Hiccups (singultus): review and approach to management

Hiccups: An Atypical Manifestation of Miliary Tuberculosis and Myocardial Ischemia

Hiccups are a benign, self-limiting condition caused by intermittent spasmodic contractions of the diaphragm. However, its persistence may be indicative of a more ominous underlying condition, and its manifestation is seen in myocardial ischemia/infarction and tuberculosis (TB). We present two unique cases where persistent hiccups lead to the diagnosis of miliary tuberculosis in one patient and myocardial infarction in the other. It stresses the importance that such a benign presentation may be a warning for a more sinister pathology and thus requires extensive work-up in high-risk and senior individuals.

Prolonged hiccups induced by renal infarction: a case report

BACKGROUND

Hiccups are common symptoms that last for less than 48 hours. However, we encountered a case of renal infarction in a patient with prolonged hiccup. The relationship between hiccups and renal infarction is important in differentiating patients with prolonged hiccups.

CASE PRESENTATION

An 87-year-old Japanese man with atrial fibrillation and receiving antithrombotic therapy presented to the emergency department with prolonged hiccups. The patient discontinued antithrombotic therapy for atrial fibrillation due to subcortical bleeding, after which he experienced right back pain. He was diagnosed with right renal infarction based on computed tomography images, and the antithrombotic therapy was continued. The patient's hiccups ceased, and he was discharged on hospital day 11.

CONCLUSION

Hiccups can be induced by various clinical conditions. It is hypothesized that the inflammation of the right kidney infarction stimulated the diaphragm and induced prolonged hiccups in this patient; this theory is supported by the computed tomography images. This case report shows that internal organ diseases irritating the diaphragm can cause hiccups, and renal disease should be considered in patients with prolonged hiccups.

An Unusual Hiccup: Severe Singultus as a Symptom in Ulcerative Colitis

Inflammatory bowel disease encompasses a group of chronic inflammatory conditions associated with both intestinal and extraintestinal manifestations. We present a 26-year-old man with a history of ulcerative colitis who presented with a disease exacerbation associated with severe intractable hiccups. We report a unique clinical symptom associated with severe ulcerative colitis and the diagnostic dilemma associated with this presentation. This case highlights the importance of recognizing unusual symptoms that can be associated with inflammatory bowel disease exacerbations and demonstrates the therapeutic potential of effective therapy of the underlying inflammatory disease.

Phrenic nerve block combined with stellate ganglion block for postoperative intractable hiccups: a case report

Postoperative intractable hiccups slow patient recovery and generate multiple adverse effects, highlighting the importance of investigating the pathogenesis and terminating the hiccups in a timely manner. At present, medical and physical therapies account for the main treatments. We encountered a case in which postoperative intractable hiccups after biliary T-tube drainage removal ceased with the application of an ultrasound-guided block of the unilateral phrenic nerve and stellate ganglion. No complications developed, and the therapeutic effect was remarkable. To our knowledge, this approach has not been reported to date. Simultaneously blocking the phrenic nerve and stellate ganglion may be a treatment option for intractable hiccups.

Forced inspiratory suction and swallow tool (FISST): an automation of Valsalva maneuver variants for therapeutic interventions

INTRODUCTION

The Valsalva maneuver and its modifications have been utilized across several conditions in medicine; however, there have been difficulties in its application. Thus, at the University of Texas Health Science Center in San Antonio, we designed and patented an affordable and accessible device that mimics Valsalva called "Forced Inspiratory Suction and Swallow Tool (FISST).

AREAS COVERED

In this review, we discuss the premise for the design of FISST, based on applications of the law of conservation energy, the continuity equation, and Bernoulli's principle. We then detail the mechanism by which FISST stimulates hiccup cessation by increasing negative inspiratory pressure when drinking through the apparatus, causing diaphragmatic contraction and disruption of the hiccup reflex. We then detail the efficacy and future applications of FISST in addressing other pathologies.

EXPERT OPINION

FISST has been used to address hiccups by utilizing its reverse-Valsalva effect to increase parasympathetic stimulation by increasing vagal tone. In a prospective study that we conducted on a cohort of 249 hiccup subjects worldwide, this tool achieved 92% effectiveness. Additionally, several cases, including a published case report, have found FISST successful in terminating supraventricular tachycardias (SVT). FISST may be further utilized in diagnosing or addressing various upper airway pathologies and should be explored further.

Risk Factors for Hiccups after Deep Brain Stimulation of Subthalamic Nucleus for Parkinson's Disease

Background: After deep brain stimulation (DBS), hiccups as a complication may lead to extreme fatigue, sleep deprivation, or affected prognosis. Currently, the causes and risk factors of postoperative hiccups are unclear. In this study, we investigated the risk factors for hiccups after DBS of the subthalamic nucleus (STN) for Parkinson’s disease (PD) under general anesthesia. Methods: We retrospectively included patients who underwent STN DBS in the study, and collected data of demographic characteristics, clinical evaluations, and medications. According to the occurrence of hiccups within seven days after operation, the patients were divided into a hiccups group and non-hiccups group. The potentially involved risk factors for postoperative hiccups were statistically analyzed by logistic regression analysis. Results: A total of 191 patients were included in the study, of which 34 (17.80%) had postoperative transient persistent hiccups. Binary univariate logistic regression analysis showed that male, higher body mass index (BMI), smoker, Hoehn and Yahr stage (off), preoperative use of amantadine, hypnotic, Hamilton anxiety scale and Hamilton depression scale scores, and postoperative limited noninfectious peri-electrode edema in deep white matter were suspected risk factors for postoperative hiccups (p < 0.1). In binary multivariate logistic regression analysis, male (compared to female, OR 14.00; 95% CI, 1.74−112.43), postoperative limited noninfectious peri-electrode edema in deep white matter (OR, 7.63; 95% CI, 1.37−42.37), preoperative use of amantadine (OR, 3.64; 95% CI, 1.08−12.28), and higher BMI (OR, 3.50; 95% CI, 1.46−8.36) were independent risk factors for postoperative hiccups. Conclusions: This study is the first report about the risk factors of hiccups after STN DBS under general anesthesia for PD patients. The study suggests that male, higher BMI, preoperative use of amantadine, and postoperative limited noninfectious peri-electrode edema in deep white matter are independent risk factors for postoperative hiccups of STN-DBS for PD patients. Most hiccups after STN-DBS for PD patients were transient and self-limiting.

Effectiveness and safety of metoclopramide in treatment of intractable hiccup: a protocol of systematic review and meta-analysis

INTRODUCTION

Hiccup is a common disease that not only occurred on adults but also on infants, which can severely do harm to patients' physical and psychological health. Metoclopramide has been reported to have effects on intractable hiccup. However, there is a limited evidence that describes the efficacy and safety of metoclopramide in the treatment of intractable hiccup. The aim of this article is to obtain evidence on the effectiveness and safety of metoclopramide in treating patients with intractable hiccup.

METHODS AND ANALYSIS

We will search the following databases, including PubMed, Cochrane Library, Embase, Web of Science, CBM, Wan-fang, VIP database, CNKI and MEDLINE from their inception to 11 November 2021. All the randomised controlled trials associated with metoclopramide in treating intractable hiccup will be included. Articles screened, selected and extracted will be performed by two researchers independently. The risk of bias will be assessed by using the Cochrane Collaboration. We will carry out the meta-analysis by using RevMan V.5.4 software.

PROSPERO REGISTRATION NUMBER

CRD42021293000.

Analysis of Factors Associated with Hiccups Using the FAERS Database

In this study, we used the large number of cases in the FDA adverse-event reporting system (FAERS) database to investigate risk factors for drug-induced hiccups and to explore the relationship between hiccups and gender. From 11,810,863 adverse drug reactions reported between the first quarter of 2004 and the first quarter of 2020, we extracted only those in which side effects occurred between the beginning and end of drug administration. Our sample included 1454 adverse reactions for hiccups, with 1159 involving males and 257 involving females (the gender in 38 reports was unknown). We performed univariate analyses of the presence or absence of hiccups for each drug and performed multivariate analysis by adding patient information. The multivariate analysis showed nicotine products to be key suspect drugs for both men and women. For males, the risk factors for hiccups included older age, lower body weight, nicotine, and 14 other drugs. For females, only nicotine and three other drugs were extracted as independent risk factors. Using FAERS, we were thus able to extract new suspect drugs for drug-induced hiccups. Furthermore, this is the first report of a gender-specific analysis of risk factors for hiccups that provides novel insights into drug-induced hiccups, and it suggests that the mechanism responsible is strongly related to gender. Thus, this study can contribute to elucidating the mechanism underlying this phenomenon.

Hiccups as a specific neurological manifestation in males with COVID-19

Several clinical manifestations of COVID-19 have been reported in the literature since then. In addition to upper respiratory symptoms, dysgeusia and anosmia are relatively common neurological manifestations with COVID-19. We had five cases of hiccups in succession; therefore, we assume that hiccups might be a specific symptom of COVID-19. We retrospectively analyzed 46 patients with COVID-19 diagnosed from February 2021 to May 2021. Among the 46 patients, 5 developed hiccups (11%). All patients were male. The median age of was 56 years. None of the patients were smokers. Further, all patients exhibited pneumonia without dysgeusia or anosmia. The median onset of hiccups was 5 days after diagnosis, with a median duration of 2 days. All patients recovered from hiccups and COVID-19. Hiccups might be a specific neurological symptom in male patients with COVID-19.

Persistent Hiccups as an Atypical Initial Presentation of COVID-19: A Case Report

INTRODUCTION

SARS-CoV-2 is a novel coronavirus that causes acute respiratory syndrome in humans. It is also known as COVID-19 and was first discovered in Wuhan, Hubei Province in China in December 2019 and soon became a global pandemic. The common symptoms of COVID-19 include fever, fatigue, and dry cough; however, there are some atypical symptoms that remain either unreported or underreported.

CASE SUMMARY

In this case report, we described a 48-year-old diabetic man who presented with the chief complaint of persistent hiccups (<48h) to the emergency room with no history of malignancy, GI, cardiovascular, or neurological diseases. The patient also mentioned intermittent cough and mild dyspnea initiated the morning of admission day. On physical examination, other than mild tachycardia and tachypnea, there were no notable findings. Following an abnormal chest X-Ray, a chest CT scan was carried out, and peripheral ground-glass opacities along with scattered round opacities were identified in both lungs' fields. Given the strong suspicion of COVID-19, an RT-PCR test was performed, and the symptomatic treatment was initiated. The patient was diagnosed with COVID-19 following the PCR result release. The treatment was initiated per the protocol, and the patient was transferred to the isolated room and discharged after four days following the relief of the symptoms.

CONCLUSION

It is critical for medical practitioners to seriously consider the possibility of COVID-19 in a patient with similar presentations and isolate the patient at the asymptomatic stages to eliminate the possibility of virus transmission.

Persistent hiccups - A rare complication of suprahepatic inferior vena cava stenting

Persistent hiccups has not been reported previously with suprahepatic inferior vena cava (IVC) stenting. Persistent hiccups after palliative oesophageal stenting has been reported. We present a case of a 41-year-old male patient diagnosed with primary Budd-Chiari syndrome who underwent IVC stenting for suprahepatic IVC stenosis. Patient developed transient hiccups post procedure which settled immediately with medications. Patient developed a recurrence of symptoms after a year due to stent migration which led to redo stenting. Post-procedure, the patient developed persistent hiccups which could not be controlled by physiological methods or chlorpromazine and needed baclofen at a dose of 10 mg three times a day. The patient has been symptom-free for the past 2 years. Persistent hiccups may present as a rare complication of suprahepatic IVC stenting due to extrinsic phrenic nerve compression or by direct irritation of the diaphragm. Baclofen has been effective in terminating persistent hiccups in our case.

Protracted Hiccups Induced by Aripiprazole and Regressed after Administration of Gabapentin

Hiccups are sudden, repeated, and involuntary contractions of the diaphragm muscle (myoclonic contraction). It involves a reflex arc that, once activated, causes a strong contraction of the diaphragm immediately followed by the closure of the glottis translating into the classic "hic" sound. Hiccups can be short, persistent, and intractable depending on the duration. The most disabling hiccups often represent the epiphenomenon of a medical condition such as gastrointestinal and cardiovascular disorders; central nervous system (CNS) abnormalities; ear, nose, and throat (ENT) conditions or pneumological problems; metabolic/endocrine disorders; infections; and psychogenic disorders. Some drugs, such as aripiprazole, a second-generation antipsychotic, can induce the onset of variable hiccups. We describe herein the cases of three hospitalized patients who developed insistent hiccups after taking aripiprazole and who positively responded to low doses of gabapentin. It is probable that aripiprazole, prescribed at a low dosage (<7.5 mg/day), would act as a dopamine agonist by stimulating D₂ and D₃ receptors at the "hiccup center" level-located in the brain stem-thus triggering the hiccup. On the other hand, gabapentin led to a complete regression of the hiccup probably by reducing the nerve impulse transmission and modulating the diaphragmatic activity. The present case series suggests the use of low doses of gabapentin as an effective treatment for aripiprazole-induced hiccups. However, our knowledge of the neurotransmitter functioning of the hiccup reflex arc is still limited, and further research is needed to characterize the neurotransmitters involved in hiccups for potential novel therapeutic targets.

Laryngeal Manifestations of Intractable Singultus

Hiccup is a common phenomenon experienced by almost everyone in life. Although the exact physiology of this phenomenon remains unknown, it is associated with multiple central and peripheral etiologic causes. Vocal fold granulomas are benign laryngeal lesions typically caused by iatrogenic trauma, voice misuse, or chronic irritation. We present, for the first time, an association between intractable hiccups and vocal fold granulomas with good response to acupuncture and voice therapy in a 62-year-old male patient. This is an important contribution to the literature as the first report describing the co-occurrence of these pathologies in the context of a patient with several treatment failures, including vagal nerve stimulator.

Hiccups and psychosis: two atypical presentations of COVID-19

The WHO defines a possible case of COVID-19 as a person experiencing fever, cough, shortness of breath, and neurological signs including anosmia, ageusia, or dysgeusia. However, experiences from hospitals all over the world have shown that presentations vary widely. Some atypical presentations include cardiac, gastrointestinal, neurological, and cutaneous and while some are driven by the inflammatory response, others are a consequence of the hypercoagulable state. In our emergency department in a private hospital in Mexico City, we received two patients with very different symptoms on the same shift. Two previously healthy men in their 40s presented to the ER with very atypical manifestations of COVID-19. Neither of them complained of fever, cough, or shortness of breath. The first referred a 3-day history of hiccups that had not resolved with metoclopramide. The second presented with an acute episode of altered mental status. While the first case revealed lung involvement of the disease, the second case had a clean chest CT scan. These cases are relevant as manifestations of COVID-19 vary widely, especially in previously healthy young adults.

Acupuncture for hiccups: A systematic review protocol of high-quality randomized trials

BACKGROUND

A Hiccup is a common disease that often occurs along with other chronic or acute conditions. At present, there is a lack of feasible therapies for hiccups, and acupuncture is a treatment method with enormous clinical practice worldwide.

METHODS

Based on a pre-defined search strategy, we searched seven databases and screened them by two independent investigators, without language and publication status restriction from inception to date. We use the pre-set form to incorporate data and utilize Revman software to synthesize data. We will evaluate the risk of bias in the inclusion of the study based on the Cochrane 'Risk of bias' assessment tool. The quality of the evidence will be evaluated according to the GRADEpro software.

RESULTS

This systematic review will evaluate the efficacy and safety of acupuncture treatment for hiccups. The entire process will be referred to the Cochrane handbook recommended by the Cochrane Collaboration.

CONCLUSION

This review will provide systematic evidence to summarize whether acupuncture is an effective intervention in the treatment of hiccup.

Acupuncture therapy for persistent and intractable hiccups: Protocol of a systematic review and meta-analysis

BACKGROUND

Persistent and intractable hiccups bring serious inconvenience to patients' work and daily life, and impair their quality of life. Relevant studies showed that acupuncture therapy might be effective in treating persistent and intractable hiccups. However, there is no consistent conclusion so far. The aim of our research is to investigate the safeties and effectiveness of acupuncture in treating patients with persistent and intractable hiccups.

METHODS

We will search randomized controlled trials (RCTs) using acupuncture therapy to treat persistent and intractable hiccups in the following 6 English electronic databases and 3 Chinese electronic databases: MEDLINE, EMBASE, the Cochrane Library, Web of Science, PsycINFO, Allied and Alternative Medicine (AMED), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP) and Wanfang data. The cure rate and the total effective rate will be considered as the primary outcomes. Complete cessation within a given period post-treatment of hiccups, changes in frequency or intensity of hiccups, concomitant symptom score, and adverse events will be considered as secondary outcomes. We will use Endnote software 9.1 for studies selection, Review Manager software 5.3, and STATA 13.0 software for analysis and synthesis.

RESULTS

we will synthesize current studies to evaluate the the safeties and effectiveness of acupuncture for persistent and intractable hiccups.

CONCLUSION

Our study will provide evidence of acupuncture therapy for persistent and intractable hiccups.

Intraoperative Laryngeal Mask Airway-Related Hiccup: An Overview

Hiccup is an involuntary contraction of the diaphragm and intercostal muscles resulting in sudden inspiration and closure of the glottis. The presence of hiccup in the perioperative period can be a challenging problem. Sudden movements of the patient from hiccups can interfere preoperative diagnostic procedures, intraoperative hiccup may delay the beginning of surgery, interfere with the surgical process, and affect intraoperative monitoring, and postoperative hiccup may affect would healing and hemodynamic stability. Hiccup can lead to have increased aspiration risk. Hiccup are is an incompletely understood phenomenon with multiple etiologies. Intraoperative hiccup related to laryngeal mask airway placement has been reported, and it presents unique challenges in diagnosis and management. Both pharmacological and non-pharmacological interventions have been utilized with various level of success. All treatment strategies are primarily aimed at interrupting the hiccup reflex arc.

Treatment of persistent hiccups after arthroplasty: effects of acupuncture at PC6, CV12 and ST36

OBJECTIVE

There are multiple treatment options for hiccups, including non-pharmacological therapies, but little evidence of superiority of one treatment over another. The aim of this study was to investigate the effects of acupuncture on persistent hiccups after arthroplasty.

METHODS

From April 2010 to December 2015, 15 patients with primary unilateral total hip/knee arthroplasty were diagnosed with persistent hiccups and given acupuncture at PC6, CV12 and ST36. Each acupuncture session lasted 30 min. The total number of treatment sessions was determined by the persistence of symptoms, but acupuncture was administered no more than three times over the course of a week. The hiccups assessment instrument (HAI) was used to assess the severity of hiccups pre-treatment and post-treatment. Adverse events were also recorded.

RESULTS

Absolute resolution was observed in all 15 patients after less than three acupuncture sessions. Of these, 10 patients required only one acupuncture session, 3 patients required two sessions and 2 patients required three sessions. The HAI score improved after each round of acupuncture treatment (P<0.05). The average HAI score improved significantly post-acupuncture compared to baseline values pre-treatment (P<0.05). Symptoms accompanying the hiccups included pain in the diaphragmatic area (five patients), mild dyspnoea (three patients), dysphagia (two patients) and nausea/vomiting (one patient). All these accompanying symptoms disappeared at the point of resolution of the hiccups. There were no adverse effects related to acupuncture during the study period.

CONCLUSION

Based on our results, acupuncture may represent a potential treatment option for hiccups after arthroplasty. Caution must be exercised, however, given the lack of a control group. Accordingly, randomised controlled trials will be required to verify the efficacy and effectiveness of acupuncture for the treatment of hiccups.

Comparison the Effects of Ephedrine and Lidocaine in Treatment of Intraoperative Hiccups in Gynecologic Surgery under Sedation

Background:

This study aimed to evaluate and compare the therapeutic effects of ephedrine and lidocaine in treatment of intraoperative hiccups in gynecologic surgery under sedation.

Materials and Methods:

This randomized clinical trial in Isfahan was done on fifty female patients referring to Shahid Beheshti Hospital who needed to have sedation for medical interventions and they afflicted hiccups during surgery or sedation. Patients divided into two groups of 25 randomly assigned to one of the two groups of ephedrine or lidocaine. Ephedrine group received 5 mg/kg of medicine, while the lidocaine group was under treatment with 1 mg/kg lidocaine. Patients were monitored about systolic and diastolic blood pressure, MAP, heart rate, duration of hiccup, frequency of betterment, duration of intervention, and recovery at 15-min intervals of surgery and recovery.

Results:

Hiccups were resolved in 14 cases (56%) in the lidocaine group, while the improvement of such problem was achieved in 24 cases (96%) in ephedrine group (P < 0.001), so that the two groups did not have any significant difference in terms of the time of onset but the stop time of hiccups (relative to its start time) in the ephedrine group with the mean value of (2.40 ± 1.16) was significantly lower than the lidocaine group with the mean of 19.64 ± 22.76 min (P = 0.014). In addition, no complications were observed in the two groups.

Conclusion:

Ephedrine has been more successful than lidocaine as a stimulant in controlling hiccups, and it has been able to suppress hiccups in a higher percentage of patients at a shorter time.

CO2 retention: The key to stopping hiccups

BACKGROUND

While investigating the mechanisms behind hiccups, our team discovered what could be the sufficient physiological conditions for terminating even persistent cases.

METHODS

To investigate the role of CO₂ retention, a healthy male volunteer was asked to perform three kinds of rebreathing experiments using different materials: (I) a 20 L air-filled plastic bag, (II) a 20 L air-filled plastic bag with a 1.5 × 1.5 cm hole and (III) a 20 L oxygen-filled plastic bag. During each experiment, CO₂ level upon expiration (EtCO₂ ) and inspiration (InspCO₂ ) were measured until the volunteer gave up. Once the safety of this manoeuvre was demonstrated with the volunteer, we performed the technique using the materials from experiment (I) on two actual patients with persistent hiccups.

RESULTS

In experiments (I) and (III), InspCO₂ increased from the beginning and reached almost the same level as EtCO₂ after 90 seconds. Both levels continued simultaneously increasing, finally reaching 56 mm Hg in (I) and 79 mm Hg in (III), respectively. In (II), both increased; however, after 120 seconds, EtCO₂ plateaued at 47 mm Hg and InspCO₂ at 37 mm Hg. In the actual patients, both CO₂ levels reached the same value of 35.9 mm Hg at 60 seconds and 37.0 mm Hg at 90 seconds, and hiccups stopped at 195 seconds and at 359 seconds when EtCO₂ reached 50 mm Hg and 53 mm Hg, respectively.

CONCLUSION

The study determined that to successfully obstruct the mechanisms causing hiccups, it is necessary that the level of InspCO₂ not only increases at the same level as EtCO₂ , but also reaches approximately 50 mm Hg.

Treatment of persistent postoperative hiccups with stellate ganglion block: Three case reports

RATIONALE

Although persistent postoperative hiccups can cause various problems (such as sleep disorders, depression, fatigue) for the patient, there has been little research on this topic. The purpose of this study is to determine the effectiveness of treating persistent postoperative hiccups with a stellate ganglion block (SGB), an injection of local anesthetic in the sympathetic nerve tissue of the neck.

PATIENT CONCERNS AND DIAGNOSES

Three patients each developed persistent hiccups within 3 days of abdominal surgery, lasting for 3 to 6 days. The patients were diagnosed as having persistent hiccups based on the hiccup duration.

INTERVENTIONS AND OUTCOMES

The 3 patients were treated with an SGB. After the procedure, the frequency and intensity of hiccups decreased and then the hiccups stopped completely.

CONCLUSION

An SGB is an effective method that can be considered in conjunction with other treatments for persistent hiccups. Clinicians should be mindful of the negative effects that persistent hiccups can exert on patients.

A Hiccup in Hiccup Management: Cardiac Arrest from Previously Undiagnosed Congenital Long QT Syndrome

We report the case of a person who went into cardiac arrest after being given chlorpromazine for hiccups and was subsequently diagnosed with congenital Long QT Syndrome. Long QT Syndrome is an uncommon, congenital condition that carries a high risk of sudden cardiac death. Clinicians need to recognize the risk that chlorpromazine may prolong the QTc and prepare to manage potential complications.

Intractable hiccups as the presenting symptom of toxic nodular goiter

Hiccups differential diagnosis is a challenging one often being inconclusive and sometimes attributed to malignancies, and so of extreme importance to an internist. Seventy-five-year-old man with history of alcohol abuse, hypertension, and hyperlipidemia presented to the emergency department after having initiated diarrhea, hiccups, and vomiting for 4 days. Physical examination revealed signs of dehydration and persistent hiccups at rest. Laboratory investigations revealed acute renal failure (creatinine 3.7 mg/dl, reference value: 0.7–1.3 mg/dl; urea 195 mg/dl, reference value: 18–55 mg/dl) and no elevation of inflammatory parameters. Findings were consistent with a gastroenteritis, it was started fluids and the patient was admitted in the internal medicine ward. As the gastroenteritis symptoms ceased and the acute renal failure was resolved, the hiccups continued and physical examination revealed 2 palpable thyroid nodules. Laboratory findings shew subclinical hyperthyroidism (serum TSH 0.02 uUI/ml, reference value: 0.35 –4.94 uUI/ml; free T4 levels 18.5 pmol/L, reference value: 9.0–19 pmol/L). It was conducted an ultrasonography that revealed an increase of thyroid dimensions and 2 nodules. One nodule in the right lobe with 32 mm of dimension and one nodule in the left lobe with 58 mm of dimension. Both nodules were hypoechoic. Patient started antithyroid medication with propylthiouracil (PTU), 200 mg every 12 hours, and a cervical CT scan was conducted. CT scan revealed images compatible with diving goiter (Fig. 1) and tracheal deviation, for the right side (Fig. 2), inducted by the thyroid left nodule. Patient was discharged with antithyroid medication and hiccups were meliorated with chlorpromazine although persisting. After thyroid function normalization thyroidectomy was conducted, a few months later, and hiccups ceased.

Management of hiccups in palliative care patients

Persistent hiccups are a frustrating experience for palliative care patients, and can have a profound impact on their quality of life. This article provides an evidence-based approach overview of the causes and treatment of this not infrequently debilitating condition for such patients, with a management algorithm. In situations where no readily reversible cause is identified, or where simple physical manoeuvres, such as breath holding have failed, a systematic approach is required. Hiccups can be broadly divided into central and peripheral types. These respond differently to pharmacological intervention. The drug of choice for central causes of persistent hiccups is baclofen, with metoclopramide recommended as the first choice for peripheral causes. Midazolam may be useful in cases of terminal illness. Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered in patients who are refractory to medications. The management of persistent hiccups still presents an ongoing clinical challenge however, requiring further research on pathophysiology and treatment strategies. Multinational randomised controlled trials to evaluate and compare both current and new medications or procedures to better manage this difficult condition are suggested as a means of reaching this goal.

Persistent Hiccups After an Epidural Steroid Injection Successfully Treated With Baclofen: A Case Report

Persistent hiccups are an established adverse reaction to epidural steroid injections. Although oral baclofen has been used to treat hiccups in various clinical settings, none of the previously reported studies that used baclofen were related to hiccups occurring after spinal injections/procedures. We report a case of a man who developed persistent hiccups after a transforaminal epidural steroid injection that was treated successfully with oral baclofen.

LEVEL OF EVIDENCE

V.

Huge left atrial appendage aneurysm revealed by chronic hiccups

Left atrial appendage (LAA) aneurysm is an extremely rare anomaly. So far, less than one hundred cases only have been reported worldwide. Revelation modes are dominated by complications such as arrhythmias and thromboembolic events. We herein report a pediatric case of huge congenital LAA aneurysm with an original revelation mode that has never been described before in medical literature.

Intractable hiccups caused by esophageal diverticular candidiasis in an immunocompetent adult: a case report

Introduction

Various causes of intractable hiccups have been reported; however, to the best of our knowledge, there are no previous reports of either intractable hiccups due to esophageal candidiasis in an immunocompetent adult or improvement following antifungal therapy.

Case presentation

An 87-year-old man presented with intractable hiccups. Although the patient was immunocompetent, he used proton pump inhibitors. An esophagogastroduodenos-copy revealed several white deposits throughout the esophagus and extensive white deposits in the midesophageal diverticulum. A mucosal culture showed candidiasis, which was suspected to be the cause of the intractable hiccups. After oral fluconazole had been prescribed, the candidiasis resolved and the hiccups improved. Therefore, we concluded that esophageal diverticular candidiasis was the cause of his intractable hiccups.

Conclusion

Physicians should consider esophageal candidiasis as one of the differential diagnoses for intractable hiccups, even in immunocompetent adults.

Analysis of factors associated with hiccups based on the Japanese Adverse Drug Event Report database

Hiccups are occasionally experienced by most individuals. Although hiccups are not life-threatening, they may lead to a decline in quality of life. Previous studies showed that hiccups may occur as an adverse effect of certain medicines during chemotherapy. Furthermore, a male dominance in hiccups has been reported. However, due to the limited number of studies conducted on this phenomenon, debate still surrounds the few factors influencing hiccups. The present study aimed to investigate the influence of medicines and patient characteristics on hiccups using a large-sized adverse drug event report database and, specifically, the Japanese Adverse Drug Event Report (JADER) database. Cases of adverse effects associated with medications were extracted from JADER, and Fisher’s exact test was performed to assess the presence or absence of hiccups for each medication. In a multivariate analysis, we conducted a multiple logistic regression analysis using medication and patient characteristic variables exhibiting significance. We also examined the role of dexamethasone in inducing hiccups during chemotherapy. Medicines associated with hiccups included dexamethasone, levofolinate, fluorouracil, oxaliplatin, carboplatin, and irinotecan. Patient characteristics associated with hiccups included a male gender and greater height. The combination of anti-cancer agent and dexamethasone use was noted in more than 95% of patients in the dexamethasone-use group. Hiccups also occurred in patients in the anti-cancer agent-use group who did not use dexamethasone. Most of the medications that induce hiccups are used in chemotherapy. The results of the present study suggest that it is possible to predict a high risk of hiccups using patient characteristics. We confirmed that dexamethasone was the drug that has the strongest influence on the induction of hiccups. However, the influence of anti-cancer agents on the induction of hiccups cannot be denied. We consider the results of the present study to be helpful for the prevention and treatment of hiccups.

Singultus: Avoiding a hiccup in care

Hiccups (singultus) is often a benign, common and self- limited condition. A case of profound electrolyte disturbances presenting with chief complaint of hiccups is presented in which chlorpromazine was not administered and could have been problematic had it been given. For those who present to the ED with chief complaint of hiccups, it is critical to consider a life threatening etiology as the cause of their symptom. This case presents a potential pitfall in the management of singultus.

Hiccups. Attitude in Otorhinolaryngology Towards Consulting Patients. A Diagnostic and Therapeutic Approach

INTRODUCTION

Hiccup crises are generally benign and self-limiting, but longer episodes affect quality of life and must be treated. There are recognisable causes that otorhinolaryngologists must know and be aware for diagnosis and therapeutic alternatives. The main expression is a spasmodic glottic noise with characteristic neck alterations.

PATIENTS AND METHODS

This was a retrospective study from 1979 with patients suffering persistent or recurrent hiccups. Chronobiology, comorbidity, findings from explorations, therapies and outcomes were noted. Thirty-seven patients were studied (mean age, 45.5±13.5 years; 30 males), with persistent hiccups in 23 (62%).

RESULTS

A potential associated aetiology was observed in 24 cases (65%): oesophageal disorders -mainly gastroesophageal reflux- were detected in 14 cases and concomitant oncological disease was found in 8. Only 3 cases were admitted for surgery due to these findings. Therapeutic strategies with metoclopramide were used in 18 subjects, chlorpromazine in 17 and baclofen in 13, while carbamazepine or haloperidol were used in a minority. Phrenic nerve stimulation was employed in 6 patients. Hiccups disappeared in 32 cases. Out of 22 cases for which follow-up was possible, the hiccups recurred in 5 subjects (the subjects requiring new therapies) and 11 patients died.

CONCLUSIONS

Chronic hiccup represents a multidisciplinary challenge that includes potential head and neck affection, a diagnostic schedule for ruling out causes, frequent base oesophageal alterations and high incidence of malignant neoplasm. Prokinetic and neuroleptic agents with antidopaminergic and anticholinergic effects are the pillars of its treatment.

Systemic review: the pathogenesis and pharmacological treatment of hiccups

BACKGROUND

Hiccups are familiar to everyone, but remain poorly understood. Acute hiccups can often be terminated by physical manoeuvres. In contrast, persistent and intractable hiccups that continue for days or months are rare, but can be distressing and difficult to treat.

AIM

To review the management of hiccups, including a systematic review of reported efficacy and safety of pharmacological treatments.

METHODS

Available articles were identified using three electronic databases in addition to hand searching of published articles. Inclusion criteria were any reports of pharmaceutical therapy of 'hiccup(s)', 'hiccough(s)' or 'singultus' in English or German.

RESULTS

Treatment of 341 patients with persistent or intractable hiccups was reported in 15 published studies. Management was most effective when directed at the underlying condition. An empirical trial of anti-reflux therapy may be appropriate. If the underlying cause is not known or not treatable, then a range of pharmacological agents may provide benefit; however, systematic review revealed no adequately powered, well-designed trials of treatment. The use of baclofen and metoclopramide are supported by small randomised, placebo-controlled trials. Observational data suggest that gabapentin and chlorpromazine are also effective. Baclofen and gabapentin are less likely than standard neuroleptic agents to cause side effects during long-term therapy.

CONCLUSIONS

This systematic review revealed no high quality data on which to base treatment recommendations. Based on limited efficacy and safety data, baclofen and gabapentin may be considered as first line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve.

Donepezil-related intractable hiccups: a case report

This case report describes a man with intractable hiccups probably caused by donepezil. The patient's symptoms were not responsive to commonly used medications for hiccups, but they were improved and completely relieved upon donepezil dose deescalation and discontinuation. We report two occasions in which the discontinuation of donepezil resulted in hiccup resolution and three occasions in which initiation of donepezil was associated with the onset of hiccups. This report contributes to the growing body of literature that describes an association between centrally acting medications and intractable hiccups.

Postoperative Singultus: An Osteopathic Approach

Singultus, or hiccups, is a common medical condition. Despite exponential leaps in medicine, the pathophysiologic cause remains poorly defined. Persistent singultus has been associated with conditions such as pulmonary embolism and myocardial infarction. Singultus is also a well-known postoperative complication. The criterion standard of care for patients with singultus involves ruling out lethal pathologic causes, attempting physical stimulation with Valsava maneuvers or drinking water, and, if no relief has been achieved, administering drugs to ease the symptoms. The authors report a case of a man whose postoperative singultus was successfully managed with osteopathic manipulative treatment. This approach addresses many of the possible underlying neuromechanical causes of the aberrant reflex with minimal potential for adverse effects. Physicians should consider osteopathic manipulative treatment in the care of patients with singultus.

Recurrent intractable hiccups treated by cervical phrenic nerve block under electromyography: report of a case

Intractable or persistent hiccups require intensive or invasive treatments. The use of a phrenic nerve block or destructive treatment for intractable hiccups has been reported to be a useful and discrete method that might be valuable to patients with this distressing problem and for whom diverse management efforts have failed. We herein report a successful treatment using a removable and adjustable ligature for the phrenic nerve in a patient with recurrent and intractable hiccups, which was employed under the guidance of electromyography.

Psychogenic hiccup in children and adolescents: a case series

Hiccups can be due to organic diseases or psychogenic causes. Psychogenic hiccup in children is an understudied area. We report a series of four cases presenting with psychogenic hiccups to the Psychiatry Outpatient Clinic of a tertiary care hospital in North India. The cases were aged 11 to 13 years; three of them were males and one female. Three of the patients belonged to a rural background and all of them were from Hindu nuclear families. The duration of hiccups for which treatment was sought ranged from three to fourteen months. The most common gains seen in two of the patients were, lesser scolding from the parents and getting eatables of their choice. The patients were managed by counseling and psychoeducation about the problem and cutting down the secondary gain. Techniques of suggestion and double bind were tried. Two of the patients had improved on the day detailed assessments were done, and all of the patients had improved on follow up. Psychogenic hiccups in children and in the adolescent age group can be effectively managed by using non-pharmacological methods and appropriate education of the parents.

Use of Osteopathic Manipulative Treatment to Manage Recurrent Bouts of Singultus

Singultus, or hiccups, are involuntary spasms of the diaphragm that in most cases are harmless and self-limited. Treatments are reserved for those cases that persist, and current options include pharmacotherapeutics, complementary methods (such as acupuncture), and osteopathic manipulative treatment. A 32-year-old woman with stiff person syndrome and concurrent aminoacidopathy in the setting of acute inpatient rehabilitation was experiencing daily bouts of singultus, ranging from 20-minute to 5-hour durations. Osteopathic manipulative treatment at the onset of spasm resulted in immediate cessation of and further suppression of singultus for approximately 12 to 24 hours. Overall, there was a noted reduction in singultus frequency, duration, and intensity, as well as better tolerance of physical and occupational therapy. The authors theorize that OMT could be a useful adjunct to, or replacement of, pharmacologic interventions for singultus, especially when pharmacologic therapies have failed.

Trochlear nerve schwannoma with intratumoral hemorrhage presenting with persistent hiccups: a case report

Trochlear nerve schwannoma without neurofibromatosis is extremely rare. To our knowledge, only 31 surgical cases have been reported to date, and only 2 cases of trochlear nerve schwannoma with intratumoral hemorrhage have been reported. None of those cases presented with persistent hiccups. We report the case of a 44-year-old man with trochlear nerve schwannoma associated with intratumoral hemorrhage who presented with a 10-day history of persistent hiccups. Computed tomography and magnetic resonance imaging revealed a solid tumor with a 3-cm diameter and intratumoral hemorrhage in the left petroclival region that compressed the midbrain and pons. Subtotal removal of the tumor was performed via the zygomatic transpetrosal approach. Intraoperative findings revealed a tumor arising from the trochlear nerve. The histologic diagnosis was schwannoma of Antoni type A cells with intratumoral hemorrhage. Although the patient's left trochlear nerve palsy worsened temporarily, his postoperative course was uneventful. We present this rare case and discuss the mechanism underlying the patient's persistent hiccups.

Transient hiccups associated with oral dexamethasone

Hiccups, or singulata (hiccup is singultus), are commonly experienced by most people at one time or another and are usually brief and self-limiting. Although pharmacotherapeutic agents are not generally considered causal in the etiology of hiccups, many clinicians empirically associate episodic hiccups in their patients as being drug induced. The two classes of drugs most often cited as causing hiccups are corticosteroids and benzodiazepines. This report involved a patient who was given preoperative dexamethasone and developed hiccups before anesthesia and surgery commenced. He at no time was in distress, and the surgical procedure was completed without complication. By the second postsurgical day his hiccups were resolved completely. Although the association may be anecdotal, many clinicians consider hiccups a potential side effect of steroid therapy, especially high doses of steroids. Of interest in this case is the relatively low dose of corticosteroid used, albeit apparently linked to his hiccups. Practitioners should be aware of this potential condition.