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Internal Medicine

Hiccup

Sudden onset of erratic diaphragmatic and intercostal muscle contraction, immediately followed by laryngeal closure.

Introduction

Sudden onset of erratic diaphragmatic and intercostal muscle contraction, immediately followed by laryngeal closure.

  • Self-limited disorder
  • Prolonged hiccup: Episodes ≥ 48 hours
  • Intractable hiccup: Episodes > 2 months

Aetiology

Induced by the rapid stomach distension and irritation in terms of overeating, eating too fast, ingesting spicy food, drinking carbonated drinks, aerophagia and sudden change in ingested food temperature.

hiccup etiology
Aetiology of persistent & intractable hiccup | Lu, F.-Y. C. and C.-L. (2012). Hiccup: Mystery, Nature and Treatment. J Neurogastroenterol Motil, 18(2), 123–130. Retrieved from http://www.jnmjournal.org/journalDOIx.php?id=10.5056/jnm.2012.18.2.123

Pathophysiology

Putative hiccup reflex arc:

jnm-18-123-g001
Putative hiccup reflex arc: It includes afferent limb to receive stimulation either located in the central nervous system or from peripheral lesions, central brain processing and efferent limb to convey responded signals to the diaphragm and respiratory muscles. Adapted from Takahashi et al. | Lu, F.-Y. C. and C.-L. (2012). Hiccup: Mystery, Nature and Treatment. J Neurogastroenterol Motil, 18(2), 123–130. Retrieved from http://www.jnmjournal.org/journalDOIx.php?id=10.5056/jnm.2012.18.2.123

Clinical features

Severe and prolonged hiccup:

  • Exhaustion
  • Fatigue
  • Malnutrition
  • Weight loss
  • Dehydration
  • Death (extreme situations)

Management

Pharmacotherapy (for persistent/intractable hiccup):

Effective hiccup treatment is exactly established upon a correct diagnosis of lesion responsible for the serious event.
  • Chlorpromazine (CPZ) (antipsychotic)
  • Gabapentin (α-2-δ ligand with structural similarity to GABA): Ability to block voltage-operated calcium channels to reduce release of several
    neurotransmitters including glutamate and substance P and finally
    to modulate the diaphragmatic activity
    • Side effect: Sleepiness
  • Baclofen (GABA derivative): For hiccups due to CNS tumors and chronic renal failure
  • Carvedilol (non-cardio selective β-blocker, calcium channel blocker and antioxident)
  • Tandospirone (5-HT agnoist): Stroke related hiccup because of direct inhibition of phrenic nerve activity via centrally located receptors
  • Olanzapine (serotonergic antagonist with action on post-synaptic receptors, was also used to diminish the phrenic motor neuron activity to treat hiccup of a brain injury case)
  • Midazolam (benzodiazepine): Acts on benzodiazepine receptors to form the benzodiazepine-GABA receptor-chloride ionophore complex in gating chloride channels which leads to hyperpolarization to inhibit neuron firing and to decrease neuronal
    depolarization.
  • Amantadine
  • Lidocaine: Stabilize cell membrane by blocking sodium channels to reduc eneuronal excitability
  • Other miscellaneous agents:
    • Calcium channel blockers
    • Antidepressants

Non-pharmacological management:

  • Phrenic nerve blockades
  • Acupuncture

Common (folk) management:

  • Gag reflex (M/C): Restoration of normal phrenic nervous rhythms due to artificial and transient stoppage of respiration
  • Supramaximal inspiration: Measure consisted of hypercapnia, diaphragm immobilization and positive airway pressure could terminate intractable hiccups in pregnancy via holding diaphragm for more than 20 seconds
  • Modified Heimlich manoeuvre: With 3 thrusts delivered at 10 second interval stabilizing diaphragmatic spasm
  • Intranasal vinegar instillation
    • Stimulate dorsal pharynx at the supplied area of afferent branches of hiccup reflex arc
  • Other measures:
    • Breathing into a bag, breath holding, swallowing granulated sugar, drinking/gargling iced water, forceful traction of tongue, biting lemon, eating peanut butter, eyeball compression, carotid/rectal massage, valsava maneuver, fright and gastric lavage

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