​Kembara Xtra - Medicine - Hiccups

​Kembara Xtra - Medicine - Hiccups 
Hiccups are brought on by a recurrent episode of quick, unconscious contraction of the inspiratory muscles (mostly the diaphragm), which is followed by an abrupt closure of the glottis, stopping the input of air and resulting in a distinctive sound.
Hiccups are categorized according to how long they last: A hiccup episode can last up to 48 hours, whereas chronic hiccups can continue for up to a month or longer.
System(s) impacted: pulmonary, nervous
Synonyms include hiccoughs and singultus 
Aspects of Geriatrics

can be a major issue, especially for the elderly.

pregnant women's issues
Fetal hiccups are rhythmic fetal motions that can be mistaken for contractions and have been sonographically proven.
Fetal hiccups are an indication of typical neural growth.

Epidemiology Males outnumber females (4:1) and are more prevalent in all ages, including fetuses.
Prevalence
Self-limited hiccups, as well as intraoperative and postoperative hiccups, are exceedingly prevalent.

Pathophysiology and Etiology 
The vagus and phrenic nerves, which make up one of the limbs of the hiccup reflux arc, are stimulated by a "hiccup center" in the upper spinal cord and brain.
Among men, >90% of the causes are organic; among women, psychogenic factors are more prevalent.
These are some specific underlying causes: - CNS disorders: posterior inferior cerebellar artery (PICA) aneurysm; seizure disorder; vascular lesions (AV malformation); infectious causes (meningitis, encephalitis); structural lesions (intracranial/brainstem mass lesions; multiple sclerosis, hydrocephalus, syringomyelia); - Diaphragmatic irritation (peritonitis, splenomegaly, pericarditis, tumors, eventration) - Tympanic membrane irritation - Pharyngitis, laryngitis, and neck tumors can all cause nerve discomfort.
- Mediastinal and other thoracic lesions (lung cancer, exostoses of the ribs, tuberculosis [TB], aortic aneurysm, myocardial infarction [MI]) - Esophageal lesions (carcinoma, blockage, Candida esophagitis, reflux esophagitis) - Digestive diseases (cancer, gastritis, GERD, PUD, distention) - COVID-19 has been described as initially presenting as hiccups.
- Cardiovascular illnesses (such as MI and pericarditis)- Lesions of the liver (hepatitis, hepatoma); lesions of the pancreas (cancer, pseudocysts, and pancreatitis) - Cholelithiasis, cholecystitis, and inflammatory bowel illness
- Prostatic conditions
- Postoperative appendicitis, especially with abdominal surgeries - Metabolic factors (diabetes, gout, hyponatremia, and uremia)
Dexamethasone, methylprednisolone, anabolic steroids, benzodiazepines, -methyldopa, propofol, levofolinate, oxaliplatin, fluorouracil, carboplatin, cisplatin, and tramadol are examples of drugs that might cause these effects. Alcohol can also be toxic.
- Psychogenic factors (such as stress, bereavement, malingering, schizophrenia, and anorexia), - Diabetic


Risk factors include overeating, drinking carbonated beverages, drinking too much alcohol, being excited or stressed, and changes in the temperature of the environment or the gastrointestinal tract.


Prevention 
Determine and address any pertinent underlying causes.
Acupuncture showed promise compared to chronic medication therapy for reducing hiccups. Avoid stomach distention.


Hiccup attacks typically come on suddenly and last a few seconds or minutes. Frequent episodes that last more than 48 hours frequently point to a medical or metabolic issue.
Hiccups that are difficult to control might last for months or even years.

Hiccups typically occur 4 to 60 times per minute, but persistent and uncontrollable hiccups call for additional assessment.

gastrointestinal, cardiac, neurologic, or pulmonary disorders; recent surgery, especially genitourinary; behavioral health history; review of medications; alcohol and illicit drug use; severity and length of hiccup episodes; associated medical conditions that may be causal;

clinical assessment 

Examining possible etiologies and correlating them (e.g., rales with pneumonia; organomegaly with splenic or hepatic illness) is a good idea.
Check the ear canal for objects that are alien.
Lymphadenopathy and lumps in the head and neck
Full neurologic examination


Multiple Diagnoses 

Rarely are hiccups and eructation (burping) confused.

Laboratory Results 
Consider condition-specific tests (e.g., CBC, electrolytes, BUN, creatinine, LFTs, amylase/lipase, metabolic panel, chest x-ray) for hiccups lasting more than 48 hours when an underlying cause is suspected.

Hemidiaphragm movement can be assessed via fluoroscopy.

Other/Diagnostic Procedures
Upper endoscopy; brain, thorax, abdomen, and pelvis CT scans (or other imaging) to explore for underlying causes
The extent of the workup is frequently inversely correlated with the frequency and intensity of the hiccups. Examples include head MRI with contrast and lumbar puncture.

Management Outpatient (typically) Inpatient (if elderly, disabled, or with intractable hiccups) A lot of hiccup remedies are completely anecdotal.

Measures 
Consider persistent or frequent hiccups.
When the underlying reason is discovered, treat it.
- Relax an esophageal blockage or stricture.
- Treat reflux problems or ulcers.
- Remove any foreign objects or hair from the ear canal.
- Angostura bitters to treat hiccups brought on by alcohol
- Pharyngeal catheter stimulation for pre- and post-operative hiccups - Candida esophagitis antifungal therapy - Electrolyte balance restoration.
• Medical interventions: induce vomiting, nasogastric aspiration, and gastric lavage to relieve gastric distention.
- Digital rectal massage, carotid sinus pressure, and careful counterirritation of the vagus nerve - Stimulants for the respiratory center (5% CO2 inhalation).
- Modification of behavioral health (hypnosis, meditation, timed breathing) - Electrical stimulation (or pacing) of the dominant hemidiaphragm or phrenic nerve block
Acupuncture and other treatments (cardioversion)


First Line of Medicine
Other methods include swallowing granulated sugar, hard bread, or peanut butter; biting on a lemon; pulling knees to chest; or leaning forward to compress the chest. Drug therapy may be used if physical methods have not worked or if treatment is focused on a particular cause of the hiccups.
Chlorpromazine is a medication that has been FDA-approved for treating hiccups. TID 25–50 mg PO/IV
- 5 to 10 mg PO QID of metoclopramide
Baclofen dosage: 5–10 mg PO TID (2)[B],(6)[B],(8)[B]
- Haloperidol: 1 to 2 mg PO TID, then 2 to 5 mg PO/IM
- 200 to 300 mg PO HS of phenytoin
- 10 to 20 mg PO daily to TID of nifedipine
10 mg of amitriptyline PO TID
Lidocaine that is viscous 5 mL PO daily to TID at 2%
- Gabapentin (Neurontin): 300 mg PO HS; may be increased to 1,800 mg/day PO in divided doses; 1,200 mg/day PO for 3 days, followed by 400 mg/day PO for 3 days in patients receiving stroke rehabilitation or in the palliative care situation when the side effects of chlorpromazine are undesirable - Lansoprazole 15 mg orally daily, clonazepam 0.5 mg orally twice daily, and dimenhydrinate 25 mg orally twice daily
- Consult the manufacturer's literature for any contraindications.
- Baclofen is not advised for use in patients with severe renal impairment, stroke, or other cerebral lesions. - Chlorpromazine is not advised for use in older individuals with dementia.
Avoid stopping baclofen abruptly.
Additional potential pharmacological treatments- Levodopa, carbidopa, and amantadine for Parkinson's disease
- An antifungal drug for Candida esophagitis; - Steroid replacement therapy for Addison disease; - Ondansetron for carcinomatosis with vomiting
- Both IV and oral formulations of nefopam, a non-opioid analgesic with antishivering effects comparable to those of antihistamines and antiparkinsonian medications, are offered outside of the United States.
- Pregabalin 375 mg daily - Olanzapine 10 mg QHS

Referral 

For cardioversion, continuous cervical epidural block, acupuncture, or electrostimulation of the phrenic nerve 

Surgery includes resection of rib exostoses and the crush, transaction, or electrostimulation of the dominant diaphragmatic leaflet on the phrenic nerve.

Alternative Medicine Acupuncture is increasingly used, particularly with cancer patients, to treat chronic or intractable hiccups.

 Natural curesswallowing peanut butter or hard candy; taking a spoonful of sugar; or
- Increasing pressure on the diaphragm while holding your breath (Valsalva maneuver) - Holding the tongue in place - Using a cold spoon to lift the uvula - Causing fear - Smelling salts - Breathing again into a paper bag (not a plastic one) - Drinking ice water - Rubbing a wet cotton-tipped applicator between the hard and soft palate for one minute 

Admission 
The majority of patients can be treated as outpatients; however, those with severe, uncontrollable hiccups might need rehydration, pain relief, intravenous medicine, or even surgery.

Follow-up patient observation until the hiccups stop

Diet 
Do not overeat, drink carbonated beverages, or engage in aerophagia to avoid stomach distension.

The majority of acute benign hiccup bouts cure spontaneously or with over-the-counter medicines. Hiccups frequently stop as you sleep.
Hiccups that won't go away could linger for years or even decades.
Despite bilateral phrenic nerve transection, hiccups have continued.

Complications include: difficulty eating; weight loss; exhaustion and sluggishness; insomnia; cardiac arrhythmias; wound dehiscence; and, in rare cases, death.