II. Pathophysiology
- Locally mediated via diaphragmatic irritation
- Sudden involuntary diaphragmatic contraction
- Inspiration interrupted by glottic closure
- Characteristic sharp sound emitted
-
Peripheral Nerves involved
- Phrenic Nerve
- Vagus Nerve
- Reflex arc
- Afferent Limb: Sympathetic chain (T6-T12)
- Efferent Limb: Phrenic nerve
III. Causes: Transient Hiccups (gastric distention)
- Excessive laughter or tickling
- Aerophagia
- Tobacco Abuse
- Overindulgence in food or Alcohol
- Gastroesophageal Reflux
- Change in gastric Temperature
- Movement into hot or cold environment
- Ingestion of hot or cold foods
IV. Causes: Intractable Hiccups (>48 hours)
- Reflex Stimulation
- Alcohol Abuse
- Anxiety Disorder
- Transient Hiccup causes above
- Neurologic disorders
- Encephalitis
- Meningitis
- Vertebrobasilar ischemia
- Intracranial Hemorrhage
- Intracranial Tumor
- Uremia
- Dementia
- Tabes Dorsalis
- Cardiac Pacemaker stimulating diaphragm
- Mediastinal disorders
- Aortic Dissection
- Phrenic nerve Trauma
- Mediastinal Lymph Node involvement
- Mycobacterium tuberculosis
- Malignant neoplasm
- Pulmonary fibrosis
- Sarcoidosis
- Bronchial obstruction
- Adherent Pericardium
- Cardiomegaly
- Myocardial Infarction
- Esophageal obstruction
- Pneumonia with Pleural irritation
- Abdominal disorders
- Diaphragmatic Hernia of Stomach
- Gastroesophageal Reflux
- Subphrenic abscess
- Subphrenic peritonitis
- Liver disease
- Liver tumor or mass
- Liver Abscess
- Stomach Cancer
- Splenic infarction
- Acute Intestinal Obstruction or Small Bowel Obstruction
- Acute hemorrhagic Pancreatitis
- Post-operative abdominal surgery
- Medications
- Miscellaneous
- Tympanic Membrane foreign body
V. Symptoms
- Hiccups occur 2-3 times per minute
VI. Management: Transient Hiccups
- Folk Remedies
- Breath-holding
- Tongue traction
- Breathing into a paper bag
- Suddenly frightened
- Gargling ice water
- Drinking water from wrong side glass and occlude ears
- Stimulate pharyngeal mucosa
- Swallow teaspoon vinegar, pickle juice or dry granulated sugar
- Stimulate Gag Reflex with Tongue depressor
- Avoid if recent food intake (aspiration risk)
VII. Management: Intractable Hiccups
- Central acting medications
- First-line central agents
- Chlorpromazine (Thorazine)
- Best studied of all agents used for Hiccups
- Initial: 50 mg IV bolus (monitor for Hypotension, QT Prolongation)
- Maintenance if effective: oral dose for 10 days
- Friedgood (1955) J Am Med Assoc 157(4): 309-10 [PubMed]
- Gabapentin (Neurontin) for up to 7-10 days
- Baclofen for up to 7-10 days
- Chlorpromazine (Thorazine)
- Other agents
- Diphenylhydantoin
- Haloperidol 5 mg orally three times daily
- Orphenadrine 60 mg IM or 100 mg PO
- Ketamine 0.1 to 0.2 mg/kg IV
- Carbamazepine 200 mg PO qid
- First-line central agents
- Peripheral acting medications
- First-line peripheral agents
- Metoclopramide (Reglan) 10 mg PO qid (most efficacious)
- Wang (2014) Intern Med J 44(12a): 1205-9 [PubMed]
- Other agents
- Quinidine 200 mg PO qid
- Atropine 1 mg IV
- Edrophonium chloride 10 mg IV
- Amphetamine 30 mg PO qd for 1 week
- Amyl nitrite
- First-line peripheral agents