Hiccups

Symptoms of Hiccups

The only symptom of hiccups is a slight tightening sensation in your chest, abdomen, or throat that causes the hiccup sound.

The hiccup reflex involves the synchronized action of the

• Diaphragm: It is a large muscle located below the lungs that demarcates the chest from the abdomen. It contracts rhythmically and continually to aid in respiration.

• The muscles that open and close the windpipe

• The nerves that act upon the diaphragm

If any of the nerves involved in this cycle are triggered, for whatever reason, the diaphragm may contract involuntarily, allowing the air to be drawn into the lungs. As a result, epiglottis( the top of the windpipe) closes, resulting in the distinctive cough-like ‘hic’ hiccup sound.

Types of Hiccups

On the basis of the duration hiccups can be classified as:

• Acute hiccups: Less than 48 hours duration

• Persistent hiccups: Last over 2 days

• Intractable hiccups: Last over a month

Causes of Hiccups

I. Common causes of acute hiccups:

• Eating too quickly or too much
• Eating very hot or very cold foods
• Consuming spicy food
• Drinking alcohol and carbonated beverages
• Swallowing air with chewing gum or sucking on candy
• Indigestion
• Bad odor
• Inhaling toxic fumes
• Cigarette smoking
• Over-stretching the neck
• Sudden temperature changes
• Feeling nervous or excited
  

II. Causes of persistent and intractable hiccups:

1. Nerve damage or irritation

Conditions that may cause damage or irritation to the nerves that control the diaphragm including Gastroesophageal Reflux Disease(GERD), sore throat, goiter, tumor or cyst.

2. Medications

Certain medications can cause hiccups, such as- 

• Antibiotics like azithromycin
• Psychiatric medications like aripiprazole 
• Anesthetic drugs like propofol 
• Steroids
• Certain epilepsy medications

3. Instrumentation

Certain procedures that require the use of instruments can mechanically irritate the nerves that control the diaphragm and induce hiccups. For eg. abdominal or chest surgery .
 

4. Other medical conditions

Some of the conditions that may prompt frequent or prolonged attacks of hiccups include:

• Oesophagitis (inflammation of the food pipe)
• An overactive thyroid gland
• Pleurisy (inflammation of the membrane surrounding the lungs)
• Pneumonia (inflammation of the lungs)
• Tuberculosis
• Influenza (flu)
• Pericarditis (inflammation of the tissue surrounding the heart)
• Diabetes
• Malaria
• Hernia
• Uremia (increased levels of waste products in blood)
• Hypocalcemia (deficiency of calcium)
• Chronic kidney failure
• Multiple sclerosis
• Stroke
• Cancer
  

III. Causes of Hiccups in Infants

It is prevalent for babies under 12 months to get hiccups. Newborns and infants may experience hiccups more frequently during or after feeding as they may swallow food too quickly or overfeed. 

This can lead to stomach distension, and when the stomach distends, it pushes against the diaphragm, which causes it to contract and cause hiccups.

Hiccups can be a sign of an infant being full. Therefore, pediatricians typically recommend short feeds with burping breaks.

Your baby will usually stop hiccupping within 5 to 10 minutes, but if your baby's hiccups do not stop within a couple of hours, you should see your doctor.

Note: Generally, hiccups are a sign of healthy growth and development.

Risk Factors For Hiccups

• Men are more prone to develop long-term hiccups as compared to women
• Anxiety, stress and intense emotions
• Patients who have received general anesthesia
• Post-surgery, particularly abdominal surgery or chest surgery
• Pregnancy

Diagnosis of Hiccups

No specific test is required in the diagnosis of hiccups, but in the case of persistent or intractable hiccups, it is important to detect any probable underlying illness.

1. History

A physician may ask for the history of the current sickness that includes the length of the hiccups, any treatments used, and their relevance to a recent condition or operation. They may also ask about your past medical history, including information about known gastrointestinal and neurologic disorders, and drug history that also includes details concerning alcohol use.

2. Physical examination

During the physical exam, the doctor may perform a neurological exam to check your-

• Balance and coordination

• Muscle strength and tone

• Reflexes

• Sight and sense of touch

3. Laboratory testing

While no specific evaluation is required for acute hiccups, the following lab tests might be suggested for diagnosis of long term hiccups:

• Serum electrolytes

• Calcium test

• Blood urea nitrogen (BUN) test

• Creatinine test

• Lipase

• Liver function tests

4. Imaging techniques

These  tests may help to identify abnormalities inside the chest, neurological changes or lesions causing hiccups.

• ECG (Electrocardiogram)
• Chest radiograph
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI)

Specialists To Visit

The majority of hiccup bouts are self-limiting and pass quickly. However, if they persist even after 2 days, it can be because of an underlying condition. Doctors that can help diagnose and treat hiccups include:

• General physicians

• Otolaryngologists

• Gastroenterologists

• Neurologists

• Pulmonologists

An otorhinolaryngologist is a surgical doctor for the management of conditions of the head and neck.

A gastroenterologist is specialized in the diagnosis and treatment of the gastrointestinal tract disorders.

A neurologist specializes in the treatment of disorders affecting the brain, spinal cord, and nerves. A pulmonologist is a doctor who treats disorders of the lungs.

When to see a doctor?

Contact a doctor if the hiccups last for more than 48 hours, return frequently, or are interfering with your life. Consult them right away if you experience the following symptoms along with the hiccups:

• Headache
• Problems in balancing
• All-over numbness

If you are facing such an issue, consult a professional immediately. To book a consultation

Prevention Of Hiccups

Hiccups are very common and usually resolve on their own. Try these tips to prevent hiccups by making some changes in your habits:

Do’s:

• Eating smaller meals
• A cold water shower
• Managing stress and anxiety effectively
• Self-protection from sudden changes in temperature

Don'ts:

• Eating too fast
• Consuming spicy food
• Drinking alcoholic, fizzy, or carbonated drinks
• Eating or drinking something very cold immediately after something hot
• Chewing gum 
• Smoking
• Over-stretching your neck
• Inhaling toxic fumes

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Treatment of Hiccups

The doctor will want to know if your hiccups are caused by a medical condition or medication you are taking. If the underlying problem is treated or you switch medications, the hiccups should go away. The underlying cause determines the pharmacological treatment, which may include:

I. Medications based on specific causes:

1. For nasal symptoms: Nebulized 0.9% saline (2 mls over 5 minutes)

2. To reduce gastric irritation: Proton pump inhibitors can be given. They include: 

• Omeprazole

• Pantoprazole

• Lansoprazole

3. To reduce gastric distension (enlargement): Medications include:

• Metoclopramide

• Domperidone

• Itopride 

4. Antiflatulent: These medications are used to treat or prevent excessive intestinal gas. They include-

• Simethicone

• Peppermint water

• Carminative agent 

II. Medications for Intractable Hiccups

1. Dopamine antagonists: These medicines can relax the diaphragm muscle or its 

 nerve supply and may stop persistent hiccups. They include:

• Haloperidol
• Olanzapine
• Chlorpromazine
• Methylphenidate

2. GABA agonist: Baclofen is the medication of choice as it helps relax muscles.

Note: Caution is advised in the elderly and patients with kidney dysfunction.

3. Local anesthetic: Low-dose of lignocaine infusion or nebulization help stop hiccups.

4. Antiepileptic: These help relax the nerve supply to the diaphragm and relieve hiccups. The most commonly used drugs include:

• Gabapentin 
• Sodium valproate

5. Calcium channel blocker: These blockers, such as nifedipine, can help control hiccups.

III. Invasive procedures 

More invasive options might be attempted only in case of extreme cases of hiccups. These include the following:

• Nasogastric intubation: Insertion of a tube into the stomach via the nose.
• Phrenic nerve block: The phrenic nerve which supplies the diaphragm can be blocked using anesthetic medication.
• Diaphragmatic pacemaker: It is a battery-powered device that can be implanted surgically. It helps to stimulate or pace the nerves supplying to the diaphragm (the phrenic nerve or vagus nerve) and regulating breathing.

Home-care For Hiccups

Hiccups usually resolve on their own. However, if the hiccups don't stop, here are some tips that can help. Not many studies evaluate the effectiveness of these hiccup remedies. However, they are backed by anecdotal evidence. Additionally, some of the most common remedies stimulate your vagus or phrenic nerves, which are connected to your diaphragm.

1. Posture and breathing tips:

• Pull your knees up to the chest and lean forward
• Hold your breath for several seconds or longer
• Breath out against closed mouth and nose
• Breathe into a paper bag (do not put it over your head)

2. Pressure points tips:

• Pull hard on the tongue
• Put pressure on your diaphragm (the diaphragm separates your abdomen from your lungs)
• Squeeze your nose closed while swallowing water.
• Use your thumb to apply pressure to the palm of your other hand.
• Give a gentle massage on your carotid artery on both sides of your neck.

3. Dietary tips:

• Swallow a teaspoon of sugar
• Slowly drink a glass of warm water without stopping to breathe.
• Sip ice-cold water or gargle with ice water.
• Bite on a lemon or taste vinegar.
  

4. Other tips:

• Distract yourself with something engaging.
• Tapping or rubbing the back of your neck.

5. Home- Care tips for hiccups in infants:

Here are some tips that can be helpful in toddler or infant hiccups.

Feeding tips:

• Encourage your baby to burp as you switch from one breast to another or after feeding.
• After each feeding, keep the baby upright for 20 to 30 minutes.
• Resuming feeding can sometimes stop hiccups.
• If your baby is bottle-fed, make sure to tip the bottle while feeding to limit the amount of air the baby swallows. 
• You can also use anti-colic bottles, which do not allow air passage during feeding.

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Other general tips:

• Cold water can be given to the baby.
• Teas containing fennel, chamomile or peppermint can be introduced into your infant's mouth using a dropper. It relieves the muscle spasms that cause hiccups.
• Rubbing the baby's back.
• Applying light downward pressure to the infant's upper stomach.
• Tickling can distract your toddler's attention from their hiccups.

 It is always advisable to seek the child's pediatrician's consent before starting these tips.

What not to do:

• Never startle or scare the baby.
• Never try holding the baby's breath.

Complications of Hiccups

Frequent episodes of acute hiccups, persistent and intractable hiccups, can significantly impact the quality of life and cause physical pain, humiliation or psychological distress.The following complications are associated with them:

• Dehydration
• Malnutrition
• Tiredness
• Insomnia (lack of sleep)
• Weight loss
• Anxiety and depression
• Delay the healing of a scar (wound) after recent abdominal surgery. This increases the likelihood of wound complications.

Strong hiccups can also cause:

• Reduced heart rate
• Drop in blood pressure
• The collapse of the lung due to air or gas in the space between the lungs and the chest wall

Alternative Therapies For Hiccups

1. Acupuncture

Acupuncture can be explored as an alternative treatment option for persistent and intractable hiccups. It stimulates the nerves that are responsible for hiccups. 

Some case studies show that acupuncture may effectively treat persistent hiccups, even when conventional forms of treatment don’t work. 

Although there is insufficient evidence evaluating the safety and effectiveness of acupuncture in resolving hiccups, some people have been able to cease their long-term hiccups with this therapy, so it may be worth a shot.

2. Massage

A carotid sinus massage may be suggested to manage chronic hiccups. This involves rubbing the main carotid artery in the neck by the healthcare provider.

Living With Hiccups

Hiccups are usually harmless and resolve themselves in a few minutes. Simple home remedies also come in handy to manage them.

However, chronic or prolonged hiccups can be highly stressful, annoying and disrupt daily routines. They can make sleeping difficult or wake you up in the middle of the night. If the condition lasts for a long time, the lack of sleep can cause a loss of energy throughout the day, leading to exhaustion. All these factors can negatively impact a person's quality of life. 

To cope with the condition, getting plenty of rest, eating and drinking small amounts regularly, and being aware of potential complications are critical.

Take prescribed medications on time. Keep yourself busy and distracted. Develop a hobby. Join support groups facing the same challenges.

Maintain regular contact with your doctor throughout treatment to avoid the recurrence of hiccups and complications associated with chronic hiccups.