Hiccups
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Non-pharmacological interventions
Hiccups are diaphragmatic spasms caused by diaphragmatic irritation, which is associated with gastric distension, phrenic nerve irritation, uraemia, infection and central nervous system tumour.
Assessment and severity
The severity of hiccups is subjective for each individual patient. However, if the hiccups are causing patients to have difficulty talking, eating and sleeping, causes weight loss, anxiety or depression, reversible causes must be sought.
The assessment should therefore consider:
- Are the hiccups troublesome to the patient?
- Know the current extent of disease to help identify pressure effects or nerve damage
- Are signs and symptoms of dyspepsia, reflux or epigastric fullness present?
- Are there signs of infection?
- Do a chest examination
- Test the patient’s urine
- Test for faecal occult blood to exclude upper GIT bleeding
- Do appropriate biochemistry to exclude reversible symptoms (U&E and creatinine, corrected calcium and albumin)
- If a myocardial infarction is suspected do appropriate tests.
Causes mediated
Via vagus nerve:
- Gastric distension
- Gastro-oesophageal reflux
- Hepatic tumours
- Ascites/abdominal distension/intestinal obstruction
Via phrenic nerve:
- Diaphragmatic tumour involvement
- Mediastinal tumour
- CNS
- Intracranial tumour
- Meningeal infiltration of tumour
Systemic:
- Renal failure
- Hyponatraemia
Drugs:
- Corticosteroids (If hiccups occur shortly after starting new drug, a therapeutic trial of stopping the drug is worthwhile)
Correct reversible factors
Where appropriate and possible correct renal function or any other reversible factors e.g. for abdominal distension try peppermint water and metaclopramide.
Non-pharmacological interventions
Many interventions are described but none have been clinically proven to help. Most interventions attempt pharyngeal stimulation.
- Massage the soft palate
- Hold your breath
- Eat dry granulated sugar
- Re-breath into a bag
First line treatment
Reduce gastric distension:
- Metaclopramide 10mg tds po
- Antacid combination such as aluminium hydroxide, magnesium hydroxide and simeticone
Relax smooth muscle
- Baclofen 5mg tds po
Second line treatment
Suppress central hiccup in intractable cases:
- Chlorpromazine 25mg po (causes sedation and hypotension)
Suppress central irritation from intracranial tumour:
- Corticosteroids in high doses (can cause hiccups, consider stopping if recently started)
- Phenytoin 200mg -300mg nocte