56-Year-Old Man With Hiccups

A 56-year-old man presented to the emergency department for a 5-day history of

persistent hiccups. He had never experienced this problem before. The hiccups had
been causing him significant distress. He had not slept during this time, and he
expressed significant frustration with the hiccups’ interference with daily activities
including eating, drinking, and speaking. He endorsed associated symptoms of mild
chest pain and abdominal pain with 1/10 intensity which he attributed to muscle
soreness from the hiccups, as well as belching more than usual since the hiccups
began. His past medical history was significant for hypertension, hyperlipidemia,
obesity, clinical diagnosis of umbilical hernia (no prior imaging available), and
adenocarcinoma of the prostate. He recently traveled by plane from the
northeastern United States to visit Mayo Clinic for robot-assisted laparoscopic
prostatectomy performed 8 days ago.
He had no additional surgical history. Review of systems was negative for
dysphagia, nausea, vomiting, constipation, dizziness, confusion, or other abnormal
movements apart from the hiccups. Current medications included sennosides-
docusate, simethicone, tadalafil, telmisartan-hydrochlorothiazide, amlodipine, and
dietary supplements including fish oil, ergocalciferol, and vitamins C and E.
Vital signs on presentation were as follows: temperature, 98.6 F; blood pressure,
141/82 mm Hg; pulse rate, 78 beats/min; respiratory rate, 22 breaths/min;
oxygen saturation, 99% on room air; height, 179 cm; weight, 121 kg; body mass
index, 38 kg/m2 . On general examination, he appeared fatigued and in
moderate distress with hiccups occurring every 1 to 3 seconds. Abdominal exam
revealed several laparoscopic abdominal incisions healing well with no drainage
of fluid or incisional hernia. There was no appreciable umbilical hernia.
Oropharyngeal, cardiac, pulmonary, neurological, and musculoskeletal
examinations were unremarkable.
Electrocardiogram, 2-hour troponin, chest radiograph, basic metabolic panel,
and complete blood count were unremarkable.
1. Which pair of afferent and efferent nerves, respectively, are the most likely
primary mediators of the reflex arc that is hyperactive in this patient?
A. Glossopharyngeal and vagus
B. Glossopharyngeal and phrenic
C. Vagus and phrenic
D. Accessory and vagus
E. Phrenic and accessory
1. Which pair of afferent and efferent nerves, respectively, are the most likely
primary mediators of the reflex arc that is hyperactive in this patient?
A. Glossopharyngeal and vagus
B. Glossopharyngeal and phrenic
C. Vagus and phrenic
D. Accessory and vagus
E. Phrenic and accessory
The glossopharyngeal nerve provides sensory innervation to the mouth and
throat, not the viscera, which is where the irritation causing hiccups generally
occurs. The vagus is the primary afferent nerve, and the phrenic is the primary
efferent nerve involved in the hiccup reflex. The accessory nerve is a purely
motor nerve and therefore cannot be an afferent in the reflex arc. The phrenic
afferents and accessory efferents play a minor role in the reflex arc compared
with the vagus afferents and the phrenic efferents.
In most patients, vagal and phrenic irritation is the most common cause of
persistent hiccups, and this seemed to be the case for this patient. A thorough
neurologic exam was performed, and there were no abnormalities. There was
no weakness, nystagmus, loss of sensation, anisocoria, or dysmetria to suggest a
medullary lesion and there was good air entry in the lungs bilaterally, intact gag
reflex, and good palate elevation, making a phrenic or vagus nerve lesion
unlikely. Considering these pertinent negatives, an irritating stimulus seemed the
most likely explanation for the patient’s hiccups.
2. Which element of the patient’s history is most informative for explaining the
etiology of his hiccups?
A. Laparoscopic prostatectomy
B. Umbilical hernia
C. Obesity
D. Residence in the Northeastern United States
E. Recent air travel
2. Which element of the patient’s history is most informative for explaining the
etiology of his hiccups?
A. Laparoscopic prostatectomy
B. Umbilical hernia
C. Obesity
D. Residence in the Northeastern United States
E. Recent air travel
In this patient’s case, the most important element of the history that explains his
new onset of persistent hiccups is his recent laparoscopic prostatectomy. The
time course is particularly telling because his hiccups began 3 days after the
surgery. In patients undergoing general anesthesia, intubation may cause
irritation of the glottis, stretching of the phrenic nerve roots due to neck
extension, or gastric distention if the endotracheal tube was initially placed into
the esophagus. Other triggers specifically associated with laparoscopic
abdominal surgery are distention of the abdomen by insufflation or traction on
the viscera.
Gastrointestinal disorders can be precipitants of hiccups, and the patient does
have an umbilical hernia. However, as a longstanding historical problem and
because the patient has no small bowel symptoms, the patient’s umbilical hernia
is less likely to be the precipitant of the hiccups. Obesity, geographic residence,
and airline travel are not known to be risk factors for persistent hiccups.
Male sex, tall height, and malignancy are other factors in this patient which are
known to be associated with increased incidence of persistent hiccups. Closer
inspection of the patient’s abdomen revealed no tympany to suggest free air, no
abdominal tenderness, no mass, and no herniation of abdominal contents at the
incision sites, which were healing well.
3. Which of the following is the most appropriate initial step for providing this
patient with relief?
A. Barium esophagram
B. Physical maneuvers targeting the hiccup reflex arc
C. Anxiolysis with a benzodiazepine
D. Discharge with urgent gastroenterology referral
E. Consult general surgery for exploratory laparotomy
3. Which of the following is the most appropriate initial step for providing this
patient with relief?
A. Barium esophagram
B. Physical maneuvers targeting the hiccup reflex arc
C. Anxiolysis with a benzodiazepine
D. Discharge with urgent gastroenterology referral
E. Consult general surgery for exploratory laparotomy
Barium esophagram would be low yield in a patient without dysphagia and would be
unlikely to uncover any additional information in this patient.
Several physical maneuvers have been described in the literature for providing immediate
relief to patients with persistent hiccups, and these maneuvers will be discussed in
greater detail below. These maneuvers modulate the function of nerves involved in the
hiccups reflex arc.
Benzodiazepines may be helpful if the patient is experiencing anxiety secondary to his
hiccups, but do not address the principal problem.
Ultimately, this patient may benefit from further workup by a gastrointestinal specialist.
However, this is not the most appropriate initial approach to help the patient find relief.
A patient with umbilical hernia and recent history of abdominal surgery may have
abdominal free air on imaging, which could be suspicious for bowel perforation requiring
emergent laparotomy. However, this patient had minimal abdominal pain and no signs of
peritonitis, and no tympany to suggest free air on exam.
We offered several physical maneuvers to the patient. However, we explained that these
may be ineffective at stopping his hiccups. He responded, “At this point, I’m willing to try
anything.”
4. Which of the following maneuvers is most likely to be effective at relieving
the patient’s hiccups?
A. Applying firm pressure to the eyes
B. Tractional tension on an extended tongue
C. Neck massage inferior to the angle of the jaw
D. Drinking water through a small straw
E. Bearing down in knee-to-chest position
4. Which of the following maneuvers is most likely to be effective at relieving
the patient’s hiccups?
A. Applying firm pressure to the eyes
B. Tractional tension on an extended tongue
C. Neck massage inferior to the angle of the jaw
D. Drinking water through a small straw
E. Bearing down in knee-to-chest position
Ocular pressure, tongue traction, and carotid massage, which is a neck massage inferior
to the angle of the jaw at the level of the carotid bifurcation, are all vagal maneuvers.
Vagal maneuvers have been used to stop hiccups but are often ineffective.
Drinking water through a small straw is a maneuver of forced inspiratory suction and
swallow (FISS), which involves simultaneous phrenic and vagus nerve stimulation.
Recent evidence suggests this may be a highly effective maneuver for relieving hiccups.
Valsalva, or bearing down in a knee to chest position is also a vagal maneuver and is not
known to be particularly effective.
All the above vagal maneuvers were attempted on this patient with no success. Finally,
the FISS maneuver was attempted using a small diameter coffee straw and an 8-oz glass
of water. The patient was instructed to forcibly sip the water using the coffee straw and
then swallow. After approximately 5 swallows, the patient had finished drinking all
water in the cup, and the hiccups completely subsided.
The patient was observed in the emergency department for an additional 30 minutes
and the hiccups did not return. He was provided with several coffee straws on discharge.
As an additional measure upon discharge, he was provided with a prescription
medication to aid in the prevention of future onset of hiccups.
5. Which of the following medications may be most useful for this patient?
A. Omeprazole
B. Azithromycin
C. Metoclopramide
D. Ondansetron
E. Lorazepam
5. Which of the following medications may be most useful for this patient?
A. Omeprazole
B. Azithromycin
C. Metoclopramide
D. Ondansetron
E. Lorazepam
If the patient had symptoms of gastroesophageal reflux, omeprazole might be a
reasonable option; initial medical management of hiccups can be targeted to the
trigger if a trigger can be identified. However, this patient had no such symptoms.
Azithromycin has prokinetic properties and may be useful for dysmotility conditions
such as diabetic gastroparesis, but in a condition of hypermotility such as hiccups,
this could potentially worsen the problem.
Evidence from small randomized controlled trials does support the use of
metoclopramide and baclofen for the empiric treatment of hiccups.
Ondansetron may be useful for the treatment of nausea; however, there is no
evidence suggesting it is useful in the treatment of hiccups.
There is no evidence to suggest that benzodiazepines are useful in the treatment of
hiccups.
After the patient’s hiccups had resolved, the patient was discharged with a
prescription for metoclopramide as an additional measure in case the hiccups
returned. He was also counseled to seek care from a gastrointestinal specialist for
further workup if the hiccups were to recur.
 DISCUSSION
Hiccups, known in medical literature as singultus, are sudden spasms of the
diaphragm and intercostal muscles followed by closure of the glottis. The afferent
limb of the hiccup reflex arc involves sensation from the viscera transmitted
primarily via the vagus nerve (and the phrenic nerve to a lesser extent) to an
integration center in the midbrain. The efferent limb of this reflex arc involves the
phrenic nerve primarily, which delivers motor input to the diaphragm and the
accessory nerve which delivers motor input to the intercostal muscles.
Hiccups lasting less than 48 hours are known as acute hiccups and, although
bothersome, these cases are generally benign. More serious are the cases of
persistent or intractable hiccups, defined as episodes lasting longer than 48 hours or
longer than 1 month, respectively. Persistent or intractable hiccups can lead to
significant complications including impaired sleep and fatigue, interference with
eating, drinking, and speech, and chest and abdominal pain, as observed in this
patient. Other associated complications include gastroesophageal reflux, anxiety,
depression, and even death. Hiccups that are persistent or intractable warrant
further evaluation for an underlying cause.
More serious etiologies of persistent and intractable hiccups include central nervous
system disorders, especially those affecting the medulla; infection and inflammation
of the lungs, mediastinum, diaphragm, or subphrenic abdomen; emergent medical
conditions including chest trauma, pulmonary embolism, or myocardial infarction;
certain medications (chemotherapeutic agents, steroids, benzodiazepines and
barbiturates, and methyldopa); electrolyte derangements; and alcohol abuse.
In postoperative patients who have undergone general anesthesia, intubation may
have caused irritation of the glottis, stretching of the phrenic nerve roots due to
neck extension, or gastric distention if the endotracheal tube was initially placed
into the esophagus. Other triggers specifically associated with laparoscopic
abdominal surgery are distention of the abdomen by insufflation or traction on the
viscera. This was the most likely explanation for the persistent hiccups in this
patient.
Vagal maneuvers are thought to break cyclic reflex arc activation in persistent
hiccups; however, the literature indicates that these maneuvers are usually
ineffective. Triggering the oculocardiac reflex, tongue traction, Valsalva, and carotid
massage are all examples of vagal maneuvers which have been used to stop hiccups.
On the other hand, FISS is thought to simultaneously stimulate both the phrenic
and vagus nerves by inducing diaphragmatic contraction and epiglottic closure.
Recently, a cross-sectional study of subjects using the FISS method has presented
a self-reported efficacy of 92% for stopping hiccups.
For patients in whom an underlying cause cannot be identified, suffering from
hiccups refractory to both medications and physical exam maneuvers, more
invasive procedures can be considered. Nerve blocks, nerve stimulation, and
positive pressure ventilation are more invasive options that have been attempted
and described in the literature.
In this patient’s case, he had no relief from any of the vagal maneuvers attempted
in the emergency department. We attempted to induce FISS in this patient using
a simple makeshift system consisting of a coffee straw and water cup. This
approach has not been described in the literature previously to our knowledge.
This maneuver entirely resolved the patient’s hiccups. He thanked the emergency
room staff profusely and was able to return home after being observed for 30
minutes in the emergency department with no recurrence of his hiccups.
“Alégrense en la esperanza, muestren paciencia en el sufrimiento, perseveren en
la oración.”
(Romanos 12.12)