Can gastroesophageal reflux disease (GERD) cause hiccups?

Can Heartburn Cause Hiccups?

Yes, gastroesophageal reflux disease (GERD) can cause hiccups, though the relationship is complex and hiccups may represent a more severe manifestation of reflux disease rather than a simple cause-and-effect relationship.

The Evidence for GERD-Induced Hiccups

The connection between GERD and hiccups is supported by clinical case series demonstrating that patients with severe erosive esophagitis and protracted hiccups improved on proton-pump inhibitor therapy after failing neurologic medications 1. This suggests hiccups may represent an atypical but clinically significant manifestation of severe reflux disease 1.

Proposed Mechanisms

The pathophysiologic link likely involves the esophageal-bronchial reflex pathway, where refluxate in the distal esophagus can stimulate neural reflexes without requiring aspiration 2. GERD can trigger reflexes through:

• Direct esophageal irritation: Refluxate into the distal esophagus alone may be sufficient to stimulate hiccups through neural pathways 2
• Vagal nerve activation: Airway reflexes including cough and potentially hiccups can be initiated from the stomach or esophagus via vagal pathways 2
• Esophageal motility disruption: During hiccups, esophageal manometry shows absence of lower esophageal sphincter pressure and loss of peristaltic activity, which could aggravate reflux 3

Critical Clinical Caveats

The relationship between hiccups and GERD may be bidirectional or coincidental rather than purely causative 3, 4. Two important case reports demonstrate that antireflux surgery (Nissen fundoplication) relieved heartburn symptoms but did not resolve hiccups in patients with both conditions 3, 4. This suggests:

• Hiccups and GERD may coexist coincidentally in some patients 4
• Hiccups themselves may worsen reflux by disrupting esophageal motility 3
• The presence of both conditions does not guarantee that treating reflux will resolve hiccups 3, 4

Practical Management Algorithm

When to Suspect GERD as the Cause

Consider GERD-related hiccups when patients present with:

• Protracted or intractable hiccups lasting days to weeks 1
• Concurrent heartburn or regurgitation symptoms 1
• Hiccups that failed to respond to standard neurologic medications 1

Important: Up to 75% of patients with GERD-related extraesophageal symptoms may have no typical GI complaints like heartburn 2, so absence of heartburn does not exclude GERD as a cause.

Treatment Approach

1. Initial empirical therapy: Trial of intensive proton-pump inhibitor therapy for patients with protracted hiccups, especially if heartburn is present 1

2. Diagnostic confirmation: If symptoms persist or alarm features are present, proceed with upper endoscopy to assess for erosive esophagitis 1

3. Adjunctive measures: Add positional therapy (elevate head of bed, avoid meals within 3 hours of bedtime) and dietary modifications 5, 6

4. Surgical caution: Do not recommend antireflux surgery solely to treat hiccups, even in patients with documented GERD and heartburn, as hiccups frequently persist post-operatively 3, 4

Key Clinical Pitfall

The most important pitfall is assuming that treating GERD will reliably resolve hiccups. While some patients with severe erosive esophagitis and hiccups respond to acid suppression 1, surgical case reports demonstrate that hiccups may persist despite successful reflux control 3, 4. Therefore, set realistic expectations with patients that acid suppression may help but is not guaranteed to eliminate hiccups, and surgical intervention specifically for hiccups is not recommended based on current evidence 3, 4.