Hiccups

1. HICCUPS
Ade Wijaya, MD
November 2017

2. OUTLINE:
 Introduction
 Classification
 Epidemiology
 Pathophysiology
 Etiology
 Investigation
 Treatment
- Pharmacological
- Non-pharmacological
o Summary

3. INTRODUCTION
 Bailey, 1943
 Involuntary repetitive myoclonic contraction of
diaphragm
 Singultus
 Rapid intake of air, interupted by glottis closure
 4-60 per minute
Kahrilas PJ, Shi G. Why do we hiccup? Gut 1997
Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil 2012; 18:123–30
Friedman NL. Hiccups: a treatment review. Pharmacotherapy 1996;16: 986–95

4. CLASSIFICATION
Acute
< 48 hours
Persistent
> 48 hours
Intractable
> 1 month
Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to Systematic review: treatment of hiccups management. Annal Emerg Med1991; 20: 565 –73.

5. EPIDEMIOLOGY
 55 per 100.000 patients
 CNS vs GI tract diseases
 20 %  PD
 10 %  reflux diseases
 3,9-4,8 %  advanced cancer
- Cymet TC. Retrospective analysis of hiccups in patients at a community hospital from 1995-2000. J Natl Med Assoc 2002; 94: 480–3.
- Rey E, Elola-Olaso CM, Rodriguez-Artalejo F, Locke GR 3rd, Diaz-Rubio M. Prevalence of atypical symptoms and their association with typical symptoms of
gastroesophageal reflux in Spain.Eur J Gastroenterol Hepatol 2006;18: 969–75.
- Khorakiwala T, Arain R, Mulsow J, Walsh TN. Hiccups: an unrecognized symptom of esophageal cancer? Am J Gastroenterol 2008;103: 801.
- Porzio G, Aielli F, Verna L, Aloisi P, Galletti B, Ficorella C. Gabapentin in the treatment of hiccups in patients with advanced cancer: a 5-year experience. Clin
Neuropharmacol 2010; 33 : 179–80.

6. PATHOPHYSIOLOGY
Friedman NL. Hiccups: a treatment review. Pharmacotherapy 1996;16: 986–95

7. ETIOLOGY
 Carbonated drinks
 Chilli papers
 Alcohol
 Smoking
 Other irritants
 Over excitement
 Anxiety
 Aerophagia
 CNS disorders
 GI tract disorders
 Cardiovascular diseases
 Electrolyte imbalance
 Hyperglycemia
 Uremia
 Toxin or recreational drugs
 Benzodiazepine, steroid,
opiates side effects
 Psychogenic
 Post surgery
Benign
More serious
(usually persistent and intractable hiccups)
Cabane J, Bizec JL, Derenne JP. A diseased esophagus is frequently the cause of chronic hiccup. A prospective study of 184 cases.Presse Med 2010;39:e141–6.
Greene CL, Oh DS, Worrell SG, Hagen JA. Hiccups and gastroesophageal reflux disease as seen on high resolution esophageal manometry.Dis Esophagus 2014; doi:
10.1111/dote.12253.
Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil 2012; 18:123–30

8. Steger, M., Schneemann, M., & Fox, M. (2015). Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary pharmacology &
therapeutics, 42(9), 1037-1050.

9. INVESTIGATION
 History
 Physical examination
 Laboratory
 Brain/chest/abdomen imaging
 Endoscopy
 24-h pH-impedance reflux study
Cabane J, Bizec JL, Derenne JP. A diseased esophagus is frequently the cause of chronic hiccup. A prospective study of 184 cases.Presse Med 2010;39:e141–6

10. TREATMENT (PHARMOCOLOGIC)
Steger, M., Schneemann, M., & Fox, M. (2015). Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary pharmacology &
therapeutics, 42(9), 1037-1050.

11. TREATMENT (NON-PHARMOCOLOGIC)
Steger, M., Schneemann, M., & Fox, M. (2015). Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary pharmacology &
therapeutics, 42(9), 1037-1050.

12. Steger, M., Schneemann, M., & Fox, M. (2015). Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary pharmacology &
therapeutics, 42(9), 1037-1050.

13. SUMMARY
 Acute vs persistent vs intractable
 Various causes, usually benign
 Persistent & intractable hiccups usually caused by
more serious pathology such as CNS, GI tracts, or
cardiovascular disorders
 Treatment: pharmocological vs non-
pharmacological
 1st line pharmacological treatment: baclofen &
gabapentin