Hiccups

Background

• Usually initiated by gastric distention from food, carbonated beverage, or air
• Also known as Singultus

Definitions

• Hiccup bout: <48 hours
• Persistent hiccups: 48 hours to 1 month
• Intractable hiccups: >1 month

Clinical Features

• Hiccups

Differential Diagnosis

Hiccups

• Central nervous system disorders
  • Vascular
    • Ischemic/hemorrhagic stroke
    • AV malformations
    • Temporal arteritis
  • Infections
    • Encephalitis
    • Meningitis
    • Brain abscess
    • Neurosyphilis
    • Subphrenic abscess
  • Structural
    • Head trauma
    • Intracranial neoplasm
    • Brainstem neoplasms
    • Multiple sclerosis
    • Syringomyelia
    • Hydrocephalus
  • Vagus and phrenic nerve irritation
    • Goiter
    • Pharyngitis
    • Laryngitis
    • Hair or foreign body irritation of tympanic membrane
    • Neck cyst or other tumor
• Gastrointestinal disorders
  • Gastric distention
  • Gastritis
  • Peptic ulcer disease
  • Pancreatitis
  • Pancreatic cancer
  • Gastric carcinoma
  • Abdominal abscesses
  • Gallbladder disease
  • Inflammatory bowel disease
  • Hepatitis
  • Aerophagia
  • Esophageal distention
  • Esophagitis
  • Bowel obstruction
• Thoracic disorders
  • Enlarged lymph nodes secondary to infection or neoplasm
  • Pneumonia
  • Empyema
  • Bronchitis
  • Asthma
  • Pleuritis
  • Aortic dissection
  • Mediastinitis
  • Mediastinal tumors
  • Chest trauma
  • Pulmonary embolism
• Cardiovascular disorders
  • Myocardial infarction
  • Pericarditis
• Toxic-metabolic
  • Alcohol intoxication
  • Diabetes mellitus
  • Herpes zoster
  • Hypocalcemia
  • Hypocapnia
  • Hyponatremia
  • Influenza
  • Malaria
  • Tuberculosis
  • Uremia
• Postoperative
  • General anesthesia
  • Intubation (stimulation of glottis)
  • Neck extension (stretching phrenic nerve roots)
  • Gastric distention
  • Traction on viscera
• Drugs
  • Alpha methyldopa
  • Short-acting barbiturates
  • Chemotherapeutic agents (eg, carboplatin)
  • Dexamethasone
  • Diazepam
• Psychogenic
  • Anorexia nervosa
  • Conversion reaction
  • Excitement
  • Malingering
  • Schizophrenia
  • Stress

Evaluation

• Clinical diagnosis
• Consider auditory canal exam (foreign body against TM can trigger hiccups)
• Consider Hyponatremia and Hypocalcemia
• Consider CXR

Management

• Physical Maneuvers (stimulating pharynx blocks the vagal portion of the reflex arc)
  • Remove foreign body from ear
  • Swallow teaspoon of sugar
  • Sip ice water
  • Drink water quickly
• Meds
  • Chlorpromazine 25–50mg IV; 25–50mg PO TID
  • Metoclopramide 10mg IV or IM; 10–20mg PO TID x 10d
  • Initiating pharmacologic treatment with a proton pump inhibitor. Alternative first-line agents include baclofen, gabapentin, and metoclopramide

Disposition

• Discharge for uncomplicated hiccups