Hiccups (Singultus)

If hiccups have lasted more than 48 hours, a full assessment should be performed to assess whether there is an underlying cause. This may require referral to secondary care.

About

• Hiccups involve an involuntary (reflex) diaphragmatic contraction, causing sudden inspiration.
• The incoming air is stopped by closure of the glottis which produces the characteristic sound.
• Hiccups do not appear to perform any useful or protective function.

General

• Hiccups are usually transient, lasting less than 48 hours.
• Persistent or protracted hiccups are rare and last more than 48 hours.
• Persistent hiccups may cause complications (for example, fatigue and weight loss).

Causes: Most are benign

• Metabolic
  • Uraemia
  • Lactate acidosis
  • Hyponatraemia
  • Diabetes mellitus,
  • Hypocalcaemia
  • Addison's disease.
• Diaphragmatic irritation
  • Sub phrenic abscess
  • Liver pathology
  • Pleural or pericardial effusion
  • Lateral myocardial infarction
• Gastrointestinal disease
  • Gastro-oesophageal reflux
  • Achalasia,
  • Gastric distension
  • Oesophageal or small bowel obstruction
  • Pancreatic or biliary disease.
• CNS
  • Structural lesions of the medulla in the region of the vagal nuclei and the nucleus tractus solitarius
  • Lateral Medulla PICA Infarction
  • Brainstem haemorrhage
  • Saccular aneurysms or ectasia of the PICA
  • Brainstem tumour or abscess
  • Arnold Chiari malformation and syrinx
  • Haematoma and demyelination
  • Viral encephalitis or meningitis
  • Encephalitis lethargica and syphilis.
  • HIV encephalopathy,
  • Toxoplasma infection
  • Progressive multifocal leukoencephalopathy

Investigations that may be considered in primary care include

• FBC: raised WCC inflammation or infection, low Hb in malignancy or GI haemorrhage).
• Urea and electrolytes (to exclude uraemia, low Na, Low K, Low Ca
• ESR or CRP level(may suggest presence of an underlying disease).
• Liver function tests (abnormal results may indicate hepatitis, liver metastases).
• Electrocardiogram (to exclude pericarditis, recent myocardial infarction).
• Chest radiograph (to exclude lung pathology).
• CT head to exclude intracerebral lesion. Rarely can be caused by lateral medullary syndrome and if possible needs MRI

General

• In general short episodes of hiccups involves offering advice on avoiding trigger factors, and suggesting the following self-help remedies:
• Stimulation of the nasopharynx: sipping iced water, swallowing granulated sugar, tasting vinegar, biting on a lemon.
• Interruption of normal respiratory function: Valsalva manoeuvre, breath holding, hyperventilating, breathing into a paper bag, sneezing.
• Counter-irritation of the diaphragm: pulling the knees up to the chest.
• Offering advice on trying hypnotherapy, acupuncture, or psychotherapy.
• Utilizing techniques to interrupt of the hiccup reflex arc (some of which require specialist referral).
• Trial of medications some of which may be given IV initially:
  • Consider Nebulised 0.9% saline (2mls over 5 minutes).
  • Peppermint water facilitates belching by relaxing the LOS.
  • Chlorpromazine 25-50 mg PO TDS or IV initially
  • Baclofen 5-20 mg TDS PO
  • Nifedipine 10-20 mg TDS PO
  • Haloperidol 1.5-3 mg at night orally or IV initially
  • Sodium Valproate, aim for 15 mg/kg/24h
  • Midazolam 10-60 mg/24h by CSCI if all else fails.
  • Gabapentin 300-400 TDS PO
• Consideration of referral for phrenic nerve disruption.
• Follow-up should be carried out at an interval determined by clinical judgement, and the person is advised to report any signs of complications such as cardiac arrhythmias, insomnia, weight loss, and oesophagitis.