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Hiccup

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Hiccup, Hiccough, Singultus

  • Pathophysiology
  1. Locally mediated via diaphragmatic irritation
  2. Sudden involuntary diaphragmatic contraction
    1. Inspiration interrupted by glottic closure
    2. Characteristic sharp sound emitted
  3. Peripheral nerves involved
    1. Phrenic Nerve
    2. Vagus Nerve
    3. Reflex arc
      1. Afferent Limb: Sympathetic chain (T6-T12)
      2. Efferent Limb: Phrenic nerve
  • Causes
  • Transient Hiccups (gastric distention)
  1. Excessive laughter or tickling
  2. Aerophagia
  3. Tobacco Abuse
  4. Overindulgence in food or Alcohol
  5. Gastroesophageal Reflux
  6. Change in gastric Temperature
    1. Movement into hot or cold environment
    2. Ingestion of hot or cold foods
  • Causes
  • Intractable Hiccups (>48 hours)
  1. Reflex Stimulation
    1. Alcohol Abuse
    2. Anxiety Disorder
    3. Transient Hiccup causes above
  2. Neurologic disorders
    1. Encephalitis
    2. Meningitis
    3. Vertebrobasilar ischemia
    4. Intracranial Hemorrhage
    5. Intracranial tumor
    6. Uremia
    7. Dementia
    8. Tabes Dorsalis
    9. Cardiac Pacemaker stimulating diaphragm
  3. Mediastinal disorders
    1. Aortic Dissection
    2. Phrenic nerve Trauma
    3. Mediastinal lymph node involvement
      1. Mycobacterium tuberculosis
      2. Malignant neoplasm
      3. Pulmonary fibrosis
      4. Sarcoidosis
    4. Bronchial obstruction
    5. Adherent Pericardium
    6. Cardiomegaly
    7. Myocardial Infarction
    8. Esophageal obstruction
    9. Pneumonia with Pleural irritation
  4. Abdominal disorders
    1. Diaphragmatic Hernia of Stomach
    2. Gastroesophageal Reflux
    3. Subphrenic abscess
    4. Subphrenic peritonitis
    5. Liver disease
      1. Liver tumor or mass
      2. Liver Abscess
    6. Stomach Cancer
    7. Splenic infarction
    8. Acute Intestinal Obstruction or Small Bowel Obstruction
    9. Acute hemorrhagic Pancreatitis
    10. Post-operative abdominal surgery
  5. Medications
    1. Corticosteroids
    2. Benzodiazepines
    3. Chemotherapy
    4. Dopamine Agonists
  6. Miscellaneous
    1. Tympanic Membrane foreign body
  • Symptoms
  1. Hiccups occur 2-3 times per minute
  • Management
  • Transient Hiccups
  1. Folk Remedies
    1. Breath-holding
    2. Tongue traction
    3. Breathing into a paper bag
    4. Suddenly frightened
    5. Gargling ice water
    6. Drinking water from wrong side glass and occlude ears
  2. Stimulate pharyngeal mucosa
    1. Swallow teaspoon vinegar, pickle juice or dry granulated sugar
  3. Stimulate Gag Reflex with Tongue depressor
    1. Avoid if recent food intake (aspiration risk)
  • Management
  • Intractable Hiccups
  1. Central acting medications
    1. First-line central agents
      1. Chlorpromazine (Thorazine)
        1. Best studied of all agents used for Hiccups
        2. Initial: 50 mg IV bolus (monitor for Hypotension, QT Prolongation)
        3. Maintenance if effective: oral dose for 10 days
        4. Friedgood (1955) J Am Med Assoc 157(4): 309-10 [PubMed]
      2. Gabapentin (Neurontin) for up to 7-10 days
      3. Baclofen for up to 7-10 days
    2. Other agents
      1. Diphenylhydantoin
      2. Haloperidol 5 mg orally three times daily
        1. Ives (1985) Am J Psychiatry 142(11): 1368-9 [PubMed]
      3. Orphenadrine 60 mg IM or 100 mg PO
      4. Ketamine 0.1 to 0.2 mg/kg IV
      5. Carbamazepine 200 mg PO qid
  2. Peripheral acting medications
    1. First-line peripheral agents
      1. Metoclopramide (Reglan) 10 mg PO qid (most efficacious)
      2. Wang (2014) Intern Med J 44(12a): 1205-9 [PubMed]
    2. Other agents
      1. Quinidine 200 mg PO qid
      2. Atropine 1 mg IV
      3. Edrophonium chloride 10 mg IV
      4. Amphetamine 30 mg PO qd for 1 week
      5. Amyl nitrite