diease

Hiccup


OVERVIEW OF Hiccup :

Hiccups occurs due to the contraction or spasm of the muscles of the diaphragm and also the spasm occurs in the throat giving rise to the hiccup sound. The larynx and vocal cords closes suddenly. Singultus is the medical term used for the hiccups.


CAUSES :

The following are the causes of the hiccup. It might arises due to:

Overeating of the food

Eating spicy food

Consuming alcohol

Drinking carbonated beverages such as Soda

Consuming very hot or very cold foods

A sudden change in the air temperature

Swallowing air while chewing gum

Excitement or emotional stress

Aerophagia

 

The majority of the hiccups which are persistent are caused by injury or irritation to either the vagus nerve or phrenic nerve. The vagus and phrenic nerves control the movement of the diaphragm. These nerves may be affected by:

Irritation of the eardrum which may be caused by a foreign object

Throat irritation or the soreness

Enlargement of the Thyroid gland which is called as Goitre.

A stomach acid backing up into the esophagus the tube that moves food from the mouth to the stomach which is called as the gastroesophagel reflux disease

A tumour or cyst that belongs to the esophagus

 

Other causes of the hiccups might occur due to the involvement of the central nervous system. The CNS includes the brain and spinal cord. If the CNS is damaged the body might lose the ability to control the hiccups.  CNS damage might lead to the persistent hiccups which  constitutes the following causes:

Stroke

Multiple sclerosis ( A chronic degenerative nerve disease)

Tumours

Meningitis

Encephalitis( infection that causes inflammation of the brain)

Head trauma

Ischaemic or cerebro vascular insult

Hydrocephalus( accumulation of fluid on the brain)

Neurosyphilis

Hiccups that lasts longer periods can also created by the following causes:

Over usage of the alcohol

Tobacco use

An anaesthetic reaction after surgery

Certain classes of drugs which includes the barbituarates, steroids and tranquilizers

Diabetes

An electrolyte imbalance

Kidney failure

Arteriovenous malformation ( a condition in whch arteries and veins are tangled in the brain)

Cancer therapy such as chemotherapy and targeted cell therapy.

 


PATHOPHYSIOLOGY :

Hiccups are spontaneous , myoclonic contraction of the diaphragm and in many cases the spasm of the intercostal musculature also occurs. The hiccups are generated by a reflex arc with afferent, central and efferent components. The afferent impulses are arrived by the vagus nerve, phrenic nerve and the sympathetic nerve fibers that is from the thoracic outflow that is T6 to T 12. Areas of the CNS involved in the hiccup response appear include the upper spinal cord ( C3 to C5), the brain stem in the medulla oblongata near the respiratory center , the reticular formation and the hypothalamus. Dopaminergic and gamma amino butyric acid ( GABA – ergic) neurotransmitters can modulate this central mechanism. These efferent response of the reflex is carried by the phrenic nerve to the diaphragm that has been observed to contract unilaterally or also bilaterally. Activation of the accessory nerves leads to the contraction of the intercostal muscles.  These mechanism of the reflex is closed by the glottis and it occurs by the recurrent laryngeal nerve. Glottal closure is an important protective reflex because without that the patients with a tracheostomy hiccups lead to significant hyperventilation


DIAGNOSTIC :

During the physical examination the physician might perform a neurological exam to check the following :

Balance and co-ordination: The physician might check for the balance and co ordination and performs various test to examine that.

Muscle strength and tone: The physician might check for the various reflexes to investigate the muscle tone and muscle strength.

The physician might check for the muscle reflexes, sight and sense of touch.

Laboratory tests:

Samples of the blood might be checked for the signs such as Diabetes, Infection and Kidney disease.

Imaging tests

These types of tests may be able to detect anatomical abnormalities that may be affecting the vagus nerve, phrenic nerve or diaphragm. Imaging tests may include:

It is usually diagnosed with the history of the patient and behavioural changes and impaired cognitive functions.

Magnetic resonance imaging-MRI

Computed tomography-CT

Single photon emission computed tomography

Electroencephalogram(EEG): the doctors might suggest EEG to detect any abnormalities in the brain.

Imaging tests: CT scan, MRI scan SPECTs and  PET scans help doctors locate the tumor and determine if it is cancerous or benign.

Neurological exam: During a neurological exam, your doctor will look for changes in your balance, coordination, mental status, hearing, vision and reflexes. These changes can point to the part of your brain that may be affected by a tumor.

Spinal tap:A doctor uses a small needle to remove fluid from around the spine. A laboratory examines this fluid to look for cancer cells. It is also known as lumbar puncture.

Endoscopic tests

These procedures utilize a thin, flexible tube containing a tiny camera, which is passed down your throat to check for problems in your esophagus or windpipe.

 


TREATMENT AND PROGNOSIS :

The problems are treated with the proton pump inhibitors for gastroesophageal reflux disease and dilatation of the esophageal stricture.

Partial amount of the carbon-di-oxide can be increased and diaphragmatic action can be inhibited by the series of deep breath holds or by breathing deeply into and out of the paper bag. Vagal stimulation by pharyngeal irritation such as swallowing dry bread, granulated sugar, crushed ice or applying traction on the tongue.

The following medications can be used to treat the hiccups:

The drug such as Baclofen a gamma aminobutyric acid agonist 5mg orally may be very effective. The  other oral drugs include chlorpromazine 10 to 50 mg 3 times a day as needed. Antiemtics such as the metoclopramide and various anticonvulsants such as gabapentin can be used to relieve the symptoms. The proton pump inhibitors are given. For severe cases Chlorpromazine IM or IV can be given.

In intractable cases , the phrenic nerve may be blocked in small amounts of 0.5 % procaine solution with caution being taken to avoid respiratory depression and pneumothorax. Even bilaterall phrenicotomy does not cure all the cases.


PREVENTION :

Avoid eating bulk or larger quantities of food

Avoid spicy foods

Stay hydrated.


REFERENCE :

https://www.medindia.net/patients/patientinfo/hiccups-reference.htm

https://www.oxfordreference.com/view/10.1093/oi/authority.20110803095935163?result=5&rskey=q1ltVs

https://emedicine.medscape.com/article/775746-overview

https://www.oxfordreference.com/view/10.1093/oi/authority.20110803095935163?result=5&rskey=q1ltVs