What are the medical causes of hiccups?

Medical Causes of Hiccups

Hiccups are most commonly caused by gastroesophageal reflux disease (GERD), with severe reflux esophagitis representing a more serious manifestation that can lead to persistent hiccups. 1

Pathophysiology

Hiccups result from a complex reflex arc involving:

• Peripheral phrenic, vagal, and sympathetic pathways
• Central midbrain modulation
• Sudden diaphragmatic and intercostal muscle contraction followed by laryngeal closure 2

Common Medical Causes

Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) - most common cause of persistent hiccups 3, 1
• Gastritis 4
• Overdistension of the stomach 4
• Inflammatory bowel diseases 5
• Celiac disease 5

Cardiovascular Causes

• Myocardial ischemia 2
• Pericarditis 6
• Pericardial effusion (due to compression of the phrenic nerve) 6

Neurological Causes

• Stroke 2
• Space-occupying lesions in the brain 2
• Traumatic brain injury 2
• Neuroma or neurilemmoma of the vagus nerve 5

Pulmonary Causes

• Pneumonia 4
• Pleural irritation 2
• Bronchitis 4

Medication-Induced Hiccups

• Anti-Parkinsonian drugs 2
• Anesthetic agents 2
• Steroids 2
• Chemotherapeutic agents 2
• Mycophenolate mofetil 5
• Propofol 5
• Beta-blockers 5

Infectious Causes

• Herpes zoster affecting the phrenic nerve 2
• Various systemic infections 4

Other Causes

• Mediastinal lesions (tumors, cysts, Hodgkin lymphoma) 5
• Post-surgical (especially with exposed endobronchial sutures) 5
• Vocal cord dysfunction 5
• Ear problems affecting the vagus nerve 5
• Psychogenic factors 4

Classification by Duration

1. Acute hiccups: Self-limited episodes lasting less than 48 hours 4
2. Persistent hiccups: Episodes lasting more than 48 hours 2
3. Intractable hiccups: Episodes lasting more than 2 months 2

Diagnostic Approach

For persistent or intractable hiccups, a thorough evaluation is necessary to identify the underlying cause:

• Detailed history focusing on medication use, recent procedures, and gastrointestinal symptoms 4
• Physical examination with attention to neurological and gastrointestinal systems 4
• For persistent cases, consider:
  • Upper endoscopy to evaluate for GERD or esophagitis 1
  • Chest imaging to rule out mediastinal pathology 5
  • Neuroimaging if central causes are suspected 2

Treatment Considerations

Treatment should target the underlying cause:

• For GERD-related hiccups: Proton pump inhibitors are first-line therapy 3
• For medication-induced hiccups: Consider withdrawal of the suspected drug 5
• For persistent cases: Pharmacotherapy options include chlorpromazine, gabapentin, baclofen, and metoclopramide 2, 7
• Non-pharmacological approaches include nerve blockade, pacing, acupuncture, and breathing techniques 2

Persistent or intractable hiccups should never be dismissed as they may indicate serious underlying pathology requiring prompt evaluation and treatment 4.