How to manage persistent hiccups in a patient post-nephrolithoplasty and stenting?

Management of Persistent Hiccups Post-Nephrolithoplasty and Stenting

Start with chlorpromazine 25-50 mg orally three times daily, and if this fails within 48-72 hours, escalate to baclofen 10 mg three times daily, which has proven effective for stent-related persistent hiccups.

Initial Pharmacologic Management

• Chlorpromazine is the first-line agent for persistent hiccups, administered at 25-50 mg orally three to four times daily 1, 2.
• If oral therapy fails after 2-3 days, intramuscular chlorpromazine 25-50 mg can be given, though this requires the patient to remain supine for at least 30 minutes due to hypotension risk 1.
• For severe, intractable cases unresponsive to chlorpromazine, intravenous administration at 25-50 mg diluted in 500-1000 mL saline can be used as a slow infusion with continuous blood pressure monitoring 1.

Second-Line Therapy When Chlorpromazine Fails

• Baclofen 10 mg three times daily is highly effective for stent-related persistent hiccups that do not respond to chlorpromazine or physiological maneuvers 3.
• This dosing regimen has demonstrated complete symptom resolution in documented cases of hiccups following suprahepatic IVC stenting, with sustained relief for up to 2 years 3.
• Metoclopramide and omeprazole can be added as adjunctive therapy, though evidence for their efficacy in stent-related hiccups is limited 4.

Mechanism and Clinical Context

• Persistent hiccups after urological stenting likely result from phrenic nerve irritation or direct diaphragmatic stimulation by the stent, similar to mechanisms seen with esophageal and IVC stenting 3, 4.
• The ureteral stent may cause referred irritation through anatomical proximity to the diaphragm or via inflammatory mediators affecting the phrenic nerve 3.
• Hiccups persisting beyond 48 hours are classified as persistent, and those lasting over one month are considered intractable, requiring aggressive management 5.

Advanced Interventional Options

• Ultrasound-guided phrenic nerve block with bupivacaine and depomedrol provides definitive relief when pharmacologic therapy fails completely 4.
• This procedure can be performed unilaterally or bilaterally (staged 3 days apart) and has achieved complete resolution of intractable hiccups with sustained benefit at 4-week follow-up 4.
• Phrenic nerve blockade should be considered before resorting to stent removal, as it addresses the underlying neurologic mechanism without compromising urinary drainage 4.

Critical Pitfalls to Avoid

• Do not delay treatment assuming hiccups will spontaneously resolve—persistent hiccups cause significant morbidity including sleep deprivation, exhaustion, and impaired wound healing 5.
• Avoid underdosing chlorpromazine; the effective range is 25-50 mg per dose, and inadequate dosing leads to treatment failure 1, 2.
• Never inject undiluted chlorpromazine intravenously—it must be diluted to at least 1 mg/mL to prevent severe hypotension and vascular injury 1.
• Monitor for orthostatic hypotension with chlorpromazine, particularly in elderly or volume-depleted post-surgical patients 1, 2.

When to Consider Stent Removal or Repositioning

• If hiccups persist despite maximal pharmacologic therapy and phrenic nerve blockade, evaluate for stent malposition or migration with imaging 3.
• Stent migration can cause recurrent symptoms even after initial successful treatment, necessitating repositioning or replacement 3.
• However, stent removal should be a last resort given the underlying indication for drainage (obstruction from nephrolithoplasty) 6, 7.

Monitoring and Follow-Up

• Reassess symptom severity daily during the first week, as most cases respond to chlorpromazine within 48-72 hours 1, 2.
• If baclofen is initiated, continue for at least 2-4 weeks before declaring treatment failure, as therapeutic effect may be delayed 3.
• Document any associated symptoms such as chest pain, dyspnea, or fever, which could indicate stent-related complications requiring urgent evaluation 8.