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MD consult
HICCUPS
Etiology
Hiccup is a common phenomenon that is usually innocuous, but that sometimes
produces significant morbidity. Hiccups are associated with many conditions
that involve the central nervous system, the vagus and phrenic nerves, the
mediastinum, the diaphragm, and the gastrointestinal and genitourinary
tracts.[204] In some cases no obvious organic disease is present, and the
hiccup phenomenon may be psychogenic. Examples of central nervous system
conditions associated with hiccups include multiple sclerosis, toxic states
such as uremia and alcohol intoxication, dexamethasone therapy, meningitis
and encephalitis, vascular lesions and brain tumor, and surgery. Peripheral
nerve causes include herpes zoster and irritation of branches of the vagus or
phrenic nerves. Visceral causes include stimulation of the gastrointestinal
tract by heat, cold, spasm, dilation, and distention, and inflammatory,
neoplastic or surgical lesions of the mediastinum, diaphragm, or upper
gastrointestinal tract.
Hiccups are usually only a nuisance. However, prolonged hiccups cause
discomfort and interfere with speech, eating, and sleep. Hiccups during or
after surgery can pose particular problems. In one adult, hiccups were
thought to be the cause, rather than the result, of severe esophageal
reflux,[205] and in one infant, hiccups were considered to have caused a
Mallory-Weiss injury to the esophageal mucosa, with serious bleeding.[206]
Pathophysiology
The spasm of hiccup is not limited to the diaphragm. There are short, sharp
contractions of the diaphragm and inspiratory intercostal muscles, coupled
with transient closure to the glottis, that can occur 10 to 30 times per
minute.[204] In infants, the upper airway closure involves pharyngeal
muscles, and it may persist after diaphragmatic spasms have stopped.[207]
Thus, in infants, the upper airway closure mechanism bears some resemblance
to that occurring in obstructive sleep apnea. The pathogenesis of hiccup is
unclear, but seems to be related to supraspinal mechanisms as well as reflex
arcs.
Treatment
Numerous treatments for hiccups have been described; many derive from
folklore, many are ineffective, and few have been investigated
systematically.[204] In one study, swallowing a teaspoonful of dry granulated
sugar rapidly stopped hiccups in 19 of 20 patients, 12 of whom had had the
hiccups for only a few hours, and 8 of whom had suffered for 1 day to several
weeks.[208] In another study, stimulation of the pharynx with a catheter
introduced through the nose stopped hiccups in 84 of 85 patients.[209] In our
experience, however, this leads to only transient relief. Electrical
stimulation of the phrenic nerves has also been reported to be
successful.[210] Treatment of the underlying irritative or metabolic cause is
sometimes helpful; in one case, hiccups stopped when a hair in contact with
the eardrum was removed from the external auditory canal.[204] Isolated
successes have occurred with anesthetic or surgical block of phrenic or vagus
nerves.[204] Other maneuvers have included hyperventilation, breath-holding,
rebreathing or inhaling carbon dioxide, rapidly swallowing water or ice
chips, induction of vomiting, carotid massage, and pressure on the eyes.
Many drug treatments have been proposed, including tranquilizers, muscle
relaxants, anticonvulsives, and narcotics.[204] Chlorpromazine,
carbamazepine, metoclopramide, haloperidol, amitriptyline, ketamine,
nifedipine, quinidine, phenytoin, baclofen, and valproic acid have been used,
with variable success.[204][211][212] Frequently, the doses must be increased
to toxic levels.
On the basis of the preceding observations, we recommend the following:
First, have the patient swallow 1 teaspoonful of dry granulated sugar. Next,
if need be, proceed to pharyngeal stimulation with a nasogastric tube, and
use the tube to decompress the stomach. Also, check for and remove foreign
bodies in the external auditory canal. Because phrenic stimulation and nerve
block procedures require special skills, we would reserve those interventions
for patients in whom all other measures fail.
If mechanical measures fail, and the hiccups persist for more than 12 hours,
we would resort to pharmacologic therapy. One may begin with intravenous
chlorpromazine, 50 mg, diluted in saline, and follow with oral chlorpromazine
for a few days if necessary. Haloperidol in doses up to 5 mg every 8 hours
may also be used. One must be cautious about the long-term use of
chlorpromazine and haloperidol because they may cause permanent dyskinesia.
Baclofen, a centrally acting muscle relaxant, often works; the initial dose
is 5 mg three times a day, increasing slowly to a maximum of 20 mg three to
four times a day if necessary. Lorazepam may be a useful supplement.
Additional or alternative drugs are amitriptyline and nifedipine.
Metoclopramide as a treatment for hiccup should probably be reserved for
patients who have gastrointestinal disease; the dose is 10 mg every 6 hours.
Carbamazepine and valproic acid are potentially very toxic drugs and should
be used only as a last resort. Other centrally acting drugs such as baclofen
or chlorpromazine should be discontinued if either carbamazepine or valproic
acid is given.
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