Hiccups

Other names

Singultus

What is it?

Hiccups are produced by involuntary spasms of the diaphragm and rib muscles, causing sudden inspiration followed by abrupt closure of the vocal cords, which gives the characteristic sound. This is a common, usually benign and short-lived phenomenon.

Hiccups lasting more than 48 hours are called persistent, and those lasting for more than 1 month are called intractable. Both of these occur more often in men than in women.

What causes it?

Bouts of benign hiccups are usually caused by stomach distension due to overeating, gassy drinks and swallowing air. Other associated causes are excess alcohol ingestion, sudden excitement or stress, and sudden changes in stomach temperature.

Persistent and intractable hiccups are associated with many underlying conditions, most easily classified as
irritation of the vagus or phrenic nerve by, for example,

• pneumonia/pleuritis/enlarged chest lymph nodes
   
• goiter
   
• stomach/gallbladder/liver/pancreatic disease
   
• heart attack/hiatus hernia

toxic states due to

• alcohol – the most common
   
• diabetes mellitus
   
• uraemia
   
• imbalances of sodium or calcium

central nervous system problems such as

• head trauma/stroke
   
• meningitis/encephalitis
   
• brain tumours/hydrocephalus

psychogenic factors

• stress
   
• excitement
   
• malingering (rare)

Tests and procedures

Short bouts of hiccups do not need attention, but persistent and intractable hiccups need to be taken seriously, and a doctor should be consulted.

For these, a medical history will include questions about the onset, duration, and any remedies already tried. Some basic investigations should include

• a complete physical examination
   
• a chest X-ray
   
• blood tests: glucose, creatinine, electrolytes

If any of these – the examination or the tests – is abnormal, then more specialised investigations must be done, such as MRI scan or endoscopy ( to see the inside of the stomach), or drug and alcohol screening.

Treatment

Many anecdotal remedies have been suggested, such as breath-holding, drinking from the “wrong” side of a glass, rebreathing into a paper bag or eating sugar.

Any known underlying causes must obviously be treated with specific therapy.

If no cause can be identified, various medications can be used for persistent or intractable hiccups. Some drugs used with varying degrees of success include:

• chlorpromazine
   
• metoclopromide
   
• baclofen
   
• amitryptaline
   
• quinidine

For some, alternative methods may be considered, such as hypnosis or acupuncture.

Surgical treatment as a last resort, may include phrenic nerve crushing – this causes permanent damage to the nerve, partially paralysing the diaphragm. As this may interfere with normal breathing, the procedure must be used only as a last resort. An alternative would be temporarily blocking the phrenic nerve with an anaesthetic agent. One report cites the successful use of an implanted vagus nerve stimulator for post-stroke hiccups.

(Dr AG Hall)