Causes Of Hiccups
Hiccups are caused by the sudden spasmodic contraction of the diaphragm which is immediately followed by a ‘hic’ sound produced by the closure of the glottis.
The dome- shaped muscular wall separating the abdominal cavity from the chest, called diaphragm, effects inhalation of air every time it contracts and exhalation when it relaxes. Normally, breathing is a rhythmic involuntary action which can also be controlled voluntarily. But a hiccup is a completely involuntary action controlled by the reflex arc and it usually repeats itself several times without the person having any direct control over it.
Almost everyone gets hiccups every now and then, though men are found to be more prone to it. Usually, hiccups start suddenly without any warning and stop just as suddenly within a few minutes causing nothing more than a temporary inconvenience and or a little embarrassment. Occasionally, they persist for several days to months at a time. Persistent hiccups not only result in severe distress; they are difficult to treat also. When they do not resolve by treatment, they are called intractable hiccups.
Causes Of Hiccups
The exact causes of hiccups are unknown but it is assumed that it results from a temporary irritation of the nerves supplying the diaphragm or malfunctioning of the centers in the brain responsible for the muscle control of the diaphragm.
Brief hiccups are found to follow the consumption of alcohol or hot liquids, hurried eating, a full stomach etc. even though there is no evidence to prove that the same actions would bring another episode. When people hyperventilate at times of stress, it may often trigger episodes of hiccups. It is attributed to low blood levels of carbon dioxide.
Persistent hiccups are usually caused by some serious problems such as malfunctioning of the control centers in the brain regulating breathing, or surgeries in the stomach or abdomen irritating the diaphragm. Cancers and other tumors in the brain and tissue damage due to stroke are the usual reasons for the malfunctioning of the brain. A toxic condition called uremia resulting from kidney failure and the accumulation of nitrogen compounds in the blood is another reason for hiccups that persist.
Usually, persistent hiccups are very difficult to stop unless the condition which is causing it can be treated and cured. They are also called intractable hiccups when they cannot be treated, as in the case of stroke. Prolonged episodes of hiccups may cause fatigue and loss of sleep. Weight loss is also common, probably because of the disruption to the peristaltic movement caused by hiccups.
Evaluation
There is no need to consult a doctor for hiccups lasting for brief periods. When it persists for more than 48 hours, the person should visit a doctor to determine the cause of the persistent hiccups and to initiate treatment for the underlying disorder. If certain warning signs such as loss of balance, headache or numbness also appear with the hiccups, they may indicate neurological problems behind the hiccups. In such cases, the patient should seek urgent medical care without any further delay.
When a patient visits the doctor with the complaint of persistent hiccups, doctor may do a physical examination and ask the patient about the duration of the condition and whether the patient can associate the episode with any physical activity or consumption of any specific food. The previous medical history of the patient is also important to arrive at a possible diagnosis. Doctors may need to know the following:
- Difficulty in swallowing
- Presence of GERD or gastro esophageal reflux disease
- Recent surgeries undergone
- Fever or cough indicative of pneumonia
- Symptoms indicative of malfunctioning of the brain.
- Presence of kidney related problems
- Alcohol consumption
During the physical examination, doctor may check for symptoms of neurological abnormalities such as unsteady gait and movement, blurring of speech etc. cachexia or wasting of muscle and fat due to severe weight loss is also assessed.
Testing: To determine the cause of persistent hiccups, the doctor may need to do certain tests including chest x-rays and ECG or electrocardiogram. Blood tests to determine kidney function are also conducted. Imaging tests such as MRI scan of the brain or CT scan of the chest are also done to detect abnormalities causing persistent hiccups.
Treatment: Brief episodes of hiccup do not usually come under the scope of medical treatment as they usually stop spontaneously without any treatment. However, various home remedies claim to stop it faster. Even though they are not proven to either decrease the severity of the hiccups, or reduce their duration; they are harmless attempts at getting quick relief. Methods like holding the breath for a longer period, or breathing several times into a paper bag and then inhaling from the bag, are attempts at increasing the carbon dioxide levels in the blood.
The vagus nerve is found to be responsible for certain abnormalities which affect the heart rhythm and it may probably affect the contraction and relaxation of the muscles of the diaphragm too, causing it to contract spasmodically. Stimulating the vagus nerve by various maneuvers may be tried to get relief from hiccups. Some of them are:
- Gulping down water; usually ice cold water is used
- Extending the tongue and pulling on it
- Rubbing the eyeballs gently with fingers
- Swallowing crushed ice or pieces of dry bread
- Attempting to startle the person with a sudden exclamation or a loud sound
- A spoonful of sugar in the mouth for eating quickly
The above actions may help stimulate the vagus nerve and may bring relief.
The main focus of treating persistent hiccups is the treatment and cure of the underlying disease responsible for the occurrence of hiccups. Pneumonia is treated with appropriate antibiotics. GERD is treated with proton pump inhibitors. When these diseases subside, hiccups also disappear.
When persistent hiccups have a cause which could not be detected or treated, measures to manage the condition is the next option. Most of the remedies which seem to work for stopping brief hiccups may have been tried already without any success. Drug therapy using several drugs such as baclofen, gabapentin, metoclopramide, chlorpromazine etc., is usually tried, but they are not always successful.
The phrenic nerves have the role of controlling the movements of the diaphragm; hence, blocking a phrenic nerve with the injection of a local anesthetic is done and the effect is observed. If blocking any one of the nerves had the effect of stopping the hiccups temporarily, and then if hiccups started again when the effect of the anesthetic wore off, phrenictomy is done thereby permanently blocking off the malfunctioning nerve.
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Yasser Elnahas
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