Hiccups

Definition

Hiccups are the result of an involuntary, spasmodic contraction of the diaphragm followed by the closing of the throat.

Description

Hiccups are one of the most common, but thankfully mildest, disorders to which humans are prey. Virtually everyone experiences them at some point, but they rarely last long or require a doctor's care. Occasionally, a bout of hiccups will last longer than two days, earning it the name "persistent hiccups." Very few people will experience intractable hiccups, in which hiccups last longer than one month.

A hiccup involves the coordinated action of the diaphragm and the muscles that close off the windpipe (trachea). The diaphragm is a dome-shaped muscle separating the chest and abdomen, normally responsible for expanding the chest cavity for inhalation. Sensation from the diaphragm travels to the spinal cord through the phrenic nerve and the vagus nerve, which pass through the chest cavity and the neck. Within the spinal cord, nerve fibers from the brain monitor sensory information and adjust the outgoing messages that control contraction. These messages travel along the phrenic nerve.

Irritation of any of the nerves involved in this loop can cause the diaphragm to undergo involuntary contraction, or spasm, pulling air into the lungs. When this occurs, it triggers a reflex in the throat muscles. Less than a tenth of a second afterward, the trachea is closed off, making the characteristic "hic" sound.

Causes and symptoms

Hiccups can be caused by central nervous system disorders, injury or irritation to the phrenic and vagus nerves, and toxic or metabolic disorders affecting the central or peripheral nervous systems. They may be of unknown cause or may be a symptom of psychological stress. Hiccups often occur after drinking carbonated beverages or alcohol. They may also follow overeating or rapid temperature changes. Persistent or intractable hiccups may be caused by any condition which irritates or damages the relevant nerves, including:

• overstretching of the neck
• laryngitis
• heartburn (gastroesophageal reflux)
• irritation of the eardrum (which is innervated by the vagus nerve)
• general anesthesia
• surgery
• bloating
• tumor
• infection
• diabetes

Diagnosis

Hiccups are diagnosed by observation, and by hearing the characteristic sound. Diagnosing the cause of intractable hiccups may require imaging studies, blood tests, pH monitoring in the esophagus, and other tests.

Treatment

Most cases of hiccups will disappear on their own. Home remedies which interrupt or override the spasmodic nerve circuitry are often effective. Such remedies include:

• holding one's breath for as long as possible
• breathing into a paper bag
• swallowing a spoonful of sugar
• bending forward from the waist and drinking water from the wrong side of a glass

Treating any underlying disorder will usually cure the associated hiccups. Chlorpromazine (Thorazine) relieves intractable hiccups in 80% of cases. Metoclopramide (Reglan), carbamazepam, valproic acid (Depakene), and phenobarbital are also used. As a last resort, surgery to block the phrenic nerve may be performed, although it may lead to significant impairment of respiration.

Prognosis

Most cases of hiccups last no longer than several hours, with or without treatment.

Prevention

Some cases of hiccups can be avoided by drinking in moderation, avoiding very hot or very cold food, and avoiding cold showers. Carbonated beverages when drunk through a straw deliver more gas to the stomach than when sipped from a container; therefore, avoid using straws.

BOOKS

Hurst, J. Willis. Medicine for the Practicing Physician. Stamford: Appleton & Lange, 1988.

Richard Robinson

KEY TERMS

Nerve—Fibers that carry sensory information, movement stimuli, or both from the brain and spinal cord to other parts of the body and back again. Some nerves, including the vagus nerve, innervate distantly separated parts of the body.