Background
The term "hiccup" derives from the sound of the event. "Hiccough" erroneously implies an association with respiratory reflexes. The medical term, singultus, is thought to have originated from the Latin, singult, which translates roughly as "the act of catching one's breath while sobbing."
Brief episodes of hiccups, which often induce annoyance in patients and merriment in observers, are a common part of life. Prolonged attacks are a more serious phenomenon and often a diagnostic dilemma. These attacks have been associated with significant morbidity and even death.
A hiccup bout is any episode lasting more than a few minutes. If hiccups last longer than 48 hours, they are considered persistent or protracted. Hiccups lasting longer than one month are termed intractable. The longest recorded attack is 6 decades.
Pathophysiology
Hiccups appear to serve no purpose in humans or other mammals. Often, only one hemidiaphragm is affected. The left hemidiaphragm is affected in 80% of cases, although bilateral involvement may occur.
Hiccups occur 4-60 times per minute until a certain number has been delivered. Typically, this is fewer than 4 or more than 30. The frequency is relatively constant for a given individual and varies inversely with arterial PCO2. Loudness and rapidity of hiccups are unrelated. Hiccups are more common in the evening and may continue for a few waking hours. Hiccups occur most frequently during the first half of the menstrual cycle, especially in the few days before menstruation, and decrease markedly during pregnancy.
The exact cause remains a mystery despite centuries of contemplation. Hippocrates and Celsus associated hiccups with liver inflammation and other conditions. Galen believed hiccups were due to violent emotions arousing the stomach.
In 1833, Shortt first recognized an association between hiccups and phrenic nerve irritation.
The hiccup reflex, originally proposed by Bailey in 1943, consists of the following:
- Afferent limb - Phrenic and vagus nerves and sympathetic chain arising from T6-12
- Hiccup center - Nonspecific location between C3 and C5
- Connections to the respiratory center, phrenic nerve nuclei, medullary reticular formation, and hypothalamus
- Efferents
- Phrenic nerve (C3-5)
- Anterior scalene muscles (C5-7)
- External intercostals (T1-11)
- Glottis (recurrent laryngeal component of vagus)
- Inhibitory autonomic processes
- Decreasing esophageal contraction tone
- Lower esophageal sphincter tone
Epidemiology
Sex
Overall incidence of hiccups is equal between males and females; however, protracted and intractable hiccups occur more frequently in men (82% of cases).
Age
Hiccups occur at any age and in utero. Preterm infants spend up to 2.5% of their time hiccupping. Although hiccups occur less frequently with advancing age, intractable hiccups are more common in adult life. Females develop hiccups more frequently during early adulthood than males of the same age.
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