Hiccups (singultus): review and approach to management

Use of paced respiration to alleviate intractable hiccups (Singultus): a case report

Heart rate variability (HRV) biofeedback is an emerging treatment for many health conditions involving dysregulation of the autonomic nervous system including hypertension, gastric pain, anxiety, and depression. Hiccups are frequently considered an annoyance. However, when intractable (lasting over 1 month), they can become debilitating, with some patients resorting to invasive treatments that often involve the phrenic nerve. Theoretically, HRV biofeedback should also provide a means to stimulate the phrenic nerve and could be an alternative option. We report the successful treatment of a 5 year-long case of intractable hiccups with one session of HRV biofeedback training. These results suggest that biofeedback may be a useful, non-invasive means of relieving intractable hiccups. No clear causality can be inferred from a single case, and further study is needed to determine if this finding has wider applicability.

Renal abscess in a patient presenting with persistent hiccups

Hiccups are common, typically limited, and rarely present with adverse complications. In the context of persistent or intractable episodes, however, hiccups may signal a more serious underlying cause. Here, we present an unexpected and pathologic case of hiccups in a patient who was ultimately diagnosed with renal abscesses.

Gabapentin in the treatment of persistent hiccups in advanced malignancy

Hiccups are a distressing symptom in advanced malignancies in the setting of palliative care. A case of persistent hiccups treated with oral Gabapentin is presented to highlight the clinical and ethical dilemmas in patients with advanced malignancy. A 70-year-old male with non-small cell cancer of the lung with widespread metastases presented with persistent hiccups. The patient and family sought only symptom relief from home, without hospitalization or further investigations. The hiccups were dramatically relieved by oral Gabapentin, highlighting the recent reports that mention this molecule as being useful for hiccups. Gabapentin is a simple tool that may be utilized by palliative care physicians to relieve hiccups in advanced malignancies.

Persistent hiccups after interventional pain procedures: a case series and review

Interventional spine procedures are nonsurgical interventions that are commonly used to treat acute and chronic pain. These procedures generally are considered to be safe, but patients may experience transient and minor complications. Hiccups previously have been reported in the pain management setting as a complication after lumbar and thoracic epidural steroid injections and an intrathecal morphine pump infusion. In this case series of 8 patients, we describe hiccups after various interventional procedures, including cervical and lumbar epidural steroid injections, facet joint injections, and sacroiliac joint injections. A comprehensive literature review of hiccups associated with interventional pain procedures is provided, along with the known pathophysiology, etiologies, and treatment options for hiccups. The objective of this case series presentation and literature review is to highlight the importance of recognizing hiccups as a potentially under-reported adverse reaction in the setting of various interventional spine procedures.

Hiccups as a presenting symptom of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic esophageal disease increasingly recognized in adults for its gastrointestinal manifestations. This paper discusses a young woman with EoE who presented with persistent hiccups and intermittent dyspepsia. The patient was initially treated with trials of both H(2) blocker and proton pump inhibitor. However, her hiccups resolved only after treatment with topical fluticasone. A repeat upper endoscopy while on steroid treatment demonstrated both histologic remission of EoE and resolution of esophageal trachealization. Our patient's clinical course supports an association between hiccups and EoE, suggesting that EoE be considered in the differential diagnosis of patients with refractory hiccups.

Low-dose Gabapentin for Intractable Hiccups in a Heart Transplant Recipient

Intractable hiccups can be a serious complication in transplant recipients. Unfortunately, many of the pharmacotherapies used to stop hiccups are associated with severe side effects as well as drug-drug interactions with immunosuppressants. We report a case of a heart transplant recipient who had had intractable hiccups for 2 months, resulting in severe insomnia, diminished appetite, and weight loss. To treat the hiccups, treatment with oral baclofen (5–10 mg 3 times daily) was started. After 6 weeks of therapy, the baclofen was titrated down and discontinued because it had not stopped the hiccups and was causing severe central nervous system side effects. Gabapentin (100 mg twice daily) was then prescribed and within 24 hours of the start of that treatment, the hiccups had resolved completely. After 3 weeks of therapy, the patient had no side effects and the gabapentin was subsequently discontinued. One year after stopping the gabapentin, the patient remains free of hiccups. Gabapentin appears to be a promising medication for the treatment of intractable hiccups in thoracic transplant recipients because of its lack of serious side effects at low doses, rapid onset of action, and lack of drug-drug interactions with transplant medications.

Comparison of the pharmacokinetics of a new 15-mg modified-release tablet formulation of metoclopramide versus a 10-mg immediate-release tablet: a single- and multiple-dose, randomized, open-label, parallel-group study in healthy Mexican male volunteers

BACKGROUND

Metoclopramide is a prokinetic and antiemetic agent.

OBJECTIVE

The goal of this study was to assess the pharmacokinetics of a new, modified-release metoclopramide tablet and compare it with an immediate-release tablet to obtain marketing approval from the Mexican regulatory agency.

METHODS

This was a single-center, randomized, open-label, parallel-group, single- and multiple-dose, pharmacokinetic study. Investigational products were administered to healthy Mexican male volunteers for 3 consecutive days: one 15-mg modified-release tablet every 12 hours or one 10-mg immediate-release tablet every 8 hours. Multiple blood samples were collected after the first and last doses of metoclopramide over a 24-hour period. Plasma metoclopramide concentrations were determined by using a validated HPLC method. Safety and tolerability were assessed by measurement of vital signs, clinical evaluations, and spontaneous reports from study subjects.

RESULTS

All 26 subjects were included in the analyses (mean [SD] age: 25 [6] years [range, 18-40 years]; body mass index, 23.44 [2.31] kg/m(2) [range, 18.26-27.49 kg/m2]). Peak plasma concentrations were lower (C(max), 33.13 [7.25] vs 46.04 [17.27] ng/mL after the first dose [P < 0.05]; C(max,ss), 48.60 [8.52] vs 75.23 [21.27] ng/mL after the last dose [P < 0.05]) and occurred later (P < 0.05) with the modified-release formulation. In terms of average plasma concentrations (C(avgτ), 20.98 [3.94] vs 23.38 [7.35] ng/mL after the first dose; C(avg,ss), 22.20 [5.64] vs 23.02 [7.77] ng/mL after the last dose), differences did not reach the level of statistical significance (P > 0.05). Four adverse events were reported in the test group (abdominal distention [n = 2], epigastric pain [n = 1], and somnolence [n = 1]), and 3 were reported in the reference group (epigastric pain [n = 1], diarrhea [n = 1], and hiccups [n = 1]).

CONCLUSIONS

This study in a sample of selected healthy Mexican male volunteers suggests that the metoclopramide15-mg modified-release tablets have features compatible with the slow-release formulation (lower C(max) and longer T(max)) compared with immediate-release tablets.

Using suboccipital release to control singultus: a unique, safe, and effective treatment

Hiccups, or singultus, are the result of spontaneous and repetitive contractions of the diaphragm. In most cases, episodes of singultus are benign and self-limited. However, prolonged attacks can result in significant discomfort, morbidity, and even death. Although the etiology of hiccups is theoretical at best, a wide array of treatments has been proposed with varying efficacy. Both pharmacologic and nonpharmacologic treatments target different components of the hiccup reflex, which includes the vagus and phrenic nerves, the respiratory center in the upper medulla, and the motor neurons in the diaphragm, glottis, and external intercostal muscles. In this case report, we describe the successful cessation of hiccups in a 9-year-old boy with a treatment called suboccipital release. With this approach, gentle traction and pressure is applied to the posterior neck, stretching the suboccipital muscles and fascia. The manual decompression of the vagus, and possibly phrenic, nerves interrupts the hiccup reflex and allows for normal autonomic function to be reestablished. We propose that the suboccipital release, noninvasive, simple, and with virtually no side effects, is an ideal initial treatment of singultus.

Hiccups as the only symptom of non-ST-segment elevation myocardial infarction

Hiccups, which are usually benign and self-limited, occasionally serve as markers of a serious underlying pathology. We present this case report to inform emergency physicians about the potential for hiccups to serve as the only presenting symptom of a myocardial infarction. The patient, a 68-year-old man with a history of diabetes mellitus, hypertension, and current tobacco use, was first seen in the emergency department after 4 days of intractable hiccups with no other complaints or symptoms. After ineffective hiccup treatment on the first visit with 2 mg Ativan and 25 intramuscular (i.m.) thorazine and a normal chest x-ray, he was discharged. Two days later, the patient returned to the emergency department with the same complaint of hiccups without any additional complaints or symptoms. An electrocardiogram displayed several abnormalities including Q waves in II, III, and aVF and T-wave inversions in aVL and V6. Troponin I was highly elevated at 4.302 ng/mL. In the catheterization laboratory, the patient exhibited severe stenosis of the left circumflex artery and obtuse marginal 1. Stents were placed in these sites, and the patient recovered uneventfully. This is the first case in which hiccups were the single presenting symptom of a myocardial infarction in the last 50 years. Although extremely common and usually benign, hiccups can occasionally be a sole symptom of serious underlying pathology, which in this case, was a non–ST-segment elevation myocardial infarction.

Hiccups as a sign of chronic myocardial ischemia

Chronic myocardial ischemia often presents with a fairly typical history, but patients can present with atypical chest pain or pain referred to a less-typical location like the jaw, stomach, or back. Sometimes patients describe symptoms usually not attributed to heart disease, like indigestion or feeling cold and clammy, in the presence or absence of chest pain. One important clue to underlying coronary artery disease is the appearance of symptoms that are induced by effort and relieved by rest. This paper describes two unusual presentations of myocardial ischemia in patients whose main symptom was hiccups, the first intractable hiccups over months and the second effort-induced hiccups. Both also described atypical chest pain.

The "cotton bud technique" as a cure for hiccups

Persistent hiccups cause psychological and physical distress and can lead to pathology such as carotid artery dissection. Therapy of hiccups is based on small case series, often using pharmacological agents. We present a method that avoids medications or invasive interventions.

Microvascular decompression for intractable singultus: technical case report

OBJECTIVE

Intractable singultus is a rare but significantly disruptive clinical phenomenon that often accompanies other diseases but can present in isolation due entirely to intracranial pathology. We report a case of intractable singultus that improved after microvascular decompression and present a comprehensive review of singultus by discussing its similarity to other cases of microvascular decompression, its history and etiology, and its evolutionary basis.

CLINICAL PRESENTATION

The patient exhibited intractable singultus for 15 years, resistant to multiple medical regimens.

INTERVENTION

Microvascular decompression to relieve pressure on the tenth cranial nerve and medulla oblongata resulted in near total resolution of the singultus.

CONCLUSION

Neurovascular compression should be considered a potentially reversible cause of intractable singultus, a significantly disabling clinical phenomenon.

Gabapentin for Intractable Hiccups in Palliative Care

Intractable hiccups are not common in the general population or in the palliative care population but can adversely impact quality of life and cause other complications such as weight loss and sleep disturbance. Many treatments have been proposed for intractable hiccups, but there is little consensus regarding treatment in the medical literature. This is partly because hiccups are relatively uncommon and many of the proposed treatments are unproven or have long-term side effects. Pharmacologic treatments rather than home remedies or surgical treatments are more appropriate for the palliative care patient. Gabapentin is a promising medication for the treatment of intractable hiccups for its safety, lack of serious side effects, and rapid onset of action. Further research is indicated to determine whether gabapentin is consistently effective.

Management of Symptoms Other than Pain

Symptom management requires an understanding of the likely cause of the symptom in the individual patient, comprehensive assessment, and evidence-based interventions. This article explores the management strategies for common symptoms encountered in palliative care practice. Stomatitis, xerostomia, dysphagia, nausea and vomiting, anorexia, constipation, dyspnea, and fatigue are among the symptoms reviewed.

Recurrent persistent hiccups after epidural steroid injection and analgesia with bupivacaine

This case report presents a patient who developed persistent hiccups after epidural administration of dilute bupivacaine on several different occasions. Substitution of saline for the dilute bupivacaine during epidural steroid injection did not result in hiccups; however, subsequent postoperative epidural analgesia with bupivacaine caused a recurrence of the hiccups.

Vagus nerve stimulation for chronic intractable hiccups

✓ Intractable hiccups are debilitating and usually a result of some underlying disease. Initial management includes vagal maneuvers and pharmacotherapy. When hiccups persist despite medical therapy, surgical intervention rarely is pursued. Cases described in the literature cite successful phrenic nerve blockade, crush injury, or percutaneous phrenic nerve pacing. The authors report on a case of intractable hiccups occurring after a posterior fossa stroke. Complete resolution of the spasms has been achieved to date following the placement of a vagus nerve stimulator.

Intractable hiccups as a presenting symptom of cerebellar hemangioblastoma. Case report

The authors report on a 52-year-old woman with a cerebellar hemangioblastoma who presented with a 2-year history of intractable hiccups. Computerized tomography scans and magnetic resonance images revealed a cerebellar hemangioblastoma with compression of the brainstem at the level of the medulla oblongata. The patient has been free of hiccups and has been neurologically intact since the day after total removal of the tumor. A review of the literature on medullary lesions presenting with intractable hiccups is provided.

Atropine for the treatment of hiccup after laryngeal mask insertion

IMPLICATIONS

We describe three patients in whom hiccups were treated successfully by atropine. Although further clinical investigation is needed, atropine may be useful in the treatment of hiccups after the laryngeal mask airway insertion.

Persistent hiccup associated with thoracic epidural injection

Epidural steroid injections are commonly used to treat lumbosacral radicular and discogenic pain. When used in this manner, these agents can cause minor, transient systemic side effects and rarely result in any serious complications. Because adverse reactions are uncommon and transient, epidural injections are considered a safe therapeutic intervention. We describe the first case of persistent hiccups as a consequence of a thoracic epidural steroid injection in a patient with thoracic discogenic pain.

Gabapentin "add-on therapy" for idiopathic chronic hiccup (ICH)

The efficacy of cisapride, omeprazole, and baclofen (COB) for treatment of idiopathic chronic hiccup (ICH). was proven in several studies. The combination is considered, at present, to be "therapy of choice" for this condition. Substituting gabapentin for baclofen in baclofen resistant ICH cases can occasionally be successful. We present here cases where gabapentin was used successfully in combination with cisapride and omeprazole (COG/one patient) or as an "add-on" with cisapride, omeprazole, and baclofen (COBG/three patients). We conclude that, with baclofen and gabapentin, we are in possession of two substances that are, as a part of a combination therapy, quite effective for ICH. Because of the far more extensive experience with baclofen, we use it as a first-line therapy, together with omeprazole and cisapride. In cases where the results are not entirely satisfactory, the addition of gabapentin should be considered.

Intractable hiccups during stroke rehabilitation

OBJECTIVE

To study the frequency of intractable hiccups during stroke rehabilitation and the impact on rehabilitation management.

DESIGN

Case series, retrospective chart review.

SETTING

Inpatient stroke rehabilitation floor within a tertiary care teaching hospital.

PATIENTS

Three patients admitted for stroke rehabilitation with hiccups of at least 48 hours out of 270 consecutive cases.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Response to pharmacologic treatment.

RESULTS

All three subjects had pontine infarcts and required gastrostomy tube feedings and lengthy rehabilitation stays. Subjects suffered from significant complications including aspiration pneumonia, respiratory arrest, and nutritional depletion. Chlorpromazine treatment was terminated in all three subjects because of sedation that interfered with therapies. Treatment with carbamazepine was successful in only one patient; in the other two subjects, their hiccups were controlled with haloperidol or baclofen. All subjects were ultimately managed with a single agent.

CONCLUSIONS

Pharmacologic interventions for intractable hiccups must be tailored to the unique circumstances of the stroke rehabilitation patient. Intractable hiccups can be associated with potentially fatal consequences, and safe management may require an inpatient rehabilitation setting and multidisciplinary team approach to optimize the feeding management of this challenging population.

Hiccups with high dose dexamethasone administration: a case report

BACKGROUND

A 59-year-old male developed intractable hiccups during monthly therapy with high dose dexamethasone for multiple myeloma. Hiccups would begin hours after his first dose and continue over the 4 days of therapy. He sought assistance after his attempt at home remedies failed and the hiccups became exhausting.

METHODS

The strong temporal relation between dexamethasone administration and the occurrence of hiccups indicated that dexamethasone was the cause of the patient's hiccups. Because he was responding to dexamethasone, the decision was made to continue therapy and to relieve his hiccups with metoclopramide.

RESULTS

Low dose oral metoclopramide allowed the patient to continue therapy without a recurrence of the hiccups.

CONCLUSIONS

Dexamethasone administration can result in intractable hiccups that persist for the duration of therapy. Low dose oral metoclopramide may prevent hiccups in patients in whom the discontinuation of dexamethasone therapy is not appropriate.

Stimulus and site specific induction of hiccups in the oesophagus of normal subjects

BACKGROUND

Hiccups that are induced by a large meal have been suggested to result from gastric overdistension. The role of the oesophagus in precipitating hiccups has never been defined.

AIMS

To determine the involvement of oesophageal mechanoreceptors in the hiccup reflex.

METHODS

Ten normal healthy subjects were prospectively evaluated at a university affiliated hospital. Controlled inflation of a polyethylene bag in the proximal and distal oesophagus was carried out using slow ramp and rapid phasic distensions, by an electronic distension device.

RESULTS

Hiccups were induced in four subjects only during rapid phasic distensions and only in the proximal oesophagus. The mean (SEM) minimal volume threshold for the hiccup reflex was 32.5 (4.8) ml, which was above the perception threshold. Hiccups appeared during inflation and resolved after deflation.

CONCLUSIONS

Sudden rapid stretch of the mechanoreceptors in the proximal oesophagus can trigger the hiccup reflex in normal subjects. Only rapid distensions above a determined volume threshold will predictably induce hiccups in a given subject. This mechanism may play a role in the physiological induction of hiccups.

Idiopathic chronic hiccup: combination therapy with cisapride, omeprazole, and baclofen

Idiopathic chronic hiccup (ICH) is defined as recurring hiccup attacks that last for longer than an arbitrary time limit (eg, 1 month) and for which no organic cause can be found. In patients with ICH, therapy is largely empiric. For practical purposes, idiopathic hiccup can be assumed to have its origin either in the viscera (gastrointestinal tract) or in the central nervous system. Cisapride and omeprazole--through reduction of gastric acid production and facilitation of gastric emptying, respectively--are thought to reduce an assumed afferent input from the periphery to a putative supraspinal hiccup center. Baclofen is thought to reduce excitability and depress reflex hiccup activity. Fifteen male patients (mean [+/- SD] age, 68.2 +/- 11.6 years) who had recurring hiccup attacks for a mean duration of 100.8 +/- 134.1 months (range, 12 to 564 months) were treated for ICH with a combination of cisapride, omeprazole, and baclofen (COB). Therapy led to a total disappearance of hiccup in 40% (6 of 15) of the treated patients. An additional 20% (3 of 15) of patients experienced substantial relief. A Mann-Whitney rank order test showed a highly significant reduction in the severity of the hiccup attacks as reflected in the subjective assessment scale scores taken before therapy (8.6 +/- 1.3) compared with those taken after 20 weeks of therapy (4.1 +/- 3.8). Thus we concluded that COB is an effective empiric therapy in at least some patients with ICH.

Drug-induced hiccups

Pharmacotherapeutic agents are uncommonly associated with hiccups. Corticosteroids and benzodiazepines have been the drug classes mentioned most frequently in the literature as being associated with the development of hiccups. However, by using a strict criterion, there is currently insufficient evidence for any drug to be considered causative in the etiology of hiccups.

Hiccups associated with lateral medullary syndrome. A case report

We present a case of persistent hiccups (singultus) after a lateral medullary cerebrovascular accident. The patient presented with a two-day history of nausea and vomiting. Clinically, the patient had a loss of pain and temperature on the left side of the face, a loss of pain and temperature on the right side of the trunk, a mild left hemiparesis, and a left-sided ataxia. Nystagmus, diplopia, and hiccups were also evident. A left lateral medullary syndrome in the vascular distribution of the posterior inferior cerebellar artery was diagnosed. Work-up included a magnetic resonance imaging angiogram, which revealed an occlusion v high-grade stenosis of the basilar artery. The patient reported that the most distressing symptom was the chronic hiccups (25/min), which interfered with nutrition, sleep, and activity. While in the acute care hospital, the patient was treated with prochlorperazine, promethazine, and chlorpromazine. Each of these medications was unsuccessful in stopping the hiccups. After a search of the European literature revealed that baclofen was recommended as the drug of choice for stopping persistent hiccups, the patient was given 5 mg of baclofen by mouth three times per day, and the hiccups abated within 48 hours. The baclofen was discontinued after one week of therapy, and the hiccups did not return. We recommend consideration of baclofen for the treatment of persistent hiccups after lateral medullary syndrome because of its desirable side effects and reported success rate compared with other drugs used to treat chronic hiccups.