6.01 Singultus (Hiccups)

agk’s Library of Common Simple Emergencies

Presentation

Recurring, unpredictable, clonic contractions of the diaphragm produce sharp inhalations. Hiccups are usually precipitated by some combination of laughing, talking, eating, and drinking, but may also occur spontaneously. Most cases also resolve spontaneously, and do not come to the emergency department unless prolonged or severe.

What to do:

• Stimulate the patient’s soft palate by rubbing it with a swab, catheter tip or finger, just short of stimulating a gag reflex, and continue this for a few minutes. Alternatively, you may stimulate the same general area by depositing a tablespoon of granulated sugar at the base of the tongue, in the area of the lingual tonsils, and letting it dissolve. Such maneuvers (or their placebo effect) may abolish simple cases of hiccups.
• If hiccups continue, look for an underlying cause, and ask about precipitating factors or previous episods. Persistence of hiccups during sleep suggests an organic cause, but conversely if a patient is unable to sleep or if the hiccups stop during sleep and recur promptly on awakening, this suggests a psychogenic or idiopathic etiology.
• Look in the ears (foreign bodies against the tympanic membrane can cause hiccups). Examine the neck, chest and abdomen, perhaps including upright chest x rays, to look for neoplastic or infectious processes irritating the phrenic nerve or diaphragm. Pericarditis and aberrant cardiac pacemaker electrode placement are potential sources of persistent hiccups, as well as acute and chronic alcohol intoxication and gastroesophageal reflux. Perform a neurological exam, looking for evidence of partial continuous seizures or brainstem lesions. Early multiple sclerosis is thought to be one of the most frequent neurologic causes of intractable hiccups in young adults.
• Routine laboratory evaluation may include a CBC with differential (looking for infection or neoplasm) and electrolytes (hyponatremia can cause persistent hiccups).
• If hiccups persist, try chlorpromazine (Thorazine) 25-50mg po tid or qid. (The same dose may be given im.) Alternatively, im haloperidol (Haldol) 2-5mg followed by po 1-4mg tid for two days may be equally effective with less potential for side effects. Another approach is to use metaclopromide (Reglan) 10mg iv or im followed by a maintenance regimen of 10 to 20mg qid for 10 days.
• Arrange for followup and additional evaluation. Although unlikely, there are potentially serious complications such as dehydration and weight loss resulting from the inability to tolerate fluids and food.

Discussion

Hiccups are a common malady and fortunately usually transient and benign. The common denominator among various hiccup cures seems to be stimulation of the glossopharyngeal nerve, but, as for every self limiting disease, there are always many effective cures.

“…hold your breath, and if after you have done so for some time the hiccup is no better, then gargle with a little water, and if it still continues, tickle your nose with something and sneeze, and if you sneeze once or twice, even the most violent hiccup is sure to go.”
– Eriximachus the physician to Aristophanes, in Plato’s Symposium

References:

• Launois S, Bizec JL, Whitelaw WA et al: Hiccup in adults: an overview. Eur Resp J 1993;6:563-575.
• Kolodzik PW, Eilers MA: Hiccups (singultus): review and approach to management. Ann Emerg Med 1991;20:565-573.
• Nathan MD, Leshner RT, Keller AP: Intractable hiccups (singultus). Laryngoscope 1980;90:1612-1618.
• Wagner MS, Stapczynski JS: Persistent hiccups. Ann Emerg Med 1982;11:24-26.

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