Peg Esper
DEFINITION AND INCIDENCE
The term “hiccups” describes the spasmodic movement of the diaphragm that is followed by a rapid closure of the glottis. Men are more likely to experience episodes of hiccups, which can occur between 2 and 60 times per minute (Ripamonti & Fusco, 2002). The medical term for “hiccup” is derived from the Latin word singultus, which means “a gasp or sigh” (Krakauer, Zhu, Bounds et al., 2005).
Hiccups have been classified in the literature as being episodic (or a “bout” of hiccups); protracted, which last over 48 hours; or intractable, lasting longer than 1 month (Waller & Caroline, 2000). These classifications appear to be more arbitrarily than scientifically based, and most individuals would probably agree that hiccups lasting more than a few hours is likely to be personally defined as intractable.
Hiccups can be experienced by individuals with and without a documented illness. The benign occurrence of hiccups is generally limited. Healthy individuals rarely require intervention beyond self-help measures. Individuals with advanced illness, however, may develop an intractable form of hiccups that can become debilitating and lead to such symptoms as anxiety, depression, dyspnea, nausea, pain, and fatigue. The actual incidence of hiccups in individuals with cancer and other chronic illnesses has not been well documented, but the occurrence of idiopathic singultus is reported to be 1:100,000 people in the general population (Petroianu, 2005).
ETIOLOGY AND PATHOPHYSIOLOGY
Hiccups are attributed to a variety of causes but generally can be placed into one of the six following categories (Krakauer et al., 2005; Ripamonti & Fusco, 2002):
▪ Conditions that cause inflammation of the peripheral branches of the phrenic and vagal nerves, such as gastric and abdominal distention (having a variety of causes, including bowel obstruction and intraabdominal hemorrhage), excessive ingestion of food, sudden changes in the gastric temperature, esophageal reflux or obstruction, pleuritis, pericarditis, pulmonary edema, pneumonia, and mediastinal or cervical tumors
▪ Central nervous system disorders, such as intracranial tumors, head injury, and stroke
▪ Infectious disorders (infrequent), including meningitis, abscess, tuberculosis, and influenza
▪ Psychogenic disturbances, such as anxiety, emotional stress, and excitement
▪ Idiopathic causes, when a causative factor is not identified; because extensive evaluation is often unwarranted in a terminally ill patient
Hiccups generally involve the left diaphragm but have a minimal effect on ventilation. An increase in P co2 decreases the frequency of hiccups (Waller & Caroline, 2000).
In patients near death, gastric distension is most likely the underlying cause of hiccups, accounting for 95% of cases (Twycross, 1997).
ASSESSMENT AND MEASUREMENT
A complete evaluation for hiccups includes identification of possible contributing etiologies. The ability to intervene and the methods of intervention will be based on the patient’s current stage of illness.
HISTORY AND PHYSICAL EXAMINATION
Underlying medical diagnoses often suggest the cause of hiccups. The history and physical examination should be directed to rule out the causes discussed. In addition, the following aspects of the history and physical examination should be considered:
▪ Length of the episode and its effect on the patient’s quality of life
▪ Review of medications (renal hemodialysis patients have been reported to have hiccups following ingestion of “star fruit”) (Noble & Green, 2001)
▪ Comprehensive medical history to evaluate for history of any recent surgery, stroke, or renal dialysis
▪ Measures, if any, the patient has used in an attempt to relieve the hiccups (a patient who indicates that inducing emesis relieved hiccups may have increased acidity causing the hiccup problem)
▪ Check for foreign bodies in the ear canal, since they can stimulate hiccups
▪ Examination of the body for possible sources of irritation to the diaphragm, vagus, and phrenic nerves (Petroianu, 2005)
▪ Evaluation for neurological findings that may be associated with hiccups such as multiple sclerosis and increased intracranial pressure (Petroianu, 2005)
DIAGNOSTICS
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