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When a hiccup is more than just a hiccup

Consumer Reports News: May 24, 2010 11:56 AM

Several years ago I faced a despondent and very tired college student in my office. Her story was punctuated every few seconds with loud hiccups. They had been present off and on for two weeks. Her life was miserable. She was unable to eat except during brief periods of respite and had lost a lot of weight. She slept in snatches, and her roommate said that the hiccups continued even during her short naps. She was too tired and too embarrassed to attend class. She had tried everything that she and those close to her could think of, without success.

The mysterious hiccup

Just about everybody hiccups, at least now and then. Even fetuses and animals hiccup. Usually it’s a nuisance, an embarrassment, but little more. It lasts for a few moments, rarely longer than an hour or two, and then disappears because of, or despite, efforts to stop it. Common triggers include alcohol, carbonated beverages, spicy foods, eating too fast, and sudden and severe emotional stress.

For reasons that are not understood, those stimuli sometimes activate the vagus nerve, behind the throat, which in turn sends a message to the diaphragm, causing it to contract and the chest to expand. That triggers a rapid influx of air through the nose and mouth. In less than 35 milliseconds the glottis (a tissue flap that guards the entrance to the trachea, or windpipe) closes and produces the characteristic sound as the incoming air is blocked from entering the trachea.

When the body malfunctions there is often a method to its madness, as with the fever that creates a hostile environment for the infecting organism, or the diarrhea that rids the colon of toxins from food poisoning. But no one has yet figured out why hiccups exist or what purpose they serve.

Hit or miss solutions

Everyone has a pet remedy for hiccups, though most probably have no idea why they try what they do. But there may actually be some rationale for certain common techniques. For example, holding your breath, breathing into a paper bag, or sipping a glass of water slowly and without breathing all increase carbon-dioxide levels in the blood, which may decrease the sensitivity of the vagal nerve center in the brain. And stuffing a finger into each ear, drinking ice water, stroking the back of the throat with a swab, or swallowing a teaspoon of table sugar may also depress vagal nerve activity.

When hiccups last longer than a day or so, medical intervention can usually end the suffering. And, as with any disorder that has no specific cure, there are many treatments that are usually tried. Chlorpromazine (Thorazine and generic), a major tranquilizer, is the old standby, closely followed by the minor tranquilizer diazepam (Valium and generic), the antispasmodic metochlopramide (Reglan and generic), and the muscle relaxant baclofen (Lioresal and generic). If one doesn’t work, the next one might. Occasionally, the topical anesthetic lidocaine can be sprayed on the back of the throat. When those measures fail, passing a tube through the nose into the stomach often works.

More than inconvenient

The longest recorded case of unexplained hiccups lasted 63 years. But hiccups that linger beyond a few days are often a worrisome sign. They can be traced to problems anywhere from the belly to the brain. Causes include benign and malignant tumors, inflammation, infections, and neurological disorders. While hiccups are often the only obvious symptom, a careful medical history and follow-up with appropriate imaging tests can usually reveal the cause.

On further questioning I learned that our college student had had an appendectomy about a month before the hiccups started, with the seemingly uneventful removal of an inflamed appendix. But she had never quite recovered and in the past two weeks had experienced night sweats and possibly a low-grade fever. A CT scan of her abdomen showed a collection of fluid under her right diaphragm that turned out to be an abscess, no doubt a result of leakage from the removed but infected appendix. Following drainage of the abscess and a prolonged course of antibiotics, her hiccups gradually diminished and eventually disappeared. She is now a very healthy professor—who still reacts with fear and trepidation to any recurrence of hiccups, no matter how short-lived.

Marvin Lipman, M.D., Consumer Reports chief medical adviser

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