Hiccups

Hiccups (singultus), an involuntary diaphragmatic spasm with a sudden closure of the glottis, is considered persistent when it lasts more than 48 hours. Its etiology can be organic, psychogenic, or idiopathic. Usually, the initial problem is to stop the hiccups, even if an organic cause is being investigated. In austere settings, some of the safer non-pharmacological remedies (Table 34-1) may be the most helpful. One of the most interesting is continuous tapping, usually for a few minutes, over the C5 vertebra until the hiccups cease. Another is self-compression of the chest by either pulling one’s knees to one’s chest or leaning forward. While some of these methods have a sound physiological base, their effectiveness is uncertain, especially with protracted hiccups.

Multiple drugs have also been successfully used. If hiccups persist, prescribe chlorpromazine (Thorazine) 25 to 50 mg orally three or four times a day. Haloperidol, 2 to 5 mg intramuscularly (IM), is a safer and possibly more successful alternative. If it works, prescribe 1 to 4 mg orally three times a day. Other drugs used for hiccup treatment include many anticonvulsants (e.g., phenytoin, phenobarbital, carbamazepime, valproic acid), benzodiazepines, metoclopramide, various sedatives, and narcotics.²

Another method of treating hiccups that is relatively benign, generally available, inexpensive, and simple to use is IV lidocaine. On multiple occasions, it has worked successfully when other medications have failed. Reported successful procedures with lidocaine doses, in both children and adults, have involved loading the patient with 1 to 2 mg/kg and then generally beginning a 2 mg/kg (sometimes up to 4 mg/kg) drip for 4 to 12 hours. This often had to be repeated within 24 hours.^3,4,5,6 My personal experience with this technique was in a remote location with an adult who had had several severe and debilitating hiccup attacks over the prior decade. I used an infusion of 2 mg/kg lidocaine over 20 minutes, which stopped the hiccups as the infusion was ending. Although they did not recur, I gave him a 20-minute infusion of 1 mg/kg on each of the next 2 days. He did not have a recurrence over the next 5 months.

Nausea and Vomiting

Treatments for the common complaint of nausea and vomiting vary around the globe. Some medications, such as the phenothiazines that are commonly used in some countries, are unavailable for this use in other countries. Other common treatments, such as metoclopramide and ginger root, are no better than placebos.⁷

Generally available and inexpensive medications that have been shown to be effective for nausea and vomiting include dexamethasone, 5 to 10 mg IV (pediatric dose: 0.5 to 1.5 mg/kg); droperidol, 0.625 to 1.25 mg IV; dimenhydrinate, 1 to 2 mg/kg IV; and ephedrine, 0.5 mg/kg IM.⁸ A side benefit of using dexamethasone is that it often relieves bowel obstruction along with the accompanying nausea and vomiting in cancer patients.⁹

Acupressure, as both a preventive (anesthesia and pregnancy) and a treatment, has shown mixed results. Acupressure may be more effective in controlling nausea symptoms than in preventing emesis.¹⁰ But, because it costs nothing, has no side effects, is simple to use, and is available in any situation, it is probably worth trying. The Pe6 Neiguan point where acupressure is applied can be located on the volar forearm about 2 inches proximal to the distal wrist crease (in adult males) between the tendons of the flexor carpi radialis and palmaris longus. For others, it is one-sixth the distance between the distal wrist crease and the elbow flexor crease (Fig. 34-1). Apply pressure to this site using a marble, ball bearing, or similar object placed beneath an armband, such as used for a venous tourniquet, or an elastic bandage. Begin by compressing the sphere intermittently for a few minutes; then apply the pressure constantly under the band.¹¹

Diarrhea

Diarrhea afflicts nearly everyone at some point. Among the Bataan prisoners of war (POWs), physician–prisoners “created pills for dysentery from cornstarch, guava leaves and charcoal.”¹² Pepto Bismol tablets are frequently used for symptomatic treatment of non-dysenteric diarrhea.

Probiotics (live nonpathogenic microorganisms, usually bacteria or yeast) may benefit patients with infectious and antibiotic-associated diarrhea, including Clostridium difficile–associated disease. Yogurt with Lactobacillus species and Saccharomyces boulardii has been shown to be effective.^13,14 However, the optimal bacterial species and dose to prescribe remains unclear.¹⁵

Gastrointestinal Bleed Scoring

When resources are limited, use the Glasgow-Blatchford bleeding score (Table 34-2) to help determine which patients with an acute upper gastrointestinal bleed can be safely discharged and which will need advanced medical interventions, such as a blood transfusion or endoscopy. If the patient has none of the criteria, he or she can be discharged. Those with a score >6 have at least a 50% chance of needing a significant intervention.¹⁶

Helicobacter pylori Treatment

While the ‘test before treatment’ policy is the recommended way to eradicate Helicobacter pylori in young patients with uninvestigated dyspepsia, if the prevalence of H. pylori is high, immediately initiating proton pump therapy may be a better option for these patients.¹⁷

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is characterized by mild-to-severe abdominal pain, discomfort, bloating, and alteration of bowel habits. In some adult patients with IBS, administering intrarectal lidocaine (300 mg) jelly may reduce rectal pain. It works within 15 minutes of administration and is reported to be safe and effective.¹⁸

Constipation

Constipation is a common complaint, especially in postoperative and pregnant patients, the elderly, those on several types of medications, and those with diabetes, hypothyroidism, depression, and inflammatory bowel disease.

Treatment for constipation can be either mechanical (i.e., enema) or with oral agents. Table 34-3

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