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On temporal structure of human hiccups: ethology and chronobiology.
During a study on the phylogeny and ontogeny of human hiccups, essentially all hiccups to occur over continuous periods of 3m - lly were recorded from 20 healthy people of either sex and various ages. Hiccups displayed considerable structure in time. If more than a few occurred together, they became "established" and a hiccup bout ensued, which did not stop until a certain "minimum" number of hiccups had occurred. For many subjects, two or more bouts frequently occurred on the same hiccup day, even though days on which bouts occurred were weeks apart. Number of hiccups was correlated with age, sex, reproductive status and stage of menstrual cycle, time of day, length of time since previous hiccup day, length of time since previous hiccup bout, and length of hiccup-hiccup intervals within a bout. Findings support the hypothesis that human hiccup is a "fixed action pattern" (FAP)--a central theoretical concept in ethology--and provide leads for further studies aimed at learning the biological function(s) of human hiccup and its possible homologues in other species.
Hiccups: esophageal manometric features and relationship to gastroesophageal reflux.
Gastroesophageal reflux (GER) has been reported to be a cause of hiccups. Conversely, some reports state that hiccups cause or adversely affect GER disease. There have been few descriptions in the literature of what hiccups do to esophageal motility. We present a patient with long-standing symptomatic GER and intractable hiccups. Esophageal manometry during hiccups showed absence of LES pressure and absence of peristaltic activity in the esophageal body in response to swallowing, factors which could aggravate GER. Esophageal motility in the absence of hiccups was normal. Antireflux surgery in our patient relieved heartburn but not hiccups. Based on our case and a review of the literature, we believe that clinicians should be cautious in recommending antireflux surgery to treat hiccups in patients with both hiccups and heartburn.
Hiccups: causes and cures.
Hiccups result from a wide variety of conditions that act on the supraspinal hiccup center or that stimulate or disinhibit the limbs of its reflex arc. While scores of hiccup remedies have been reported over the centuries, no single "cure" stands out as being the most effective. Measures that stimulate the uvula or pharynx or disrupt diaphragmatic (respiratory) rhythm are simple to use and often help to speed the end of a bout of otherwise benign, self-limited hiccups. Such manueuvers may also terminate persistent hiccups. Drug therapy usually becomes necessary for more intractable hiccups; chlorpromazine and metoclopramide being two of the most widely employed agents for this purpose. Physical disruption of the phrenic nerve, hypnosis, and acupuncture are other modes of therapy that have been used in severe cases. Because so many reports of hiccup "cures" are based on anecdotal experience rather than controlled clinical studies, I review the available treatments to provide a rational approach for the management of hiccups.
Hiccups and gastroesophageal reflux: cause and effect?
Chronic hiccups may be a problem of great significance to the affected patient. A 62-year-old man with severe heartburn and persistent hiccups despite numerous diagnostic tests and therapeutic drug trials presented to our clinic. Esophageal motility and intraluminal pH studies demonstrated decreases in intraesophageal pressure during hiccups and acid exposure during 68% of the measured time. The patient underwent Nissen fundoplication, which improved his heartburn but not his hiccups. The association between gastroesophageal reflux and hiccups is discussed. Our experience suggests that the presence of hiccups and gastroesophageal reflux in the same patient may be coincidental rather than having a cause-and-effect relationship.
Intractable hiccup induced by brainstem lesion.
Four patients with brainstem lesions presented with intractable hiccup and mild to moderate neurological signs. Two of the patients had been initially diagnosed as having a psychogenic cause for their hiccup. Magnetic resonance imaging (MRI) demonstrated brainstem infarction in one case, tuberculoma at the junction of the medulla oblongata and the cervical spinal cord in two, and a vermian tuberculoma compressing the brainstem in one. The brainstem infarct and one of the medullary tuberculoma were not detected on high resolution enhanced computed tomography. The 3 patients with CNS tuberculoma were free of hiccup 1-5 months after antituberculous chemotherapy. It is proposed that hiccup is not an abnormal reflex, but a myoclonus generated by repetitive activity of the "inspiratory solitary nucleus" due to release of higher nervous system inhibitory/-regulatory control. The neuroanatomical network and the mechanisms underlying the formation of intractable hiccup are outlined. The value of MRI in the initial diagnosis and follow-up of patients with intractable hiccup due to brainstem lesions is emphasised.
Termination of intractable hiccups with digital rectal massage.
A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a nasogastric tube. Removal of the latter did not terminate the hiccups which had also been treated with different drugs, and several manoeuvres were attempted, but with no success. Digital rectal massage was then performed resulting in abrupt cessation of the hiccups. Recurrence of the hiccups occurred several hours later, and again, they were terminated immediately with digital rectal massage. No other recurrences were observed. This is the second reported case associating cessation of intractable hiccups with digital rectal massage. We suggest that this manoeuvre should be considered in cases of intractable hiccups before proceeding with pharmacological agents.
Hoquet diabolique: intractable hiccups as a manifestation of multiple sclerosis.
In three patients, intractable hiccups occurred as part of the symptomatology of multiple sclerosis. In one patient intractable hiccups were the presenting complaint, and in another patient exacerbations of symptoms were almost always heralded by intractable hiccups. Intractable hiccups occur in a variety of diseases, including many that affect the brainstem and cervical cord, but have not been reported in multiple sclerosis. The hiccup may be a "primitive" gastrointestinal reflex that is disinhibited by lesions such as multiple sclerosis plaques. Carbamazepine was successful in arresting the hiccups in one of the cases presented.
Long-standing hiccup in a patient with sarcoidosis.
The patient was a 67-year-old male. A diagnosis of sarcoidosis was made both by transbronchial lung biopsy and by scalene node biopsy. The findings of his chest roentgenogram were categorized as the group II. There were no symptoms during follow-up period of one year at the out-patient clinic with no medication. The chest X-ray findings of the patient were slowly progressive. Intractable hiccup developed one year after his first visit to the hospital. With administration of prednisolone, serum angiotensin converting enzyme level decreased promptly, and the incidence of the hiccup attack decreased. As the dose of prednisolone was tapered, the hiccup recurred. All the drugs used for hiccup including quinidine sulfate and metoclopramide was not effective. A thoracic CT revealed slight enlargement of mediastinal lymph nodes. A brain CT and a brain MRI demonstrated no abnormalities. Acetazolamide, which induces acidosis in brain extra-cellular fluid, worsened the symptoms. As prednisolone was given again, infiltrates on the chest roentgenogram began to resolve and the incidence of hiccup decreased. We concluded that the long-standing hiccup observed in this patient may be brought by the lesion in central nervous system due to sarcoidosis.
Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study.
Four patients with intractable hiccup were treated in a double-blind, randomized, placebo, cross-over study with an analogue of gamma-aminobutyric acid, Baclofen. There was a consistent and statistically significant (p = 0.03) improvement in hiccup severity with Baclofen, both subjectively (p = 0.03) and by hiccup-free periods (p = 0.003). The actual frequency of hiccup was not significantly altered by the medication. We propose that the mechanical aspects of hiccup are reduced by Baclofen, leading to a perceptual blockage and a decrease in the reflex severity induced by the gamma-aminobutyric acid analogue. We conclude that this medication may be useful for the treatment of intractable hiccup.
Hiccups and esophageal dysfunction.
Presented herein are the detailed esophageal manometric, radiologic, ambulatory pH, and scintigraphic findings from a patient who developed protracted and recurrent hiccups (singultus) after a lateral medullary infarction. Because of the usually transient and benign nature of hiccups, previous reports on esophageal dysfunction during hiccups have been sporadic and confined to manometric findings. Utilizing various esophageal function techniques, the main features observed during hiccups were esophageal body dilation and aperistalsis, absent lower esophageal sphincter relaxation in response to swallowing, poor emptying of the distal two-thirds of the esophageal body, and low distal esophageal pH. Most of these features normalized in the absence of hiccups. A comparison is made of these findings during prolonged hiccups with those of esophageal achalasia.
The effect of ketamine in patients with refractory hiccup in the postoperative period. Preliminary report.
In 5 cases of refractory postoperative hiccup the authors observed a favourable effect of a single dose of ketamine administered intravenously. Earlier applied procedures and drugs failed to control hiccup or alleviated it for only a short time. In all cases the overfilling of the stomach was ruled out as a cause of hiccup by routine preliminary examination. The doses of ketamine used (0.5 mg/kg of body weight) caused no central nervous system disturbances in postoperative patients. In view of the small number of observed cases the authors regard this report as a preliminary communication and as an encouragement for further investigations on the usefulness of ketamine in the treatment of postoperative hiccup and also in treatment of hiccup in patients in other medical specialities.
[A case of multiple sclerosis with intractable hiccups and sleep apnea syndrome].
A 48-year-old female with multiple sclerosis (MS) accompanied by intractable hiccups of over one month' duration and the sleep apnea syndrome was reported. This MS patient had been well controlled until September 16, 1991 when she experienced nausea, vomiting and hiccups. The patient was admitted to Kawasaki Medical School Hospital on October 9, 1991. A physical examination revealed intractable hiccups. T1-weighted MRI showed a low and T2-weighted image disclosed a high signal intensity area in the tegmentum of the medulla oblongata. The intractable hiccups and vomiting improved with intravenous high dose methylprednisolone injection therapy. The following day, she complained of insomnia and her family observed severe snoring and apnea during the night. These symptoms and the results of a breathing monitor were compatible with the sleep apnea syndrome. These symptoms disappeared following the administration of amitriptyline. There have been few reports of the combination of intractable hiccups and the sleep apnea syndrome in MS. The MRI findings suggest that the causative lesion of these symptoms is in the tegmentum of the medulla oblongata.
[Persistent hiccup: causes, diagnosis and treatment].
Hiccup is a common phenomenon produced by the activation of a primitive reflex, which has its own center in the central nervous system. Most episodes last only a few minutes and are self-limited, but hiccup can get persistent and become a real problem for physician and patient alike. The center of hiccup may be activated by a great variety of stimuli travelling along different nerve path ways and bring different effector responses. Causes of hiccup are various and merit a systematic study of any patient with persistent hiccup.
Hiccups. A case presentation and etiologic review.
Hiccups (singultus) usually present as a common annoyance lasting for short periods. Rarely, they may be the harbinger of a serious disease. We present the case of a 19-year-old man in which intractable hiccups was the first and most prominent symptom of a serious underlying neurologic disorder. The patient had been examined by his pediatrician, and despite multiple medical regiments and physical maneuvers, his symptoms persisted. A thorough head and neck examination revealed a right-sided vocal cord paralysis. This finding prompted obtaining a magnetic resonance imaging scan, which demonstrated a type I Arnold-Chiari malformation associated with a large cervicothoracic syringomyelia. The patient was referred to the neurosurgical service and subsequently underwent a ventriculoperitoneal shunt placement. There was considerable initial improvement in his neurologic status and cessation of the hiccups. However, the symptoms recurred within 1 month. The case report as well as a brief review of the relevant pathophysiologic and etiologic considerations and several treatment modalities for hiccups is presented.
Fetal hiccups; characteristics and relation to fetal heart rate.
In 35 two-hour recordings of fetal heart rate and fetal movements, 14 periods of fetal hiccups were present (1.2% of the recording time) with a median duration of 3.5 min (range 1 to 8 min). No specific relation to behavioural states or movement patterns could be identified. The hiccupping frequency varied from 10 to 21 per min. Within a hiccupping spell, the mean frequency decreased from 20 +/- 11 to 12 +/- 6.2 per min. A small but evident increase in baseline frequency was present during the hiccupping spells, independent from other movements performed by the fetus.
[Chronic hiccups].
We report 18 cases of chronic hiccup (defined as lasting for more than 48 hours) in adults. Among the numerous possible causes, reflux esophagitis proved to be by far the most frequent (50% of the cases). However, hiccup often initiated a self-perpetuating vicious circle. This is possibly because hiccup per se can give esophageal dyskinesia, which in turn leads to gastro-esophageal reflux. The treatment was difficult and whenever possible has been directed chiefly towards the cause. However hiccup remained intractable in many cases even after a possible cause had been adequately cured (e.g., successful Nissen procedure in reflux cases). Central nervous system depressants and myorelaxing drugs were not very helpful, except for baclofen (initial response rate = 60%).
Hiccups: an unusual manifestation of an abdominal aortic aneurysm.
A patient with hiccups was found to have an abdominal aortic aneurysm that subsequently ruptured. We believe that a leaking abdominal aortic aneurysm led to an ileus-induced distention of the splenic flexure of the colon with consequent diaphragmatic irritation and phrenic nerve stimulation. This led to persistent hiccups as a result of repetitive stimulation of the reflex arc mediating hiccups. Persistent hiccups require investigation for an underlying organic etiology, and a leaking abdominal aortic aneurysm should be included in the differential diagnosis.