What is the evaluation and treatment approach for hiccups (hiccup eval and treat)?

Evaluation and Treatment Approach for Hiccups

Chlorpromazine is the first-line pharmacological treatment for intractable hiccups, administered at 25-50 mg orally three to four times daily or intramuscularly if symptoms persist for 2-3 days. 1, 2

Definition and Classification

• Hiccups (singultus) are sudden, involuntary contractions of the diaphragm and intercostal muscles followed by abrupt laryngeal closure, producing the characteristic "hic" sound 3
• Classification based on duration:
  • Acute: less than 48 hours (most common, self-limiting)
  • Persistent: 48 hours to 2 months
  • Intractable: longer than 2 months 3, 4

Evaluation

History and Physical Examination

• Identify potential triggers:
  • Gastric distention (most common cause of acute hiccups) 4
  • Gastroesophageal reflux disease (GERD) 4
  • Alcohol consumption 5
  • Medication side effects 3
• Assess for concerning features suggesting underlying pathology:
  • Duration of hiccups (persistent or intractable)
  • Associated symptoms (weight loss, chest pain, neurological symptoms)
  • Recent surgeries, particularly abdominal 5
  • Recent instrumentation (endoscopy, intubation) 3

Diagnostic Workup for Persistent/Intractable Hiccups

• Laboratory studies: Complete blood count, electrolytes, renal function, liver function tests 4
• Upper GI evaluation: Endoscopy, pH monitoring, and manometry (should be included systematically) 5
• Imaging studies based on clinical suspicion:
  • Chest X-ray or CT to evaluate for thoracic pathology
  • Abdominal ultrasound or CT for intra-abdominal causes
  • Brain imaging (CT or MRI) if neurological causes are suspected 5, 4

Treatment Algorithm

1. Acute Hiccups (< 48 hours)

• Non-pharmacological physical maneuvers (first-line):
  • Stimulation of the uvula or pharynx 6
  • Disruption of respiratory rhythm (breath holding, Valsalva maneuver) 6
  • Measures to stimulate vagal response (drinking cold water, gargling) 3

2. Persistent Hiccups (48 hours - 2 months)

• Treat identified underlying cause if possible 4
• First-line pharmacological therapy:
  • Chlorpromazine 25-50 mg orally three to four times daily 1, 2
  • For pediatric patients: 0.25 mg/kg body weight every 4-6 hours as needed 1

3. Intractable Hiccups (> 2 months)

• Continue to address underlying cause if identified 4
• Pharmacological options:
  • Chlorpromazine: 25-50 mg orally three to four times daily 1, 2
  • If oral therapy fails after 2-3 days, switch to intramuscular administration: 25-50 mg IM 2
  • For severe cases requiring IV administration: 25-50 mg in 500-1000 mL saline as slow infusion (with close blood pressure monitoring) 2
• Alternative pharmacological options if chlorpromazine is ineffective or contraindicated:
  • Baclofen 3, 5
  • Gabapentin 3
  • Metoclopramide 6, 5
• Consider referral for specialized interventions:
  • Phrenic nerve block 3
  • Acupuncture 6, 3

Special Considerations

• Monitor for side effects of chlorpromazine:
  • Sedation, orthostatic hypotension, anticholinergic effects 1, 2
  • QT interval prolongation (avoid in patients with cardiac conditions or those on other QT-prolonging medications) 7
• Use lower doses in elderly patients and monitor closely for hypotension and neuromuscular reactions 1, 2
• For pediatric patients (6 months to 12 years):
  • Chlorpromazine should generally not be used in children under 6 months of age 1
  • Dosage: 0.25 mg/kg body weight every 4-6 hours as needed 1

Common Pitfalls and Caveats

• Failure to identify and treat underlying causes of persistent/intractable hiccups 5, 4
• Overlooking gastroesophageal disorders, which are commonly associated with chronic hiccups 5
• Inadequate monitoring for side effects of chlorpromazine, especially in elderly patients or those with comorbidities 1, 2
• Using subtherapeutic doses of medications before declaring treatment failure 3
• Not recognizing that persistent or intractable hiccups can be a sign of serious underlying pathology requiring thorough investigation 4