Persistent Postoperative Hiccups

Hiccups are a common transient ailment that affects most people at least once in their lifetime. Hiccups occur due to an involuntary contraction of the diaphragm and intercostal muscles, causing sudden inspiration with the “hic” sound and subsequent abrupt closure of the glottis [1]. Although its pathophysiology is a bit unclear, hiccups are thought to be a reflex arc with afferent limbs including the phrenic nerve, vagus nerve, and sympathetic chain and efferent limbs of the phrenic nerve and intercostal muscles. In rare situations, persistent hiccups can occur in the postoperative period.

 

The categorization of hiccup severity depends on the timeline of symptoms. Hiccups that last <48 hours are defined as “transient” and are unlikely to be due to underlying disease. Most people experience these type of hiccups and experience little to no change in quality of life beyond a mild annoyance. Common causes include gastric distention from overeating or carbonated beverages. “Persistent” hiccups last 48 hours – 1 month while “intractable” hiccups last greater than 1 month [2]. These longer lasting hiccups are often more serious and can be caused by stroke, head trauma, phrenic nerve irritation, and alcohol. Less common but possible causes include postoperative complications from general anesthesia, intubation, neck extension causing stretching of phrenic nerve roots, gastric distention, and traction on viscera. Few studies have elucidated the frequency and pathophysiology of postoperative hiccups.

 

Initial management of persistent hiccups include physical maneuvers such as breath holding as tolerated, the Valsalva maneuver for 5 seconds, and pulling on the tongue, which may have varying efficacy depending on the individual [3]. New researchers at the University of Texas have developed a forced inspiratory suction and swallow tool (FISST) patented as “HiccAway” which induces diaphragmatic contraction and epiglottic closure [4]. Subjects that had hiccups at least once a month were given FISST and asked to track their hiccup duration. FISST stopped hiccups in 92% of cases and was demonstrated to be more efficacious than traditional home remedies, making it a promising new tool for hiccup treatment.

 

For persistent and intractable hiccups, workup should include looking for underlying causes, such as a structural issue or medication side effect. Many times, a clear cause may not be found. If physical maneuvers do not work for eliminating hiccups, pharmacotherapy is the next step to consider. Treatment includes medications such as baclofen or metoclopramide depending on the etiology of the hiccups [5]. If the hiccups are refractory to medication, more invasive treatments such as nerve blocks can be performed. Lee et al. reported success in treating 3 patients who developed postoperative hiccups with a stellate ganglion block. After the procedure, the frequency and intensity of hiccups decreased and eventually stopped completely [6]. Similarly, phrenic nerve blocks stop hiccups in refractory cases [7]. Other options include vagus nerve stimulators, implantable breathing pacemakers, or acupuncture, though the evidence for these treatments consists mainly of case reports due to lack of research.

 

Hiccups are a symptom that are associated with a wide range of underlying causes. Treatment will depend on severity and duration of hiccups. For most people, transient hiccups resolve spontaneously or can be alleviated with physical maneuvers. For more serious types of hiccups, there are a wide range of treatment options, though they lack systematic study. Hopefully, with more research in the future, we can further characterize the causes of hiccups in addition to developing more treatment options.

 

References

 

  1. Lembo AJ. Hiccups. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
  2. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med. 1991 May;20(5):565-73. doi: 10.1016/s0196-0644(05)81620-8. PMID: 2024799. 
  3. Hosoya R, Uesawa Y, Ishii-Nozawa R, Kagaya H. Analysis of factors associated with hiccups based on the Japanese Adverse Drug Event Report database. PLoS One. 2017 Feb 14;12(2):e0172057. doi: 10.1371/journal.pone.0172057. PMID: 28196104; PMCID: PMC5308855. 
  4. Alvarez J, Anderson JM, Snyder PL, et al. Evaluation of the Forced Inspiratory Suction and Swallow Tool to Stop Hiccups. JAMA Netw Open. 2021;4(6):e2113933. doi:10.1001/jamanetworkopen.2021.13933 
  5. Jeon YS, Kearney AM, Baker PG. Management of hiccups in palliative care patients. BMJ Support Palliat Care. 2018 Mar;8(1):1-6. doi: 10.1136/bmjspcare-2016-001264. PMID: 28705925. 
  6. Lee AR, Cho YW, Lee JM, Shin YJ, Han IS, Lee HK. Treatment of persistent postoperative hiccups with stellate ganglion block: Three case reports. Medicine (Baltimore). 2018 Nov;97(48):e13370. doi: 10.1097/MD.0000000000013370. PMID: 30508930.
  7. Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol. 1985 Dec;7(6):539-52. doi: 10.1097/00004836-198512000-00021. PMID: 2868032.