History and exam

Key diagnostic factors

common

"hic" sound

Hiccups are characterized by a distinctive "hic" sound resulting from sudden glottic closure interrupting an abrupt inhalation secondary to diaphragmatic spasm.

Other diagnostic factors

common

duration <48 hours (typically benign hiccups)

Benign hiccups are self-limited with no associated complications.

uncommon

duration >48 hours (chronic hiccups)

Chronic hiccups are not self-limited and may at times last for several years. They are often associated with an underlying organic cause, which may include a wide range of conditions related to cardiac, respiratory, gastrointestinal, or neurologic conditions, and complications may develop.

persistence during sleep

This suggests an organic cause and may lead to insomnia, with subsequent fatigue and exhaustion during the day.[15] This in turn leads to impaired alertness and concentration, with consequences for work and social activities.

associated features of underlying cause

Chronic hiccups may be associated with symptoms and signs of the underlying cause.

weight loss and malnutrition

Severe forms of chronic hiccups can complicate eating and drinking. This may lead to malnutrition and dehydration, with subsequent weight loss.

Weight loss may also be a sign of an underlying etiology.

Risk factors

weak

aerophagia, temperature changes, and emotional states

Factors known to predispose to benign hiccups are gastric distension from aerophagia, excessive food and alcohol consumption, and drinking carbonated beverages.[5]

Other causes include sudden changes in ambient or gastrointestinal temperature (e.g., cold showers, drinking hot or cold beverages), sudden excitement, and emotional stress.[5]

diaphragmatic and phrenic nerve irritation

Diaphragmatic and phrenic nerve irritation may result from subphrenic abscess, splenomegaly, hepatomegaly, myocardial infarction, pericarditis, a hiatus hernia, esophageal cancer, or an aberrant cardiac pacemaker electrode.

vagus nerve irritation

Irritation of the vagus nerve may result from a foreign body irritating the tympanic membrane, pharyngitis, laryngitis, a goiter or neck cyst, pneumonia, empyema, bronchitis, asthma, pleuritis, tuberculosis, lung cancer, esophagitis, aortic aneurysm, cor pulmonale, mediastinitis, gastric atony, gastric cancer, gastritis, duodenal ulcer, pancreatitis, pancreatic cancer, intra-abdominal abscess, bowel obstruction, cholecystitis, cholelithiasis, ulcerative colitis, Crohn disease, gastrointestinal hemorrhage, appendicitis, hepatitis, or prostatic disease.[6][7][8][9]

central nervous system disorders

Central causes of hiccups include structural lesions (intracranial neoplasm, syringomyelia, multiple sclerosis, ventriculo-peritoneal shunt), vascular lesions (intracranial hemorrhage or infarction, arterio-venous malformation, vascular insufficiency), infection (meningitis, encephalitis, neurosyphilis, malaria, herpes zoster), trauma, and epilepsy.[10][11][12]

metabolic/electrolyte abnormalities

Metabolic causes include uremia, diabetes mellitus, gout, hyponatremia, hypocalcemia, hypokalemia, and alkalosis. Electrolyte disturbances can decrease the central inhibition of the hiccup reflex arc, leading to chronic hiccups.

toxins/drugs

Alcohol, dexamethasone, diazepam, sulfonamides, antiepileptics, and alpha-methyldopa may cause hiccups.[13] Cancer chemotherapy may cause episodic hiccups.[14]

psychogenic disorders

Include personality disorder, conversion reaction, hysterical neurosis, anorexia nervosa, sudden shock, and grief reaction.[8][17]

sedation or anesthesia

Considered as a separate subtype. The hiccup reflex is usually inhibited by the cortex, but during sedation and anesthesia this inhibition is decreased, leading to hiccups.[1][15][16]

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