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Hiccups
Vanessa W. McNair, MD, MPH
Jeannette M. McIntyre, MD
Steven B. Sapida, DO
image BASICS
DESCRIPTION
  • Hiccups are caused by a repetitive sudden involuntary contraction of the inspiratory muscles (predominantly the diaphragm) terminated by abrupt closure of the glottis, which stops the inflow of air and produces a characteristic sound.
  • Hiccups are classified based on their duration: Acute hiccups last <48 hours; persistent hiccups last >48 hours but <1 month; intractable hiccups last for >1 month.
  • System(s) affected: nervous, pulmonary
  • Synonym(s): hiccoughs; singultus
Geriatric Considerations
Can be a serious problem, particularly among the elderly
Pregnancy Considerations
  • Fetal hiccups are noted as rhythmic fetal movements (confirmed sonographically) that can be confused with contractions.
  • Fetal hiccups are a sign of normal neurologic development (1).
EPIDEMIOLOGY
  • Predominant age: all ages (including fetus)
  • Predominant sex: male > female (4:1)
Prevalence
Self-limited hiccups are extremely common, as are intra- and postoperative hiccups.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Results from stimulation of ≥1 limbs of the hiccup reflux arc (vagus and phrenic nerves) with a “hiccup center” located in the upper spinal cord and brain (2)
  • In men, >90% have an organic basis; whereas in women, a psychogenic cause is more common.
  • Specific underlying causes include the following:
    • Alcohol abuse
    • CNS lesions (brain stem tumors, vascular lesions, Parkinson disease, multiple sclerosis, syringomyelia, hydrocephalus)
    • CNS infections (encephalitis, meningitis)
    • Seizure disorder
    • Diaphragmatic irritation (tumors, pericarditis, eventration, splenomegaly, hepatomegaly, peritonitis)
    • Irritation of the tympanic membrane
    • Pharyngitis, laryngitis
    • Mediastinal and other thoracic lesions (pneumonia, aortic aneurysm, tuberculosis [TB], myocardial infarction [MI], lung cancer, rib exostoses)
    • Esophageal lesions (reflux esophagitis, achalasia, Candida esophagitis, carcinoma, obstruction)
    • Gastric lesions (ulcer, distention, cancer)
    • Hepatic lesions (hepatitis, hepatoma)
    • Pancreatic lesions (pancreatitis, pseudocysts, cancer)
    • Inflammatory bowel disease
    • Cholelithiasis, cholecystitis
    • Prostatic disorders
    • Appendicitis
    • Postoperative, abdominal procedures
    • Toxic metabolic causes (uremia, hyponatremia, gout, diabetes)
    • Drug-induced (dexamethasone, methylprednisolone, anabolic steroids, benzodiazepines, &agr;-methyldopa, propofol)
    • Psychogenic causes (hysterical neurosis, grief, malingering)
    • Idiopathic
RISK FACTORS
  • General anesthesia; conscious sedation
  • Postoperative state
  • Genitourinary disorders
  • Irritation of the vagus and phrenic nerve (or branches)
  • Gastroesophageal reflux
  • Structural, vascular, infectious, neoplastic, or traumatic CNS lesions
GENERAL PREVENTION
  • Identify and correct the underlying cause if possible.
  • Avoid gastric distention.
  • Acupuncture shows promise in comparison to chronic drug therapy to control hiccups (3).
COMMONLY ASSOCIATED CONDITIONS
See “Etiology.”
image DIAGNOSIS
  • Hiccup attacks usually occur at brief intervals and last only a few seconds or minutes. Persistent bouts lasting >48 hours often imply an underlying physical or metabolic disorder.
  • Intractable hiccups may occur continuously for months or years (4).
  • Hiccups usually occur with a frequency of 4 to 60 per minute (4).
  • Persistent and intractable hiccups warrant further evaluation.
PHYSICAL EXAM
  • Correlate exam with potential etiologies (e.g., rales with pneumonia; organomegaly with splenic or hepatic disease).
  • Examine the ear canal for foreign bodies.
  • Head and neck exam to look for neck masses and lymphadenopathy
  • Complete neurologic exam
DIFFERENTIAL DIAGNOSIS
Hiccups may rarely be confused with burping (eructation).
DIAGNOSTIC TESTS & INTERPRETATION
  • If history suggests an underlying etiology, consider condition-specific testing as appropriate (e.g., CBC, metabolic panel, chest x-ray).
  • Fluoroscopy is useful to determine whether one hemidiaphragm is dominant.
Diagnostic Procedures/Other
  • Upper endoscopy; colonoscopy; CT scan (or other imaging) of brain, thorax, abdomen, and pelvis looking for underlying causes
  • The extent of the workup is often in proportion to the duration and severity of the hiccups (2,5).
image TREATMENT
  • Outpatient (usually)
  • Inpatient (if elderly, debilitated, or intractable hiccups)
  • Many hiccup treatments are purely anecdotal.
GENERAL MEASURES
  • Seek medical attention for frequent bouts or persistent hiccups.
  • Treat any specific underlying cause when identified (2, 4, 5)[C]
    • Dilate esophageal stricture or obstruction.
    • Treat ulcers or reflux disease.
    • Remove hair or foreign body from ear canal.
    • Angostura bitters for alcohol-induced hiccups
    • Catheter stimulation of pharynx for operative and postoperative hiccups
    • Antifungal treatment for Candida esophagitis
    • Correct electrolyte imbalance.
  • Medical measures
    • Relief of gastric distention (gastric lavage, nasogastric aspiration, induced vomiting)
    • Counterirritation of the vagus nerve (supraorbital pressure, carotid sinus massage, digital rectal massage)—use with caution
    • Respiratory center stimulants (breathing 5% CO2)
    • Behavioral health modification (hypnosis, meditation, paced respirations)
    • Phrenic nerve block or electrical stimulation (or pacing) of the dominant hemidiaphragm
    • Acupuncture
    • Miscellaneous (cardioversion)
MEDICATION
First Line
Possible drug remedies (5,6,7)[B]
  • Baclofen, a GABA analog: 5 to 10 mg PO TID (2, 4, 5, 8)[B]
  • Chlorpromazine (FDA approved for hiccups): 25 to 50 mg PO/IV TID
  • Haloperidol: 2 to 5 mg PO/IM followed by 1 to 2 mg PO TID
  • Phenytoin: 200 to 300 mg PO HS
  • P.483

  • Metoclopramide: 5 to 10 mg PO QID
  • Nifedipine: 10 to 20 mg PO daily to TID
  • Amitriptyline: 10 mg PO TID
  • Viscous lidocaine 2%: 5 mL PO daily to TID
  • Gabapentin (Neurontin): 300 mg PO HS; may increase up to 1,800 mg/day PO in divided doses (4)[B]; 1,200 mg/day PO for 3 days, then 400 mg/day PO for 3 days in patients undergoing stroke rehabilitation or in the palliative care setting where chlorpromazine adverse effects are undesirable (4)[B].
  • Combination of lansoprazole 15 mg PO daily, clonazepam 0.5 mg PO BID, and dimenhydrinate 25 mg PO BID (6)[B].
  • Contraindications: Refer to manufacturer's literature.
    • Baclofen is not recommended in patients with stroke or other cerebral lesions or in severe renal impairment.
  • Precautions: Refer to manufacturer's literature.
    • Abrupt withdrawal of baclofen should be avoided.
Second Line
Possible drug therapies (2, 6, 8,9,10)[C]
  • Amantadine, carbidopa-levodopa in Parkinson disease
  • Steroid replacement in Addison disease
  • Antifungal agent in Candida esophagitis
  • Ondansetron in carcinomatosis with vomiting
  • Nefopam (a nonopioid analgesic with antishivering properties related to antihistamines and antiparkinsonian drugs) is available outside the United States in both IV and oral formulations.
  • Olanzapine 10 mg QHS
  • Pregabalin 375 mg/day
ISSUES FOR REFERRAL
For acupuncture or phrenic nerve crush, block, or electrostimulation; cardioversion
SURGERY/OTHER PROCEDURES
  • Phrenic nerve crush or transaction or electrostimulation of the dominant diaphragmatic leaflet
  • Resection of rib exostoses
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture is increasingly used to manage persistent or intractable hiccups, especially in cancer patients (3,4)[A].
  • Simple home remedies (2,7)[C]
    • Swallowing a spoonful of sugar
    • Sucking on hard candy or swallowing peanut butter
    • Holding breath and increasing pressure on diaphragm (Valsalva maneuver)
    • Tongue traction
    • Lifting the uvula with a cold spoon
    • Inducing fright
    • Smelling salts
    • Rebreathing into a paper (not plastic) bag
    • Sipping ice water
    • Rubbing a wet cotton-tipped applicator between hard and soft palate for 1 minute
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Most patients can be managed as outpatients; those with severe intractable hiccups may require rehydration, pain control, IV medications, or surgery.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Until hiccups cease
DIET
Avoid gastric distension from overeating, carbonated beverages, and aerophagia.
PATIENT EDUCATION
See “General Measures.”
PROGNOSIS
  • Hiccups often cease during sleep.
  • Most acute benign hiccups resolve spontaneously or with home remedies.
  • Intractable hiccups may last for years or decades.
  • Hiccups have persisted despite bilateral phrenic nerve transection.
REFERENCES
1. Witter F, Dipietro J, Costigan K, et al. The relationship between hiccups and heart rate in the fetus. J Matern Fetal Neonatal Med. 2007;20(4): 289-292.
2. Calsina-Berna A, García-Gómez G, González-Barboteo J, et al. Treatment of chronic hiccups in cancer patients: a systemic review. J Palliat Med. 2012;15(10):1142-1150.
3. Ge AX, Ryan ME, Giaccone G, et al. Acupuncture treatment for persistent hiccups in patients with cancer. J Altern Complement Med. 2010;16(7):811-816.
4. Thompson DF, Brooks KG. Gabapentin therapy of hiccups. Ann Pharmacother. 2013;47(6): 897-903.
5. Ramírez FC, Graham DY. Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study. Am J Gastroenterol. 1992;87(12):1789-1791.
6. Maximov G, Kamnasaran D. The adjuvant use of lansoprazole, clonazepam and dimenhydrinate for treating intractable hiccups in a patient with gastritis and reflux esophagitis complicated with myocardial infarction: a case report. BMC Res Notes. 2013;6:327.
7. Lewis JH. Hiccups and their cures. Clin Perspect Gastroenterol. 2000;3(5):277-283.
8. Moretto EN, Wee B, Wiffen PJ, et al. Interventions for treating persistent and intractable hiccups in adults. Cochrane Database Syst Rev. 2013;(1):CD008768.
9. Marinella MA. Diagnosis and management of hiccups in the patient with advanced cancer. J Support Oncol. 2009;7(4):122-127, 130.
10. Matsuki Y, Mizogami M, Shigemi K. A case of intractable hiccups successfully treated with pregabalin. Pain Physician. 2014;17(2):E241-E242.
Additional Reading
&NA;
  • Berger TJ. A rash case of hiccups. J Emerg Med. 2013;44(1):e107-e108.
  • Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil. 2012;18(2): 123-130.
  • Choi TY, Lee MS, Ernst E. Acupuncture for cancer patients suffering from hiccups: a systematic review and meta-analysis. Complement Ther Med. 2012;20(6):447-455.
  • Hurst DF, Purdom CL, Hogan MJ. Use of paced respiration to alleviate intractable hiccups (Singultus): a case report. Appl Psychophysiol Biofeedback. 2013;38(2):157-160.
  • Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol. 1985;7(6):539-552.
  • Rizzo C, Vitale C, Montagnini M. Management of intractable hiccups: an illustrative case and review. Am J Hosp Palliat Care. 2014;31(2):220-224.
Codes
&NA;
ICD10
  • R06.6 Hiccough
  • F45.8 Other somatoform disorders
Clinical Pearls
&NA;
  • Most hiccups resolve spontaneously.
  • An organic cause for persistent hiccups is more likely to be found in men and individuals with intractable hiccups.
  • Rule out a foreign body in the ear canal as hiccup trigger.
  • Baclofen and gabapentin are the only pharmacologic agents proven effective in a clinical trial.
  • Acupuncture may be effective for persistent hiccups.