Hiccup

A hiccup (also spelled hiccough) is an involuntary contraction (myoclonic jerk) of

Hiccup
the diaphragm that may repeat several times per minute. The hiccup is an
involuntary action involving a reflex arc.[1] Once triggered, the reflex causes a Synonyms Singultus, hiccough,
strong contraction of the diaphragm followed about 0.25 second later by closure of synchronous
the vocal cords, which results in the classic "hic" sound. diaphragmatic
flutter (SDF)
Hiccups may occur individually, or they may occur in bouts. The rhythm of the Pronunciation /ˈhɪkəp, -ʌp/ HIK -
hiccup, or the time between hiccups, tends to be relatively constant.
əp, -up
A bout of hiccups, in general, resolves itself without intervention, although many Specialty Otorhinolaryngology
home remedies are often used to attempt to shorten the duration.[2] Medical
treatment is occasionally necessary in cases of chronic hiccups.

Contents
Signs and symptoms
Causes
Pathophysiological causes
Pre-phrenic nucleus irritation of medulla
CNS disorders
Nerve damage
Evolutionary causes
Clearance of air from stomach
Phylogenetic hypothesis

Treatment
Self-care and folk remedies
Society and culture
See also
References
Further reading
External links

Signs and symptoms

A single or a series of breathing diaphragm spasms, of variable spacing and duration
A brief (less than one half second), unexpected, shoulder , abdomen, throat, or full body tremor
Hiccups may present as an audible chirp, squeak, "hupp", or if controlled, a quick inhaling gasp, sigh, or snif
f.
Hiccups may present as brief but distracting or painful, frequent or occasional interruptions in normal breathing, with
sudden momentary pain of the throat, chest, and/or abdomen.

Causes

Pathophysiological causes
 Swallowing air excessively[3]
Gastroesophageal reflux[4]
Hiatal hernia[5]
Rapid eating[6]
Carbonated beverages,alcohol, dry breads, and some spicy foods[7]
Opiate drug use[8]
Laughing[9]
Hiccups may be triggered by a number of common human conditions. In rare cases, they can be a sign of serious medical problems.

Pre-phrenic nucleus irritation of medulla

Kidney failure[10]

CNS disorders

Stroke[10]
Multiple sclerosis[11]
Meningitis[10]

Nerve damage

Damage to the vagus nerve after surgery[5]

Evolutionary causes

Clearance of air from stomach

A recent explanation by Howes in 2012 suggests that hiccups may have evolved along with other reflexes developed in mammals that
allow them to coordinate suckling milk and breathing.[6] Hiccups are only found in mammals, and are most common in infants,
becoming rarer as mammals age.This may suggest that they evolved to allow air trapped in the stomach of suckling infants to escape,
allowing more milk to be ingested. The hypothesis suggests that the air bubble in the stomach stimulates the sensory limb of the
reflex at receptors in the stomach, esophagus and along the diaphragm. This triggers the hiccup, which creates suction in the chest,
pulling air from the stomach up and out through the mouth, effectively burping the animal. This theory is supported by the strong
tendency for infants to get hiccups, the component of the reflex that suppresses peristalsis in the esophagus, and the existence of
hiccups only in milk-drinking mammals.

Phylogenetic hypothesis
An international respiratory research group composed of members from Canada, France, and Japan proposed that the hiccup is an
evolutionary remnant of earlier amphibian respiration.[12] Amphibians such as tadpoles gulp air and water across their gills via a
rather simple motor reflex akin to mammalian hiccuping. The motor pathways that enable hiccuping form early during fetal
development, before the motor pathways that enable normal lung ventilation form. Thus, the hiccup is evolutionarily antecedent to
modern lung respiration.

Additionally, this group (C. Straus et al.) points out that hiccups and amphibian gulping are inhibited by elevated CO2 and may be
stopped by GABAB receptor agonists, illustrating a possible shared physiology and evolutionary heritage. These proposals may
explain why premature infants spend 2.5% of their time hiccuping, possibly gulping like amphibians, as their lungs are not yet fully
formed.[13]
Fetal intrauterine hiccups are of two types. The physiological type occurs prior to twenty-eight weeks after conception and tend to
last five to ten minutes. These hiccups are part of fetal development and are associated with the myelination of the phrenic nerve,
which primarily controls thethoracic diaphragm.

The phylogeny hypothesis explains how the hiccup reflex might have evolved, and if there is not an explanation it may explain
[14] This hypothesis has been questioned because of the
hiccups as an evolutionary remnant, held over from our amphibious ancestors.
existence of the afferent loop of the reflex, the fact that it does not explain the reason for glottic closure, and because the very short
contraction of the hiccup is unlikely to have a significant strengthening ef
fect on the slow-twitch muscles of respiration.

Treatment
Hiccups are normally waited out, as any fit of them will usually pass quickly. Folkloric 'cures' for hiccups are common and varied,
but no effective standard for stopping hiccups has been documented. Hiccups are treated medically only in severe and persistent
(termed "intractable") cases.

Numerous medical remedies exist but no particular treatment is known to be especially effective, generally because of a paucity of
high-quality evidence.[15][16] Many drugs have been used, such as baclofen, chlorpromazine, metoclopramide, gabapentin, and
various proton-pump inhibitors. Hiccups that are secondary to some other cause like gastroesophageal reflux disease or esophageal
webs are dealt with by treating the underlying disorder. The phrenic nerve can be blocked temporarily with injection of 0.5%
procaine, or permanently with bilateral phrenicotomy or other forms of surgical destruction. Even this rather drastic treatment does
not cure some cases, however.

An anecdotal medical approach is to install lidocaine liniment 3% or gel 2% into the ear canal. Somehow this creates a vagus nerve-
triggering reflex through its extensions to the external ear and tympanus (ear drum). The effect can be immediate, and also have
lasting effect after the lidocaine effect expires after about two hours.[17]

Haloperidol (Haldol, an anti-psychotic and sedative), metoclopramide (Reglan, a gastrointestinal stimulant), and chlorpromazine
(Thorazine, an anti-psychotic with strong sedative effects) are used in cases of intractable hiccups. Effective treatment with sedatives
often requires a dose that renders the person either unconscious or highly lethargic. Hence, medicating with sedatives is only
appropriate short-term, as the affected individual cannot continue with normal life activities while under their ef
fect.

Persistent digital rectal massage has also been proven effective in terminating intractable hiccups.[18] It is notable, that an Ig Nobel
Prize has been awarded for this discovery. Later in an interview the laureate Francis Fesmire explained another, probably more
popular, treatment for hiccups: "An orgasm results in incredible stimulation of the vagus nerve. From now on, I will be
recommending sex – culminating with orgasm – as the cure-all for intractable hiccups."[19]

The administration of intranasal vinegar was found to ease the chronic and severe hiccups of a three-year-old Japanese girl. Vinegar
may stimulate the dorsal wall of the nasopharynx, where the pharyngeal branch of the glossopharyngeal nerve (the afferent of the
hiccup reflex arc) is located.[20]

Bryan R. Payne, a neurosurgeon at the Louisiana State UniversityHealth Sciences Center inNew Orleans, has had some success with
an experimental procedure in which a vagus nerve stimulator is implanted in the upper chest of patients with an intractable case of
hiccups. "It sends rhythmic bursts of electricity to the brain by way of the vagus nerve, which passes through the neck. The Food and
epilepsy."[21]
Drug Administration approved the vagus nerve stimulator in 1997 as a way to control seizures in some patients with

Lockhart stated that hiccups can sometimes be cured by pinching the skin that covers the surface of the deltoid muscles, which is
[22]
supplied by the axillary nerve which shares the c5 nerve root with the phrenic nerve.

Self-care and folk remedies

There are many superstitious and folk remedies for hiccups, including headstanding, drinking a glass of water upside-down, being
frightened by someone, breathing into a bag, and eating a large spoonful of peanut butter. Placing sugar on or under the tongue has
also been used.[23][24]

A simple treatment involves increasing the partial pressure of CO2 and inhibiting diaphragm activity by holding one’s breath or
rebreathing into a paper bag.[25] Other potential remedies suggested byNHS Choices include pulling your knees up to your chest and
.[26]
leaning forward, sipping ice-cold water and swallowing some granulated sugar

Since an orgasm results in incredible stimulation of the vagus nerve, masturbation or sex - culminating in an orgasm - can also be
used as a highly effective treatment.

In Plato's Symposium, Aristophanes has a case of the hiccups and is advised byEryximachus, a physician, to cure them by holding his
breath, or, failing that, by gargling or provoking sneezing. This ancient recommendation can be compared with the vagus nerve
stimulation techniques mentioned previously
.

Society and culture

The word hiccup itself was created through imitation. The alternative spelling of hiccough results from the incorrect assumption that
it originates from the wordcough.[27]

American Charles Osborne had hiccups for 68 years, from 1922 to February 1990,[28] and was entered in the Guinness World
Records as the man with the longest attack of hiccups, an estimated 430 million hiccups.[29] In 2007, Florida teenager Jennifer Mee
gained media fame for hiccuping around 50 times per minute for more than five weeks.[30][31] Christopher Sands, a Briton,
hiccupped an estimated 10 million times in a 27-month period from February 2007 to May 2009. His condition, which meant that he
could hardly eat or sleep, was eventually discovered to be caused by a tumor on his brain stem pushing on nerves causing him to
hiccup every two seconds, 12 hours a day.His hiccups stopped in 2009 following surgery.[32]

In Slavic, Baltic, German, Hungarian, Turkish, Romanian and Indian folklore it is said that hiccups occur when the person
[33][34]
experiencing them is being talked about by someone not present.

See also
Cough
Thumps, a more serious form of hiccups found in equines
Getting the wind knocked out of you
Mr. Hiccup
Sneeze
Yawn

References
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10. "Hiccups: Causes" (http://www.mayoclinic.com/health/hiccups/DS00975/DSECTION=causes). MayoClinic.com.
2011-06-03. Retrieved 2013-07-10.
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12. Straus C, Vasilakos K, Wilson RJ, Oshima T, Zelter M, Derenne JP, Similowski T, Whitelaw WA (February 2003). "A
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15. Porter, Robert S., ed. (2011)."Hiccups" (http://www.merckmanuals.com/professional/gastrointestinal_disorders/appr
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治療 Hiccup treated by administration of intranasal vinegar".No to Hattatsu. Brain and Development(in Japanese).
39 (3): 202–5. PMID 17515134 (https://www.ncbi.nlm.nih.gov/pubmed/17515134).
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6/01/10/health/10hicc.html). New York Times. Retrieved 24 April 2008.
22. Lockhart, R. D. (1974).Anatomy of the human body(2nd ed.). Lippincott. pp. 202–5.
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Further reading
Provine, Robert R. Curious Behavior: Yawning, Laughing, Hiccupping, and Beyond (Harvard University Press; 2012)
246 pages; examines the evolutionary context for humans
Shubin, Neil (February 2008). "Fish Out of W
ater". Natural History. 117 (1): 26–31. INIST:19986878. – hiccup related
to reflex in fish and amphibians.

External links
BBC News: Why we hiccup Classification ICD-10: R06.6 · D
WIRED: The Best Cure for Hiccups: Remind Y our Brain You’re Not a Fish ICD-9-CM: 786.8 ·
Cymet TC (June 2002)."Retrospective analysis of hiccups in patients at a MeSH: D006606 ·
community hospital from 1995–2000". J Natl Med Assoc. 94 (6): 480–3.
PMC 2594386. PMID 12078929. DiseasesDB: 5887
WebMD: Hiccups External MedlinePlus:
resources 003068 ·
eMedicine:
emerg/252 · Patient
UK: Hiccup

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