The role of the physician face a hiccup is important because it must determine the cause, prognosis, and whether further tests are needed. While the basic physiology is the same, everything opposes the different varieties of hiccups.
There are three kinds of hiccups:
– Isolated: brief and organized physiological contraction of the respiratory muscles, unique, involuntary and everyday, which often goes unnoticed. It is a physiological activity in children as in adults;
– Acute: repetitive shocks lasting less than 48 hours, sometimes noisy, the subject is conscious. This is an annoying phenomenon, but not serious, as everyone knows, and smile; banal experience that occurs at any age, and whose prognosis is excellent;
– Chronic: repetitive shaking for more than 48 hours, with a guarded prognosis. Indeed, it can be a symptom of a disease or pathological underlying complication and is often rebellious. His prognosis is the long-term continuation of variable frequency tremors and often at intervals of a few days or weeks per month.
It is the cause of significant disability.
It is usually the only hiccup that involves a serious medical care with particular research its cause to try an etiological treatment. The reflux esophagitis is the most frequent, far ahead of the causes thoracic, abdominal, cerebral or psychic.
The physiological mechanisms of hiccups are incompletely known. We know that this physiological phenomenon has coordinated brutal contraction of all the inspiratory muscles, quickly followed by the closure of the upper airway.The usefulness of hiccups remains a mystery, but it is a MOTION The role of the physician face a hiccup is important because it must determine the cause, prognosis, and whether further tests are needed. While the basic physiology is the same, everything opposes the different varieties of hiccups.
There are three kinds of hiccups:
– Isolated: brief and organized physiological contraction of the respiratory muscles, unique, involuntary and everyday, which often goes unnoticed. It is a physiological activity in children as in adults;
– Acute: repetitive shocks lasting less than 48 hours, sometimes noisy, the subject is conscious. This is an annoying phenomenon, but not serious, as everyone knows, and smile; banal experience that occurs at any age, and whose prognosis is excellent;
– Chronic: repetitive shaking for more than 48 hours, with a guarded prognosis. Indeed, it can be a symptom of a disease or pathological underlying complication and is often rebellious. His prognosis is the long-term continuation of variable frequency tremors and often at intervals of a few days or weeks per month.
It is the cause of significant disability.
It is usually the only hiccup that involves a serious medical care with particular research its cause to try an etiological treatment. The reflux esophagitis is the most frequent, far ahead of the causes thoracic, abdominal, cerebral or psychic.
The physiological mechanisms of hiccups are incompletely known. We know that this physiological phenomenon has coordinated brutal contraction of all the inspiratory muscles, quickly followed by the closure of the upper airway.The usefulness of hiccups remains a mystery, but it is a common complex respiratory movement to all vertebrates.
Hiccups are a nervous complex organized through all the nerve centers cérébromédullaires activity whose primary afferent esophagus is via the vagus.
MAIN CONDITIONS:
Acute hiccups:
The acute hiccups really pose any medical problem, since the discomfort is limited in time to a few hours at most.
The etiology is often obvious: power abuse or drink, occlusion, caustic ingestion, side effect of a drug, etc. Many popular methods course in order to interrupt the hiccup.
They generally have the mechanism apnea or diversion of attention. Given the strong tendency of spontaneous acute hiccups disappear and not come back, the real effectiveness of these methods remains questionable.
Nevertheless, if we are faced with acute hiccups that we want to block, Salem maneuver may help, as well as, if applicable, gastric emptying by suction (Fig. 1).
A semi-rigid plastic probe is inserted horizontally from front to back through the nose to touch the back wall of the pharynx.
Once this contact is made, the probe is printed small movements back and forth to simulate the pharyngeal receptors and trigger a hiccup inhibitory reflex.
The touch of the posterior wall of the pharynx nasal probe is physical method of blocking the more reliable hiccup. It is only effective shortly. It can be very useful to block acute hiccups. Repetition in a chronic hiccup is sometimes the cause of trauma to the posterior pharyngeal wall.
Chronic hiccup:
Diagnosis:
Quite different is the problem of chronic hiccups.Indeed, on one hand it can be a sign of a serious medical problem and therefore justify a diagnostic approach focused primarily towards the esophagus, on the other hand, it is per se to cause a stir serious somatic, which imposes its reduction by all means.
After detailed clinical examination, if the etiology of hiccups is not clear, additional tests are prescribed in two steps: 1) Esophageal balance sheet; 2) Research other causes whose causes neuropsychological (Fig. 2). As in acute hiccups, if deemed necessary, the Salem movement can relieve the patient by temporarily blocking hiccups (Fig. 1). This allows to perform more quietly additional tests.
Given the high frequency of esophageal abnormalities that may be responsible for the hiccups and therapeutic resulting impact, priority is given to the clinic and to the achievement of upper gastrointestinal investigations. Only in a second time than other systems will be explored.The diagnosis of hiccups of central origin, organic or psychological, will only be done rarely and sometimes exclusion.
Upper gastrointestinal endoscopy:
Upper gastrointestinal endoscopy is the priority review.
Abnormalities (mainly esophageal) were observed in the majority of patients: hiatal hernia, esophagitis more or less severe exposure to the risk of Barrett’s esophagus, gastritis, bulbite, ulcer.
24-hour pH monitoring:
This examination is complementary to endoscopy directly showing the importance of acid reflux, which is not always parallel to endoscopic lesions. The relevance of this reflux is proved by the Bernstein test which could in certain observations trigger hiccups.
Manometry:
Oesophageal dyskinesia is demonstrated in the majority of chronic hiccups.
There may be minor abnormalities associated with GERD (hypotonia or abnormal relaxation of the lower esophageal sphincter, abnormal esophageal motility) of a mega-esophagus or hypertension. Some patients behave like “gullets cassenoisette” although they have no sténocardiques pain.
Thoracic and brain imaging:
Imaging is disappointing in chronic hiccups. with rare mediastinal tumors or abnormalities, rare brain tumor or vascular pathologies, it does not show most often the cause of hiccups.
Etiology:
Non digestive causes:
Many non-gastrointestinal causes of hiccups have been identified. Their accountability is based at least on the coincidence between the disappearance of hiccup and treatment. In some cases, relapses can be concluded causal link.
More fragile are symptomatic associations, especially as chronic hiccups usually occurs in male patients of the third or fourth age, or with cachectic terminally ill with a fatal disease (AIDS or cancer most often). Polypathology frequent in these patients requires caution before drawing conclusions about the genesis of the hiccups.
Other causes:
Multiple bowel disease have been associated with chronic hiccups, of peritonitis in subphrenic abscess through neoplasia of all organs (kidney cancer, pancreatic, lymphoma, sarcoma, tumors of the mesentery, parasites, diseases liver or diaphragmatic).
It was also described hiccups related intrathoracic affections as tuberculosis, suppuration, pleurisy or pericarditis, cancers.
Some neck diseases like goitre, lymphadenopathy or lymphoma, throat or ENT diseases of the ear canal, tumors of the skull base have been reported with hiccups.
Neurological, mainly in the posterior fossa, the hiccups are classically instead of the bird of ill omen and head injuries as meningitis or encephalitis in, hiccup is a sign of poor prognosis.
It is the same in intracranial hypertension tumor or vascular cause.
Some meningitis sequelae, vascular malformations or operated tumors can be expressed as chronic hiccups.
TREATMENT:
Treatment and evolution of chronic hiccups:
The overall objective of the management is the identification and treatment of the cause of chronic hiccups. Patient follow-up shows that the majority is in complete remission after etiological treatment, usually of reflux esophagitis. A minority is in partial remission (persistent hiccups, but with a frequency and a much reduced frequency), and a few patients are failing (persistent hiccups with identical frequency and periodicity or even higher despite therapeutic trials). Often periods of hiccups persist for several days alternating with remissions.
The most typical clinical case is that of an old male subject suffering from periodic hiccups, one to three weeks per month, including related medical treatments (Table I) will allow the best to reduce the frequency and intensity the hiccup attacks. These patients often have respiratory blockages, hiccups paroxysms for a few seconds during which no inspiratory or expiratory air flow is possible, the chest being blocked by paralyzed muscles in maximal inspiration.An improvement is possible by coupling the tricyclic antidepressants, inhibitors of serotonin reuptake, and baclofen.
Drug treatment:
The drugs in Table I have set an example.
The list merely reflects some therapeutic possibilities, and prescribing habits. They have no claim to completeness.
CONCLUSION:
Acute hiccups poses little care problems unless it is associated with a progressive pathological condition, usually obvious, and whose treatment rule hiccups. But in most cases, it does not require to apply a strong medical activity.
Chronic hiccup, it is a rare and debilitating condition that requires specialized care. Research and treatment of his case priority. Obviously, the clinical context can strongly towards a solution, but usually lack clinical trail, the decision tree of Figure 2 applies. It often leads to the discovery and treatment of esophageal dyskinesia.
It remains to determine which anomalies are primarily esophageal and which are of other origin: in other words, if the esophagus is guilty or if he is just a victim of hiccups triggered and perpetuated elsewhere. Most often, the treatment esophageal settles it. In case of failure of the latter, one can have the use of other drugs antihoquet (Table I).
