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NCBI Bookshelf. Justin A. Cole ; Michael C. Authors Justin A. Cole 1 ; Michael C. Hiccups can be acute, lasting less than 48 hours, persistent, lasting over 2 days, or intractable, lasting more than one month. They can result from a variety of causes.

In particular, hiccups are often caused by gastrointestinal disorders such as gastroesophageal reflux. Other causes include medication side-effects, cardiovascular disorders, central nervous system disorders, ear, nose, and throat disorders, psychogenic disorders, or metabolic disorders.

Ths activity reviews the spectrum of hiccups from acute to intractable, outlines the causes, and offers recommendations for medical treatment based on clinical presentation. This activity stresses the role of the interprofessional team in the care of affected patients. Objectives: Outline medications and medical conditions known to cause hiccups.

Describe useful bedside maneuvers for aborting acute hiccups. Identify medical therapies for aborting persistent or intractable hiccups. Explain a well-coordinated interprofessional team approach to provide effective care to patients affected by persistent or intractable hiccups. Access free multiple choice questions on this topic. Hiccups are a not uncommon occurrence that most people experience at some point in their lifetime. Often, these episodes are transient and resolve within 48 hours. They can occur in adults, children, infants, and in utero. Drunk hiccups stories adults, they serve no physiological purpose.

The belief is that they may play a role in respiratory muscle training in utero. The classification of hiccups is by their duration. Acute hiccups are of less than 48 hours duration, persistent last over 2 days, and intractable last over a month.

As acute hiccups are self-limited and usually unreported, most of the research has focused on persistent and intractable hiccups. There are various causes of hiccups including organic causes, psychogenic, idiopathic, or medication-induced. Persistent and intractable hiccups may ify a more serious underlying etiology. Gastrointestinal processes, particularly gastroesophageal reflux disease GERD and associated hiatal hernias, are implicated as the most common cause of acute hiccups. In patients with esophageal tumors, as many as one in four can present with persistent hiccups.

Many drugs correlate with hiccups, especially alcohol.

Some drugs, such as benzodiazepines, have a dose-dependent and an inverse relationship with hiccups. At low doses, benzodiazepines correlate with the development of hiccups. At higher doses, they may be useful in the treatment of hiccups. Chemotherapeutic agents and some glucocorticoids have shown a strong association with hiccups. Numerous reports exist of persistent and intractable hiccups due to a multitude of etiologies, including:.

Hiccups occur in all ages, from in utero to the elderly. The incidence and prevalence of hiccups in the community are unknown, and there does not appear to be differences based on racial or geographic variation. Reports suggest there are as many as 4, admissions yearly in the U. Hiccups are thought to be due to a complex reflex arc composed of three main units. Any condition that acts on one of these pathways has the potential to induce hiccupping. First, the afferent limb is composed of the vagus nerve, the phrenic nerve, and the peripheral sympathetic nerves supplying the viscera.

Second, the central processing unit likely involves the interaction between various midbrain and brainstem structures, such as the medulla oblongata and reticular formation, chemoreceptors in the periaqueductal gray, glossopharyngeal and Drunk hiccups stories nerve nuclei, solitary and ambiguous nuclei, hypothalamus, temporal lobes and upper spinal cord at levels C3 to 5.

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Hiccups commonly repeat at cycles of 4 to 60 per minute, depending on the individual. The diaphragmatic spasm is often unilateral, and the left hemidiaphragm is involved more than the right. Without closure of the glottis, hyperventilation would occur. Evaluating a patient with hiccups warrants a thorough medical history review. Ask about precipitating causes, such as large meals, excitement or emotional stress. Inquire regarding associated symptoms such as gastroesophageal reflux, coughing, weight loss, and abdominal pain. Ask about neurologic symptoms that might suggest a medullary stroke, multiple sclerosis or Parkinson's disease.

Hiccups during sleep are uncommon and can occur with gastroesophageal, neurologic or pulmonary disorders, but negate psychogenic cause. Ask about recent surgery, known cancer or chemotherapy. A detailed medication review may identify a likely cause, and if discontinuing this offending medication provides ificant relief then causality is confirmed.

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In cases of persistent and intractable hiccups, one should investigate organic causes. A full HEENT evaluation may reveal processes such as a hair or foreign body pressing against the tympanic membrane, masses, goiters, tonsillitis, and pharyngitis. Listen to the lung sounds to assess for thoracic causes such as pneumonia or empyema.

Palpate the abdomen for tenderness or mass to exclude obstruction, volvulus, pancreatitis, hepatitis or mass. A full neurological exam may expose CNS pathology such as strokes and tumors, though it is rare for hiccups to be the only presenting symptom. Acute hiccups are typically benign and usually do not require a workup, however persistent and intractable hiccups should trigger a thorough evaluation to identify a treatable cause. It is reasonable to obtain lab work for evaluation of electrolyte abnormalities or to rule out infectious and neoplastic processes not identified on history and physical exam.

Laboratory studies such as Drunk hiccups stories, calcium, blood urea nitrogen BUNcreatinine, lipase, and liver tests can be useful.

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A chest radiograph may identify intrathoracic sources of hiccups such as pneumonia, empyema, diaphragmatic hernia, adenopathy or aortic disease. The guiding of further imaging or interventions is best by the duration of hiccups, history and physical exam findings. For persistent or intractable hiccups associated with neurologic symptoms or s, brain imaging by computerized tomography CT or magnetic resonance imaging MRI may demonstrate causes such as stroke, multiple sclerosis, tumor, syringomyelia, neuromyelitis optica, aneurysm or vascular malformation.

For some cases, thoracic or abdominal CT imaging may identify cancer, aneurysm, abscess or a hernia.

Referral to gastroenterology for upper endoscopy is essential to exclude lesions such as esophageal cancer in those cases of persistent hiccups refractory to initial antacid and proton pump inhibitor therapy. It is essential to review blood gases in any ventilated patient that develops hiccups. Hiccups in ventilated patients may cause ventilator desynchronization, severe respiratory derangements, and hemodynamic changes.

In the acute phase, hiccups are likely to be terminated by a variety of simple physical maneuvers supported by anecdotal evidence. Most of the maneuvers aim for some portion of the hiccup reflex arc. The frequency of hiccups decrease as PCO2 rises, [32] so Valsalva, breath holding, and breathing into a paper bag may be therapeutic. Supra-supramaximal inspiration is a technique where subject exhales completely, then inhale deeply and hold for 10 seconds, then without exhaling inhale two times again, each time holding for 5 seconds.

The persistent phase is usually multifactorial and more difficult to treat. Important steps in the treatment of persistent and intractable hiccups are, first, to assess whether the patient is using a medication known to induce hiccups, and second, to determine whether hiccups are associated with GERD. Discontinuation of an offending medication or use of an alternative agent such as methylprednisolone instead of dexamethasone can resolve medication-induced hiccups.

In the persistent phase, most studies have evaluated pharmacotherapies acting on one or more components of the reflex arc. Pharmacotherapy is aimed at neurotransmitters and can be broken down into central and peripheral treatments though some act on both.

The neurotransmitters involved in central processing include GABA, dopamine, and serotonin. Peripherally, they include acetylcholine, histamine, epinephrine, and norepinephrine. Classically, chlorpromazine had been the drug of choice for persistent hiccups and remains the only drug for hiccups approved by the U. Chlorpromazine acts as an antagonist on multiple central and peripheral neurotransmitter sites including dopamine, serotonin, histamine receptors, alpha-adrenergic receptors, and muscarinic receptors.

Other typical antipsychotics, such as Drunk hiccups stories or risperidone, have been tried with varying degrees of success. Often, the side effects of the typical antipsychotic drugs may be unbearable for the patient. The most commonly studied drugs for persistent or intractable hiccups are metoclopramide and the GABA agonists baclofen and gabapentin. If no etiology is found with a thorough exam, metoclopramide, gabapentin or baclofen are reasonable second-line therapies.

Metoclopramide acts centrally as a dopamine antagonist and peripherally by increasing gastric motility and has been successful in relief of hiccups from cancer, stroke and brain tumors. There are a variety of medications suggested for the treatment of persistent hiccups in anecdotal reports such as amantadine, [47] amitriptyline, antipsychotic agents haloperidol, risperidone, olanzapine[9] atropine, benzonatate, carvedilol, glucagon, ketamine, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid.

For cases refractory to medical therapy, more invasive techniques for management include acupuncture, positive pressure ventilation, vagus nerve stimulators, Drunk hiccups stories and stellate or phrenic nerve block. Hiccups are usually a self-limited process and relatively benign. Management of underlying etiologies typically improves the hiccup frequency and duration. Acute hiccups result in temporary discomfort, GERD, emotional disturbance and rarely aspiration, however persistent and intractable hiccups can have profound effects on quality of life, with decreased ability to tolerate oral intake leading to dehydration, malnutrition, fatigue, and weight loss, as well as insomnia, despair, depression, and exhaustion.

Hiccups can interfere with surgery or threaten the integrity of post-operative thoracic or abdominal wounds. Forceful hiccups can lead to bradycardia, carotid dissection, barotrauma such as pneumothorax or pneumomediastinum, and decreased venous return leading to hypotension. Hiccups are often benign and self-limiting. Patients with acute hiccups should be advised to try some aforementioned physical maneuvers and should receive reassurance. In healthy patients with no overt cause for intractable and persistent hiccups, treatment of reflux may provide relief. Patient education and therapies aimed at improving reflux and gastrointestinal motility are reasonable first steps.

The provider should give guidance on the potential for any quality of life issues that may occur.