Makindo Medical Notes

🤔 Hiccups are usually short-lived and harmless, but if they last >48 hours, a full medical assessment is needed to exclude serious underlying causes. Persistent hiccups may require referral to secondary care.

📖 About

• Hiccups are caused by an involuntary reflex contraction of the diaphragm, leading to sudden inspiration.
• The incoming air is abruptly stopped by glottic closure, producing the characteristic "hic" sound.
• They serve no protective function and are usually transient.

⏱️ Duration

• 🕐 Acute: Lasts <48 hours, almost always benign.
• ⏳ Persistent: >48 hours, requires evaluation.
• 📉 Complications of prolonged hiccups: fatigue, weight loss, insomnia, aspiration risk.

🔎 Causes (Most are benign)

• ⚡ Metabolic:
  • Uraemia, lactic acidosis
  • Hyponatraemia, hypocalcaemia, diabetes
  • Addison’s disease
• 🫁 Diaphragmatic irritation:
  • Subphrenic abscess, liver pathology
  • Pleural or pericardial effusion
  • Lateral MI
• 🍽️ Gastrointestinal disease:
  • Gastro-oesophageal reflux, achalasia
  • Gastric distension, obstruction
  • Pancreatic or biliary disease
• 🧠 CNS causes:
  • Medullary lesions (e.g. lateral medullary/PICA infarct)
  • Brainstem haemorrhage or tumour
  • Arnold-Chiari malformation, syrinx
  • Encephalitis, meningitis, syphilis
  • HIV encephalopathy, toxoplasmosis, PML

🧪 Investigations (Primary Care)

• 📋 FBC: WCC (infection), Hb (malignancy, bleeding)
• 🧂 U&E: Uraemia, electrolytes (Na, K, Ca)
• 🔥 ESR/CRP: Inflammatory or malignant process
• 🩸 LFTs: Hepatitis, metastases
• 📈 ECG: Pericarditis, MI
• 🩻 CXR: Lung or diaphragmatic pathology
• 🧠 CT/MRI head: Brainstem lesions (e.g. lateral medullary syndrome)

💊 Management

• General/self-help:
  • 🥶 Iced water, granulated sugar, vinegar, lemon
  • 🫁 Valsalva, breath-hold, hyperventilation, paper bag breathing
  • 🧎 Pull knees to chest, sneezing induction
  • Alternative: hypnotherapy, acupuncture, psychotherapy
• Medications (stepwise):
  • 💨 Nebulised 0.9% saline (2 mL over 5 min)
  • 🌿 Peppermint water – relaxes lower oesophageal sphincter
  • 💊 Chlorpromazine 25–50 mg PO TDS or IV
  • 💊 Baclofen 5–20 mg PO TDS
  • 💊 Nifedipine 10–20 mg PO TDS
  • 💊 Haloperidol 1.5–3 mg PO nocte
  • 💊 Sodium Valproate (15 mg/kg/day)
  • 💊 Gabapentin 300–400 mg PO TDS
  • 💉 Midazolam 10–60 mg/24h via CSCI (refractory cases)
• Specialist options:
  • Referral for phrenic nerve block/disruption
  • Consider secondary care for underlying cause

📌 Follow-up

• Monitor for complications: arrhythmias, oesophagitis, malnutrition, insomnia.
• Encourage patient to report worsening or prolonged episodes.