Hiccup

Aka: Hiccup, Hiccough, Singultus

II. Pathophysiology

Locally mediated via diaphragmatic irritation
Sudden involuntary diaphragmatic contraction
1. Inspiration interrupted by glottic closure
2. Characteristic sharp sound emitted
Peripheral nerves involved
1. Phrenic Nerve
2. Vagus Nerve
3. Reflex arc
  1. Afferent Limb: Sympathetic chain (T6-T12)
  2. 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
1. Movement into hot or cold environment
2. Ingestion of hot or cold foods

IV. Causes: Intractable Hiccups (>48 hours)

Reflex Stimulation
1. Alcohol Abuse
2. Anxiety Disorder
3. Transient Hiccup causes above
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
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
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
Medications
Miscellaneous
1. Tympanic Membrane foreign body

V. Symptoms

Hiccups occur 2-3 times per minute

VI. Management: Transient Hiccups

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
Stimulate pharyngeal mucosa
1. Swallow teaspoon vinegar, pickle juice or dry granulated sugar
Stimulate Gag Reflex with Tongue depressor
1. Avoid if recent food intake (aspiration risk)

VII. Management: Intractable Hiccups

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
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

VIII. References

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term “Hiccup.” Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images