What is the appropriate workup for a 67-year-old male presenting to the Emergency Department (ED) with intractable hiccups lasting 24 hours?

From the Guidelines

For a 67-year-old male presenting with hiccups for 24 hours, the workup should begin with a thorough history and physical examination to identify potential causes, focusing on medication review, recent procedures, and associated symptoms. The initial step in evaluating this patient involves a detailed history to uncover any recent changes in medication, especially those known to cause hiccups as a side effect, and any procedures that might have triggered the hiccups [no direct evidence from 1]. Key elements of the history include:

• Medication review, particularly for steroids, benzodiazepines, or chemotherapy agents
• Recent medical procedures
• Associated symptoms like chest pain, abdominal pain, or neurological symptoms The physical examination should focus on:
• Chest examination to rule out cardiopulmonary causes
• Abdominal examination to evaluate for gastrointestinal causes
• Neurological assessment to identify any central nervous system issues Initial diagnostic tests should include:
• Basic laboratory studies (complete blood count, comprehensive metabolic panel, amylase/lipase) to rule out metabolic or infectious causes
• Chest X-ray to evaluate the lungs and diaphragm
• ECG to assess for cardiopulmonary causes, although the study 1 discusses QTc prolongation in the context of antipsychotics, which is not directly relevant to the initial workup for hiccups but highlights the importance of cardiac monitoring in certain contexts. If these initial tests are unrevealing and hiccups persist, consider additional imaging such as:
• CT of the chest/abdomen to evaluate for diaphragmatic irritation, phrenic nerve compression, or intra-abdominal pathology
• Brain imaging (CT or MRI) may be warranted to rule out central nervous system causes, although the provided evidence does not directly support this approach for hiccups, it is a consideration in persistent cases. While conducting the workup, symptomatic treatment can be initiated with:
• Physical maneuvers (breath holding, drinking cold water)
• Pharmacological options like chlorpromazine 25-50mg orally or intramuscularly, as mentioned in 1 for its use in treating intractable hiccups, metoclopramide 10mg orally or IV, or baclofen 5-10mg three times daily. This comprehensive approach is necessary because, while most hiccups are benign and self-limiting, in older patients they may indicate serious underlying conditions requiring prompt diagnosis and management.

From the FDA Drug Label

Intractable Hiccups– 25 mg to 50 mg t.i.d. or q.i.d. If symptoms persist for 2 to 3 days, parenteral therapy is indicated. If symptoms persist for 2-3 days after trial with oral therapy, give 25 to 50 mg (1-2 mL) IM. Should symptoms persist, use slow IV infusion with patient flat in bed: 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline.

The workup for a 67-year-old male presenting to the ED with hiccups for 24 hours may include a trial of oral chlorpromazine 25 mg to 50 mg t.i.d. or q.i.d. If symptoms persist, parenteral therapy with 25 to 50 mg IM or slow IV infusion may be indicated 2 3. Key considerations include:

• Monitoring for hypotension and neuromuscular reactions, especially in elderly patients
• Adjusting dosage gradually and carefully
• Considering alternative diagnoses and underlying causes of intractable hiccups

From the Research

Workup for Hiccups

The workup for a 67-year-old male presenting with hiccups for 24 hours involves a detailed history and thorough physical examination to identify the underlying cause of the hiccups 4, 5.

Common Causes of Hiccups

• Gastroesophageal reflux disease (GERD) is the most common cause of hiccups 4
• Other causes include overdistension of the stomach, gastritis, and underlying gastrointestinal, neurological, cardiovascular, pulmonary, infectious, and psychogenic disorders 5

Initial Evaluation

• A detailed history to identify potential causes of hiccups, such as recent meals, medications, or underlying medical conditions 5
• Physical examination to evaluate for signs of underlying conditions, such as abdominal tenderness or neurological deficits 5

Treatment

• First-line therapy for hiccups involves the use of a proton pump inhibitor (PPI) and gastrointestinal consultation 4
• If symptoms persist, other etiologies such as central causes need to be explored 4
• Pharmacologic interventions, such as metoclopramide, baclofen, and gabapentin, may be considered for intractable and persistent hiccups 6, 7, 8

Further Evaluation

• If the underlying cause is not known or not treatable, further evaluation may include laboratory tests, imaging studies, or specialty consultations to rule out underlying conditions 5