Singultus (Hiccups)

CHAPTER 75

Singultus

(Hiccups)

Presentation

Recurring, unpredictable, clonic contractions of the diaphragm produce sharp inhalations. Hiccups are usually precipitated by some combination of laughing, talking, eating, and drinking but may also occur spontaneously. Most cases resolve spontaneously, and patients do not come to a physician’s office unless hiccups are prolonged or severe. A bout of hiccups is any episode lasting more than a few minutes. If hiccups last longer than 48 hours, they are considered persistent or protracted. Hiccups lasting longer than 1 month are called intractable.

What To Do:

For a bout of hiccups, stimulate the patient’s soft palate by rubbing it with a swab, spoon, catheter tip, or finger, just short of stimulating a gag reflex, and, if necessary, repeat this several times. Alternatively, stimulate the same general area by depositing a tablespoon of granulated sugar at the base of the tongue, in the area of the lingual tonsils, and letting it dissolve. Such maneuvers (or their placebo effect) may abolish simple cases of hiccups. Other simple measures include having the individual bite on a lemon or inhale a noxious agent (e.g., ammonia). You can also have them perform a Valsalva maneuver, breath hold, or pull their knees up to their chest and lean forward.

With persistent and protracted hiccups, look for an underlying cause and ask about precipitating factors or previous episodes. Drugs that are known to cause hiccups include benzodiazepines, short-acting barbiturates, and dexamethasone. Persistence of hiccups during sleep suggests an organic cause; conversely, if a patient is unable to sleep or if the hiccups stop during sleep and recur promptly on awakening, a psychogenic or idiopathic cause is indicated.

Perform a complete physical examination. Look in the ears. (Foreign bodies, such as a hair against the tympanic membrane, can cause hiccups.) Examine the neck (look for thyromegaly and lymphadenopathy), chest, and abdomen, perhaps including an upright chest radiograph, to look for neoplastic, inflammatory, or infectious processes irritating the phrenic nerve or diaphragm. Pericarditis, myocardial infarction, and aberrant cardiac pacemaker electrode placement are potential sources of persistent hiccups, as well as acute and chronic alcohol intoxication and gastroesophageal reflux or other gastrointestinal disorders. Perform a neurologic examination, looking for evidence of partial continuous seizures or brain stem lesions. Early multiple sclerosis is thought to be one of the most frequent neurologic causes of intractable hiccups in young adults.

Routine laboratory evaluation may include a complete blood count (CBC) with differential (looking for infection or neoplasm) and a basic metabolic panel. (Hyponatremia, hypokalemia, hypocalcemia, and uremia can cause persistent hiccups.)

Additional testing is not limited to, but may include, an ECG, chest CT, and upper endoscopy.

Direct treatment toward the specific illness causing the hiccups, if this is identified.

If hiccups persist after using simple measures, try chlorpromazine (Thorazine), 25 to 50 mg PO tid or qid. (The same dose may be given IV or IM.) To avoid or minimize hypotension, consider giving a 500- to 1000-mL bolus of IV normal saline. Chlorpromazine is contraindicated in elderly patients with dementia. Side effects include dystonic reaction, drowsiness, and the risk of tardive dyskinesia. Alternatively, haloperidol (Haldol), 2 to 5 mg IM, followed by 1 to 4 mg PO tid for 2 days may be equally effective, with less potential for hypotension. Another approach is to use metoclopramide (Reglan), 10 mg PO tid or qid, followed by a maintenance regimen of 10 to 20 mg PO tid to qid for 10 days. Reglan and Haldol are also associated with tardive dyskinesia.

For intractable hiccups, phenytoin (Dilantin), valproic acid (Depakote), or carbamazepine (Tegretol) can be given in typical anticonvulsant doses. Alternatively, baclofen (a centrally acting muscle relaxant) can be prescribed at 10 to 20 mg 2 to 3 times a day with gabapentin (Neurontin) as an “add-on,” if necessary, especially in patients with solid malignancies.

There are some reports of acupuncture or hypnosis being efficacious; these can be tried if the aforementioned are unsuccessful.

Arrange for follow-up and additional evaluation if the hiccups recur or persist.

Discussion

The medical term singultus apparently originates from the Latin singult, which is very descriptive and roughly translates as “the act of catching one’s breath while sobbing.”

Hiccups result from an involuntary spasmodic contraction of the diaphragm and external intercostal muscles with ensuing quick inspiration. This is followed by a rapid closure of the glottis, which prevents overinflation of the lungs.

Hiccups are mediated by a reflex arch consisting of the afferent and efferent limbs and supraspinal central connection, which are thought to be independent of the respiratory center in the brain stem. The exact cause remains unclear. When there is an organic cause, irritation of the various branches of the vagus nerve are often involved. Despite a long list of possible causes, in most cases no organic cause can be identified, and a diagnosis of idiopathic chronic hiccups is made.

Although unlikely, there are potentially serious complications, such as dehydration and weight loss, resulting from the inability to tolerate fluids and food.

Patients who experience syncope with the hiccups should be hospitalized and evaluated for possible life-threatening arrhythmias, which have been reported as both the cause and the effect of hiccups.

Hiccups, in general, are a common malady, and fortunately most bouts are usually transient and benign. Persistent or intractable episodes are more likely to result from serious pathophysiologic processes that affect a component of the hiccup reflex mechanism.

The common denominator among various hiccup cures for brief episodes seems to be stimulation of the glossopharyngeal nerve, but as for every self-limiting disease, there are always many effective cures.

… hold your breath, and if after you have done so for some time the hiccup is no better, then gargle with a little water, and if it still continues, tickle your nose with something and sneeze, and if you sneeze once or twice, even the most violent hiccup is sure to go.