Series: "Disorders that upset us in gastroenterology"
We chose this title to define a particular set of conditions that are difficult to manage. According to the Dictionary of the Royal Academy, a disorder is defined as a “mild alteration in health” and the verb to upset means “to disturb or remove tranquility or peace.” Doctors are often disturbed by these conditions that, although not serious, greatly upset the patient and represent a frequent reason for consultation. In many cases we lack an effective treatment and the literature is insufficient to help us. The purpose of this guide is to know how far we have come in the study and treatment of these disorders, what experts think and what evidence-based medicine contributes.
Series index
- oral thrush
- burning mouth
- anal itching
- Prolonged hiccups
- Functional anorectal pain
- Belching
- balloon
- Halitosis
In each of them we will make an introduction where we will summarize the basics of current medical knowledge and the treatments usually recommended. Below, we will refer in more depth to the recommended literature and what informs evidence-based medicine when it is available.
Persistent hiccups: the clinical problem
Generally, temporary hiccups are quite frequent and subside spontaneously in a few minutes or a few hours throughout that same day. It can have a frequency of 4 to 60 contractions per minute
In certain cases, however, it becomes a prolonged condition that sometimes prevents the patient from sleeping and eating, leading to exhaustion.
Unfortunately we do not have absolutely effective therapeutic measures at the moment.
Introduction and epidemiology
It can be observed at any age, from infants to the elderly and has also been proven in the fetus.
Alcohol and gastric distension related to heavy eating sometimes act as triggers. Up to 20% of patients with Parkinson’s disease experience hiccups at some point during the course of their disease. Persistent hiccups are those that last more than 48 hours.
Pathophysiology
It is triggered by repeated and involuntary myoclonic contractions of the diaphragm, and sometimes of the intercostal muscles, followed by rapid closures of the glottis that produce the "hic" sound that characterizes it. It has been reported that in 80% of cases the contractions only involve the left hemidiaphragm.
Clinical picture
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Treatment
A series of maneuvers have been described to control hiccups. For example:
- Inhale deeply and then hold your breath for as long as possible. If the hiccups subside, it is advisable to release the air slowly and then breathe very shallowly.
- Breathe into a paper bag (not any other material) to increase the concentration of CO2 in the blood and thus stimulate the respiratory center.
- Place 2 drops of vinegar or ether in the nose (the latter cannot be placed with a common dropper due to its low surface tension; a small syringe with a very fine needle will be used).
- Drink 2 glasses of ice water without breathing.
- Pulling of the tongue.
- Swallow sugar or crushed ice.
- Place a nasogastric tube and others.
- Acupuncture has also been used.
Regarding medications, the following have been used:
High-dose proton pump inhibitors (eg esomeprazole 40 mg every 12 hours). This treatment can even be tried as an initial therapeutic trial.
- Chlorpromazine
- Baclofen
- Metoclopramide
- Haloperidol
- Carbamazepine
- Gabapentin
- Amitriptyline
In the study published by the Cochrane organization, it was concluded that there were no studies at the moment that provided sufficient evidence to recommend any type of treatment, whether pharmacological or non-pharmacological, for primary hiccups.
In refractory cases, it should be investigated whether it is a hiccup secondary to another pathology, since in this case the treatment will be that of the underlying pathology, which is where the therapy is most effective.
To detect secondary hiccups, a laboratory routine that includes an ionogram is recommended as initial studies; and an upper video endoscopy.
Upper video endoscopy is important since any esophagitis can be a cause of persistent hiccups; Although the most common is reflux esophagitis, this has also been described in herpetic esophagitis. Later, a brain MRI and a chest CT may be required before classifying the hiccups as primary.
Anecdote:
The Guinness Book of Records includes the case of a man who suffered from hiccups for 69 years and 9 months . The hiccups subsided with prayers to Saint Jude Thaddeus, the saint of impossible causes.
In the first half of the last century, in Spain and in our country, to treat infants with hiccups, it was customary to place a red thread on the forehead.
It is also reported that hiccups subside with orgasm, even those achieved through masturbation.
Recommended Readings
Steger M, Schneemann and Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42(9) 1037-1050.
