Daily Medicos

Intractable Hiccups: The chronic type of hiccups

Introduction

Hiccups can be defined as a powerful involuntary contraction of the diaphragm that is followed by abrupt inspiration and closing of glottis. Hiccups usually end up by themselves but sometimes it is associated with the indication of any disease or occur after any surgery. In the case of hiccups that limit or restrict the lifelike intractable hiccups should be treated after the quick identification of the reason behind it. Not always but sometimes hiccups indicate serious problems and seem associated with: 

  • Pregnancy
  • Liver cancer
  • Hepatitis
  • Bowel disease

Intractable hiccups are rare and uncommon which occur in 1 out of 100,000 people. The largest duration of intractable hiccups that is recorded up till now is of 60 years.

What is meant by Intractable Hiccups?

Intractable hiccups or intractable singultus can be defined as “Hiccups that last for more than one month are known as intractable hiccups”. Hiccups are temporary and spontaneous experience for most of the people that end itself without causing any serious complications. A person can experience the following types of hiccups: 

1. Normal hiccups

They last for a few minutes to an hour. Normal hiccups occur due to repetitive and involuntary contraction of diaphragm and end by themselves without causing any troubling situation. There is no specific age for hiccups. It can even occur in developing fetuses inside womb of mother but males are generally more susceptible to get hiccups as compared to women. It may result due to: 

  • Alcoholic beverages
  • Large meal 
  • In a state of excitement

2. Acute hiccups

They last for less than 48 hours or 2 days. Mostly, they are not too serious and occur due to a variety of factors like: 

  • Intake of too much alcohol
  • Emotional stress
  • Intake of air with chewing gum or candy
  • Sudden change in temperature

3. Persistent hiccups or protracted hiccups

They last between 48 hours until one month. Persistent hiccups may result in exhaustion and weight loss. Persistent hiccups may result due to many factors are reasons which are described as follows:

  • Nerve damage (vagus nerve or phrenic nerve due to tumor or gout in the neck) or irritation
  • CNS disorder like meningitis, stroke, brain injury
  • Metabolic disorders like alcoholism, electrolyte imbalance

4. Intractable hiccups

This type of hiccups last for more than 1 month.

Epidemiology of Intractable hiccups

A brief attack of hiccups that last less than 48 hours is considered normal and common. But prolonged hiccups may be a sign of some serious disease. It is reported that patients with advanced cancer are found to have persistent or interacted hiccups. The ratio of such patients is found to be 1 to 9 percent. Recent Studies report the prevalence of normal hiccups more in men and in tall people. Also, a case study of 220 patients with intractable hiccups reported that among these 220 patients, 80% of patients are of older age without any documented racial, socioeconomic, or geographic variation in hiccups.

Pathophysiology of Intractable hiccups

The pathophysiology of intractable hiccups is almost the same as that of normal hiccups with a difference in its duration. A hiccup occurs due to intermittent, spontaneous, involuntary, and spasmodic contraction of intercostal muscles and diaphragm. It results in sudden closure of the glottis producing “Hic” sound. In 80% of cases, there is approximate involvement of left hemidiaphragm. The frequency of normal hiccups is 4 to 60  per minute.

Etiology of hiccups

Intractable or persistent hiccups exist due to some serious pathophysiological conditions that in turn affect the mechanism of hiccups reflex. More than 100 of the causes and reasons for intractable hiccups have been mentioned but many times its cause remains unknown. Some psychogenic causes are also present behind intractable hiccups such as:

  • Shock
  • Fear
  • Hysteria
  • Personality disorders

The pathological conditions that cause irritation of diaphragm may also give rise to intractable hiccups like:

  • Pericarditis
  • Hiatal hernia
  • Myocardial ischemia
  • Subphrenic abscess

Irritation of vagus nerve is another main cause of hiccups, therefore all that conditions which irritate vagus nerve may initiate extraordinary hiccups. These conditions include:

  • Meningitis
  • Pharyngitis
  • Esophagitis
  • Goiter

Consequences of Intractable hiccups

Persistent or intractable hiccups are categorized as chronic hiccups. It is deviation with normal physiology and of course, cause a serious disturbance that makes an individual unable to perform his daily activities. It is problematic for an individual and needs appropriate treatment as it results in: 

  • Disturbance in sleeping
  • Change in eating patterns
  • Irregular heartbeats
  • Gastro-oesophageal reflux disease (GERD)

Causes of Intractable Hiccups

The actual cause of intractable hiccups is still undefined. It is not a genetic disease, therefore, cannot be inherited from parents to offspring. In order to diagnose the main cause of intractable hiccups, doctors may ask you to perform several tests like a blood test, imaging, etc. But still there is a probability that actual cause remains undetermined. However, there are several underlying conditions that may indirectly cause Intractable hiccups which are mentioned as follows:

  • Brain tumor, infections and strokes
  • Pneumonia and pleurisy
  • Metabolic disorders
  • Psychological distress like fear, shock or hysteria
  • Liver and kidney problems
  • Chemotherapy 
  • Medications like barbiturates, corticosteroids, morphine and anesthetic

Diagnosis of intractable hiccups

Intractable hiccups themselves have their prominent sign of “Hiccupping”. Extraordinary duration of hiccups is itself a troubling issue. However, intractable hiccups still don’t have any specific signs and symptoms. A detailed history of the patient is beneficial for the doctor to take a step towards proper diagnosis by asking::

A full and focused physical examination of the following body parts may help the doctor to draw some conclusion like:

  • Head
  • Mouth
  • Neck
  • Abdomen
  • Cardiovascular system for arrhythmias
  • The nervous system for focal lesions

Laboratory testing for diagnosis is another strategy to find an underlying cause of intractable hiccups. These maybe:

  • Electrolytes test
  • Renal function test 
  • Liver function test
  • WBC count
  • Cerebrospinal fluid & sputum test

 If the situation and conditions remain unjustified so your doctor will suggest some more advanced imaging tests to detect the underlying pathology of intractable hiccups:

  • CT scan of head, thorax, and abdomen
  • Chest radiography
  • MRI (Magnetic resonance imaging)
  • ECG (Electrocardiography)
  • Bronchoscopy 
  • Esophageal acid perfusion test 

Treatment for Intractable hiccups

Luckily, these chronic hiccups can be treated and may include various methods. These are:

Home remedies

Home remedies are a traditional or conventional method to stop recurrent hiccups. They help in the management of hiccups by your own without consulting any doctor or taking any medications. They act as first aid and called self-help techniques. You can try out the following home remedies to treat your intractable hiccups:

  1. Taking a sip of chilled water
  2. Holding breath for 1 to 2 minutes
  3. Licking a lemon
  4. Roll the tongue 
  5. Eating one tablespoon of sugar
  6. Folding knees and stretch them back to touch the chest

Medication

Hiccups that do not end by tying all remedies need to take serious concern by consulting a doctor. Although many times doctors are also unable to find the root cause of these hiccups, therefore, medicines are prescribed for temporary relief. All medications that are used for its treatment and management have side-effects, therefore a proper discussion between a pharmacist & doctor is necessary to keep the patient at a safe side. These medicines are:

  • Baclofen (muscle relaxant)
  • Haloperidol (tranquilizer)
  • Chlorpromazine (a psychoactive drug)
  • Metoclopramide (to treat GERD)
  • Sedatives
  • Pain medications
  • Stimulants

One medicine is prescribed by a doctor for several weeks at one time that slowly decreases the hiccups by increasing dose. Most of the time these medicines remain ineffective and another treatment plan may be suggested by your doctor. This strategy includes:

  • Acupuncture
  • Hypnosis

Warning: Don’t take any medicine without consulting a doctor.

Non-pharmacological Management

Management of intractable hiccups without medicines is termed as non-pharmacological management. It includes techniques to stop the contraction of the diaphragm that may end the hiccups. There are several techniques that may help for the temporary management of intractable hiccups, these are mentioned as follows:

  • Gastric emptying
  • Holding the breath
  • Digital rectal massage
  • By maintaining positive airway pressure
  • Stimulation of nasopharynx
  • Mental distraction
  • Meditation
  • Behavioral conditioning

Surgery

When all the medications seem ineffective then surgery will be recommended by the doctor. This surgical process will temporarily or permanently block the phrenic nerve that runs from the spinal cord to diaphragm and transmit nerve impulses that cause involuntarily spasm. Blockage of this nerve impulse unable the nerve impulses to reach diaphragm that causes a sudden contraction in diaphragm causing interacted hiccups.

Before you leave!

Intractable hiccups are under research and clinical trials are on their way to determine their main root cause. A case study helps by reviewing the literature to know the most possible mechanism of intercalated hiccups in the progression of thyroid storm and pulmonary embolism. 

Well, normal hiccups have a tendency to self limit themselves. But if they last for more than 2 days then it should be taken into serious consideration for immediate management and treatment.

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