. Hiccups are more common in males than females (approximately 4:1).
Etiology
Gastrointestinal causes include gastric distention, overeating, rapid eating, gastroesophageal reflux disease, achalasia, candida esophagitis, esophageal or gastric cancer, ulcers, hepatitis, hepatoma, pancreatitis, pancreatic pseudocyst or cancer, bowel obstruction, inflammatory bowel disease, cholelithiasis, cholecystitis, appendicitis, abdominal aortic aneurysm, and postoperative or post–abdominal procedures.
Diaphragmatic irritation may result from hiatal hernia, intra-abdominal mass, pericarditis, diaphragmatic eventration, splenomegaly, hepatomegaly, or peritonitis.
Central nervous system causes include ischemic or hemorrhagic stroke, head trauma, arteriovenous malformations, encephalitis, meningitis, abscess, malignancy, Parkinson disease, multiple sclerosis, hydrocephalus, and ventriculoperitoneal shunts.
Thoracic causes include pneumonia, tuberculosis, myocardial infarction, pericarditis, aortic aneurysm, malignancy, and mediastinal lymphadenopathy.
Head and neck causes include otic foreign bodies irritating the tympanic membrane, pharyngitis, laryngitis, goiter, retropharyngeal or peritonsillar abscess, and neck masses.
Metabolic causes include uremia, hyponatremia, hypocalcemia, gout, and diabetes mellitus.
Toxic and drug-related causes include alcohol, tobacco, α-methyldopa, benzodiazepines, steroids, barbiturates, narcotics, chemotherapeutic agents, antibiotics, and general anesthesia.
Psychogenic causes include stress, excitement, grief, malingering, and conversion disorder. Many cases remain idiopathic.
Diagnosis
Signs And Symptoms
Hiccups produce a characteristic sound that abruptly ends an inspiratory effort. Attacks usually occur at brief intervals and last seconds to minutes. Episodes persisting longer than 48 hours or continuing during sleep strongly suggest an underlying organic cause.
History
A targeted history should assess the severity and duration of the current episode, prior episodes, previous treatment attempts, and associated symptoms that may suggest an underlying etiology.
Physical Examination
A focused examination should evaluate the head and neck, chest, abdomen, and neurologic system to identify potential causes.
Essential Workup
For persistent or intractable hiccups, further evaluation is guided by findings from the history and physical examination.
Diagnostic Tests And Interpretation
Laboratory evaluation may include a complete blood count with differential and measurement of electrolytes, blood urea nitrogen, and creatinine. A chest radiograph is commonly obtained. Additional imaging or testing should be based on clinical suspicion and is often appropriate for outpatient evaluation.
Differential Diagnosis
Eructation (belching).
Treatment
Emergency Department Treatment And Procedures
Specific causes should be treated when identified, such as removal of an ear foreign body or decompression of gastric distention with a nasogastric tube.
Nonpharmacologic maneuvers include posterior pharyngeal stimulation with a catheter or cotton swab, direct uvular stimulation, supraorbital pressure, carotid sinus massage, digital rectal massage, and suboccipital release with gentle traction and pressure to the posterior neck.
Pharmacologic therapy includes chlorpromazine, the only FDA-approved medication for hiccups. Other agents used include gabapentin, metoclopramide, baclofen, haloperidol, nebulized lidocaine, amitriptyline, and phenytoin.
Medications
Amitriptyline 10 mg PO TID
Baclofen 10 mg PO TID
Chlorpromazine 25–50 mg IV or IM, or 25–50 mg PO BID–TID
Gabapentin 100 mg PO TID–QID
Haloperidol 2–5 mg IM
Lidocaine 4% solution, 3 mL nebulized, may repeat
Metoclopramide 10 mg IV or IM, or 10–20 mg PO QID
Phenytoin 200 mg IV
Follow-Up And Disposition
Admission Criteria
Admission is indicated when hiccups interfere with daily activities or lead to complications such as poor oral intake, aspiration, insomnia, or wound dehiscence.
Discharge Criteria
Patients may be discharged if hiccups last less than 48 hours and evaluation does not suggest an underlying organic cause.
Issues For Referral
Referral is recommended for intractable hiccups requiring further investigation or advanced therapies such as phrenic nerve block or transection, hypnosis, behavioral modification, acupuncture, or psychiatric intervention.
Follow-Up Recommendations
Patients may try home remedies for recurrence, including swallowing a spoonful of sugar, sucking on hard candy, swallowing peanut butter, breath holding or Valsalva maneuver, biting a lemon, tongue traction, lifting the uvula with a cold spoon, drinking from the far side of a glass, applying noxious stimuli, or rebreathing into a paper bag.
Clinical Insights And Common Pitfalls
Prolonged or persistent hiccups are strongly suggestive of an underlying organic disease and should not be dismissed as benign without appropriate evaluation.
Basics
Description
Hiccups are sudden, involuntary contractions of the diaphragm (usually unilateral) and other inspiratory muscles, abruptly terminated by closure of the glottis. The medical term is singultus. Episodes typically occur at a frequency of 4–60 per minute and result from stimulation of the hiccup reflex arc involving irritation of the vagus and phrenic nerves. The hiccup center is believed to be located in the upper spinal cord or brainstem.
Classification includes hiccup bouts lasting less than 48 hours, persistent hiccups lasting 48 hours to 1 month, and intractable hiccups persisting longer than 1 month. Hiccups are more common in males than females (approximately 4:1).
Etiology
Gastrointestinal causes include gastric distention, overeating, rapid eating, gastroesophageal reflux disease, achalasia, candida esophagitis, esophageal or gastric cancer, ulcers, hepatitis, hepatoma, pancreatitis, pancreatic pseudocyst or cancer, bowel obstruction, inflammatory bowel disease, cholelithiasis, cholecystitis, appendicitis, abdominal aortic aneurysm, and postoperative or post–abdominal procedures.
Diaphragmatic irritation may result from hiatal hernia, intra-abdominal mass, pericarditis, diaphragmatic eventration, splenomegaly, hepatomegaly, or peritonitis.
Central nervous system causes include ischemic or hemorrhagic stroke, head trauma, arteriovenous malformations, encephalitis, meningitis, abscess, malignancy, Parkinson disease, multiple sclerosis, hydrocephalus, and ventriculoperitoneal shunts.
Thoracic causes include pneumonia, tuberculosis, myocardial infarction, pericarditis, aortic aneurysm, malignancy, and mediastinal lymphadenopathy.
Head and neck causes include otic foreign bodies irritating the tympanic membrane, pharyngitis, laryngitis, goiter, retropharyngeal or peritonsillar abscess, and neck masses.
Metabolic causes include uremia, hyponatremia, hypocalcemia, gout, and diabetes mellitus.
Toxic and drug-related causes include alcohol, tobacco, α-methyldopa, benzodiazepines, steroids, barbiturates, narcotics, chemotherapeutic agents, antibiotics, and general anesthesia.
Psychogenic causes include stress, excitement, grief, malingering, and conversion disorder. Many cases remain idiopathic.
Diagnosis
Signs And Symptoms
Hiccups produce a characteristic sound that abruptly ends an inspiratory effort. Attacks usually occur at brief intervals and last seconds to minutes. Episodes persisting longer than 48 hours or continuing during sleep strongly suggest an underlying organic cause.
History
A targeted history should assess the severity and duration of the current episode, prior episodes, previous treatment attempts, and associated symptoms that may suggest an underlying etiology.
Physical Examination
A focused examination should evaluate the head and neck, chest, abdomen, and neurologic system to identify potential causes.
Essential Workup
For persistent or intractable hiccups, further evaluation is guided by findings from the history and physical examination.
Diagnostic Tests And Interpretation
Laboratory evaluation may include a complete blood count with differential and measurement of electrolytes, blood urea nitrogen, and creatinine. A chest radiograph is commonly obtained. Additional imaging or testing should be based on clinical suspicion and is often appropriate for outpatient evaluation.
Differential Diagnosis
Eructation (belching).
Treatment
Emergency Department Treatment And Procedures
Specific causes should be treated when identified, such as removal of an ear foreign body or decompression of gastric distention with a nasogastric tube.
Nonpharmacologic maneuvers include posterior pharyngeal stimulation with a catheter or cotton swab, direct uvular stimulation, supraorbital pressure, carotid sinus massage, digital rectal massage, and suboccipital release with gentle traction and pressure to the posterior neck.
Pharmacologic therapy includes chlorpromazine, the only FDA-approved medication for hiccups. Other agents used include gabapentin, metoclopramide, baclofen, haloperidol, nebulized lidocaine, amitriptyline, and phenytoin.
Medications
Amitriptyline 10 mg PO TID
Baclofen 10 mg PO TID
Chlorpromazine 25–50 mg IV or IM, or 25–50 mg PO BID–TID
Gabapentin 100 mg PO TID–QID
Haloperidol 2–5 mg IM
Lidocaine 4% solution, 3 mL nebulized, may repeat
Metoclopramide 10 mg IV or IM, or 10–20 mg PO QID
Phenytoin 200 mg IV
Follow-Up And Disposition
Admission Criteria
Admission is indicated when hiccups interfere with daily activities or lead to complications such as poor oral intake, aspiration, insomnia, or wound dehiscence.
Discharge Criteria
Patients may be discharged if hiccups last less than 48 hours and evaluation does not suggest an underlying organic cause.
Issues For Referral
Referral is recommended for intractable hiccups requiring further investigation or advanced therapies such as phrenic nerve block or transection, hypnosis, behavioral modification, acupuncture, or psychiatric intervention.
Follow-Up Recommendations
Patients may try home remedies for recurrence, including swallowing a spoonful of sugar, sucking on hard candy, swallowing peanut butter, breath holding or Valsalva maneuver, biting a lemon, tongue traction, lifting the uvula with a cold spoon, drinking from the far side of a glass, applying noxious stimuli, or rebreathing into a paper bag.
Clinical Insights And Common Pitfalls
Prolonged or persistent hiccups are strongly suggestive of an underlying organic disease and should not be dismissed as benign without appropriate evaluation.
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