Hiccup

Aka: Hiccup, Hiccough, Singultus

1. Pathophysiology
   1. Sudden involuntary diaphragmatic contraction
      1. Inspiration interrupted by glottic closure
      2. Characteristic sharp sound emitted
   2. Peripheral nerves involved
      1. Phrenic Nerve
      2. Vagus Nerve
      3. Reflex arc
         1. Afferent Limb: Sympathetic chain (T6-T12)
         2. Efferent Limb: Phrenic nerve
   3. Locally mediated via diaphragmatic irritation
2. Causes: Transient Hiccups (gastric distention)
   1. Excessive laughter or tickling
   2. Aerophagia
   3. Tobacco abuse
   4. Overindulgence in food or Alcohol
   5. Change in gastric temperature
      1. Movement into hot or cold environment
      2. Ingestion of hot or cold foods
3. Causes: Intractable Hiccups
   1. Reflex Stimulation
      1. Alcohol Abuse
      2. Anxiety Disorder
      3. Transient Hiccup causes above
   2. 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
   3. Mediastinal disorders
      1. Phrenic nerve trauma
      2. Mediastinal lymph node involvement
         1. Mycobacterium tuberculosis
         2. Malignant neoplasm
         3. Pulmonary fibrosis
         4. Sarcoidosis
      3. Bronchial obstruction
      4. Adherent Pericardium
      5. Cardiomegaly
      6. Myocardial Infarction
      7. Esophageal obstruction
      8. Pneumonia with Pleural irritation
   4. Abdominal disorders
      1. Diaphragmatic Hernia of Stomach
      2. Subphrenic abscess
      3. Subphrenic peritonitis
      4. Liver disease
         1. Liver tumor or mass
         2. Liver Abscess
      5. Stomach Cancer
      6. Splenic infarction
      7. Acute Intestinal Obstruction
      8. Acute hemorrhagic Pancreatitis
      9. Post-operative abdominal surgery
4. Symptoms
   1. Hiccups occur 2-3 times per minute
5. Management: Transient Hiccups
   1. Folk Remedies
      1. Breath-holding
      2. Tongue traction
      3. Breathing into a paper bag
      4. Suddenly frightened
      5. Drinking water from wrong side glass and occlude ears
   2. Stimulate pharyngeal mucosa
      1. Swallow teaspoon vinegar or dry granulated sugar
   3. Stimulate Gag Reflex with Tongue depressor
      1. Avoid if recent food intake (aspiration risk)
6. Management: Intractable Hiccups
   1. Central acting medications
      1. Chlorpromazine (Thorazine)
         1. Best studied of all agents used for Hiccups
         2. Initial: 50 mg IV bolus (monitor for Hypotension)
         3. Maintenance if effective: oral dose for 10 days
      2. Diphenylhydantoin
      3. Haloperidol 5 mg PO tid
      4. Orphenadrine 60 mg IM or 100 mg PO
      5. Ketamine 0.4 mg/kg IV
      6. Carbamazepine 200 mg PO qid
   2. Peripheral acting medications
      1. Metoclopramide 10 mg PO qid (most efficacious)
      2. Quinidine 200 mg PO qid
      3. Atropine 1 mg IV
      4. Edrophonium chloride 10 mg IV
      5. Amphetamine 30 mg PO qd for 1 week
      6. Amyl nitrite
7. References
   1. Davis (1970) Brain 93:851-72
   2. Kolodzik (1991) Ann Emerg Med 20:563-73
   3. Nathan (1980) Laryngoscope 90:1612-18
   4. Samuels (1952) Can Med Assoc 67:315-22
   5. Williamson (1977) BMJ 2:501-3