Hiccups (Singultus)
🤔 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.
