Hiccups Clinical Presentation

  • Author: Garry Wilkes, MBBS, FACEM; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Apr 4, 2012
 

History

Medical training is not required to diagnose hiccups. Brief episodes that self-terminate or that respond to simple maneuvers need no investigation or follow-up care.

In contrast, persistent and intractable hiccups frequently are associated with an underlying pathological process and may induce significant morbidity. The focus of the history, examination, and investigation is to identify these causes and effects.

  • Hiccups that abate with sleep and temporally relate to stressful circumstances commonly are psychogenic in origin.
  • Arrhythmia-induced syncope has been reported as both the cause and the effect of hiccups.[1]
  • Gastroesophageal reflux may cause or result from hiccups.
  • Weight loss, insomnia, and emotional distress may complicate prolonged episodes.
  • A full systemic inquiry, surgical history, and comprehensive drug history may reveal one of the many causes (see Causes).
  • Alcoholism and acute alcohol ingestion may contribute to the development of hiccups.
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Physical

A full physical examination is necessary. Considering the wide range of differentials, a complete and focused physical examination may yield evidence of the following:

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Causes

The cause of hiccups in children and infants is rarely found. Brief episodes in adults are usually benign and self-limiting.

Typical causes include gastric distention (ie, food, alcohol, air), sudden changes in ambient or gastric temperature, and use of alcohol and/or tobacco in excess. Psychogenic causes (ie, excitement, stress) also may elicit hiccups.

Persistent or intractable episodes are more likely to result from serious pathophysiological processes affecting a component of the hiccup reflex mechanism. More than 100 causes have been described; however, in many cases, the cause remains idiopathic. These may be classified as follows:

  • Eighty-two percent of persistent or intractable episodes occur in men. An organic cause can be identified in 93% of men and in 8% of women, resulting in an overall organic incidence of 80%. The remaining 20% are considered psychogenic in origin.
    • Hysteria
    • Shock
    • Fear
    • Personality disorders
    • Conversion disorders
    • Malingering
  • Central nervous system
    • Structural[2] - Congenital malformations, malignancies, multiple sclerosis
    • Vascular lesions
    • Infection
    • Trauma
  • Diaphragmatic irritation
    • Hiatal hernia
    • Subphrenic abscess or collection
    • MI[3]
    • Pericarditis
  • Vagus nerve irritation
    • Meningeal branches - Meningitis, glaucoma
    • Auricular branches - Foreign body, hairs
    • Pharyngeal branches - Pharyngitis
    • Recurrent laryngeal nerve - Mass lesions in neck, goiter, laryngitis[4]
    • Thoracic branches - Infection, tumors,[5] esophagitis (ie, reflux), MI, asthma, trauma, thoracic aortic aneurysm, pacemaker lead complications[6]
    • Abdominal branches - Tumors,[7] gastric distension, peptic ulcer, AAA, infection, organ enlargement, inflammation (eg, appendicitis, cholecystitis, pancreatitis,[8] inflammatory bowel disease)
  • Procedure/anesthesia related[9, 10]
    • Hyperextension of neck - Stretching phrenic nerve roots
    • Manipulation of diaphragm or stomach
    • Laparotomy
    • Thoracotomy
    • Craniotomy
  • Metabolic
  • Drugs
    • Benzodiazepines[11]
    • Short-acting barbiturates
    • Dexamethasone
    • Alpha methyldopa
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Contributor Information and Disclosures
Author

Garry Wilkes, MBBS, FACEM  Director of Emergency Medicine, Calvary Hospital, Canberra, ACT; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

Specialty Editor Board

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Brief episodes of hiccups are typically of little impact and often merely a source of amusement. In contrast, persistent and intractable can be of enormous impact, impairing all aspects of daily life. My thanks to those who have shared their stories including success or otherwise.

References

  1. Suh WM, Krishnan SC. Violent hiccups: an infrequent cause of bradyarrhythmias. West J Emerg Med. Aug 2009;10(3):176-7. [Medline]. [Full Text].

  2. Vanamoorthy P, Kar P, Prabhakar H. Intractable hiccups as a presenting symptom of Chiari I malformation. Acta Neurochir (Wien). Nov 2008;150(11):1207-8; discussion 1208. [Medline].

  3. Krysiak W, Szabowski S, Stepien M, Krzywkowska K, Krzywkowski A, Marciniak P. Hiccups as a myocardial ischemia symptom. Pol Arch Med Wewn. Mar 2008;118(3):148-51. [Medline].

  4. Morinaka S. Herpes zoster laryngitis with intractable hiccups. Auris Nasus Larynx. Mar 3 2009;[Medline].

  5. Yeatman CF 2nd, Minoshima S. F-18 fluorodeoxyglucose PET/CT findings in active hiccups. Clin Nucl Med. Mar 2009;34(3):197-8. [Medline].

  6. Celik T, Kose S, Bugan B, Iyisoy A, Akgun V, Cingoz F. Hiccup as a result of late lead perforation: report of two cases and review of the literature. Europace. Jul 2009;11(7):963-5. [Medline].

  7. Zügel NP, Kox M, Lang RA, Hüttl TP. Laparoscopic resection of an intradiaphragmatic bronchogenic cyst. JSLS. Jul-Sep 2008;12(3):318-20. [Medline].

  8. Wilcox SK, Garry A, Johnson MJ. Novel use of amantadine: to treat hiccups. J Pain Symptom Manage. Sep 2009;38(3):460-5. [Medline].

  9. Salanitri S, Goncalves AJ, Helene A Jr, Lopes FH. Surgical complications in hair transplantation: a series of 533 procedures. Aesthet Surg J. Jan-Feb 2009;29(1):72-6. [Medline].

  10. Doshi H, Vaidyalingam R, Buchan K. Atrial pacing wires: an uncommon cause of postoperative hiccups. Br J Hosp Med (Lond). Sep 2008;69(9):534. [Medline].

  11. Uldum B, Hallonsten AL, Poulsen S. Midazolam conscious sedation in a large Danish municipal dental service for children and adolescents. Int J Paediatr Dent. Jul 2008;18(4):256-61. [Medline].

  12. Chang CC, Chang ST, Lin JC, Li TY, Chiang SL, Tsai KC. Resolution of intractable hiccups after near-infrared irradiation of relevant acupoints. Am J Med Sci. Aug 2006;332(2):93-6. [Medline].

  13. Chang CC, Chang YC, Chang ST, Chang WK, Chang HY, Chen LC, et al. Efficacy of near-infrared irradiation on intractable hiccup in custom-set acupoints: evidence-based analysis of treatment outcome and associated factors. Scand J Gastroenterol. 2008;43(5):538-44. [Medline].

  14. Dietzel J, Grundling M, Pavlovic D, Usichenko TI. Acupuncture for persistent postoperative hiccup. Anaesthesia. Sep 2008;63(9):1021-2. [Medline].

  15. Farin A, Chakrabarti I, Giannotta SL, Vaynman S, Samudrala S. Microvascular decompression for intractable singultus: technical case report. Neurosurgery. May 2008;62(5):E1180-1; discussion E1181. [Medline].

  16. Johnson DL. Intractable hiccups: treatment by microvascular decompression of the vagus nerve. Case Report. J Neurosurg. May 1993;78(5):813-6. [Medline].

  17. Moretti R, Torre P, Antonello RM, Ukmar M, Cazzato G, Bava A. Gabapentin as a drug therapy of intractable hiccup because of vascular lesion: a three-year follow up. Neurologist. Mar 2004;10(2):102-6. [Medline].

  18. Ong AM, Tan CS, Foo MW, Kee TY. Gabapentin for intractable hiccups in a patient undergoing peritoneal dialysis. Perit Dial Int. Nov-Dec 2008;28(6):667-8. [Medline].

  19. Marinella MA. Diagnosis and management of hiccups in the patient with advanced cancer. J Support Oncol. Jul-Aug 2009;7(4):122-7, 130. [Medline].

  20. Turkyilmaz A, Eroglu A. Use of baclofen in the treatment of esophageal stent-related hiccups. Ann Thorac Surg. Jan 2008;85(1):328-30. [Medline].

  21. Andres DW. Transesophageal diaphragmatic pacing for treatment of persistent hiccups. Anesthesiology. Feb 2005;102(2):483. [Medline].

  22. Anthoney TR, Anthoney SL, Anthoney DJ. On temporal structure of human hiccups: ethology and chronobiology. Int J Chronobiol. 1978;5(3):477-92. [Medline].

  23. Bobele M. Nonmedical management of intractible hiccups: a brief review of the literature. Psychol Rep. Aug 1987;61(1):225-6. [Medline].

  24. Brostoff JM, Birns J, Benjamin E. The "cotton bud technique" as a cure for hiccups. Eur Arch Otorhinolaryngol. May 2009;266(5):775-6. [Medline].

  25. Dunst MN, Margolin K, Horak D. Lidocaine for severe hiccups. N Engl J Med. Sep 16 1993;329(12):890-1. [Medline].

  26. Guelaud C, Similowski T, Bizec JL, Cabane J, Whitelaw WA, Derenne JP. Baclofen therapy for chronic hiccup. Eur Respir J. Feb 1995;8(2):235-7. [Medline].

  27. Howard RS, Charmers RM. Causes and treatment of persistent hiccups. Natl Med J India. May-Jun 1996;9(3):104-6. [Medline].

  28. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med. May 1991;20(5):565-73. [Medline].

  29. Kou S. An analysis on the therapeutic effects of auriculo-acupuncture in 38 obstinate hiccup cases of different races. J Tradit Chin Med. Mar 2005;25(1):7-9. [Medline].

  30. Krahn A, Penner SB. Use of baclofen for intractable hiccups in uremia. Am J Med. Apr 1994;96(4):391. [Medline].

  31. Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol. Dec 1985;7(6):539-52. [Medline].

  32. Malhotra S, Schwartz MJ. Atrioventricular asystole as a manifestation of hiccups. J Electrocardiol. Jan 1995;28(1):59-61. [Medline].

  33. Marshall JB, Landreneau RJ, Beyer KL. Hiccups: esophageal manometric features and relationship to gastroesophageal reflux. Am J Gastroenterol. Sep 1990;85(9):1172-5. [Medline].

  34. Marsot-Dupuch K, Bousson V, Cabane J, Tubiana JM. Intractable hiccups: the role of cerebral MR in cases without systemic cause. AJNR Am J Neuroradiol. Nov-Dec 1995;16(10):2093-100. [Medline].

  35. Payne BR, Tiel RL, Payne MS, Fisch B. Vagus nerve stimulation for chronic intractable hiccups. Case report. J Neurosurg. May 2005;102(5):935-7. [Medline].

  36. Rousseau P. Hiccups. South Med J. Feb 1995;88(2):175-81. [Medline].

  37. Tegeder I, Meier S, Burian M, Schmidt H, Geisslinger G, Lotsch J. Peripheral opioid analgesia in experimental human pain models. Brain. May 2003;126:1092-102. [Medline].

 
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