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        Though usually a benign and self-limited annoyance, hiccups may be persistent and a sign of serious underlying illness. In patients being maintained on mechanical ventilation, hiccups can trigger a full respiratory cycle and result in respiratory alkalosis.

        Dr S Sathya Narayanan of Sage Surgical Centre at Nanganallur explains on singultus (hiccoughs), the state of having reflex spasms of the diaphragm accompanied by a rapid closure of the glottis producing an audible sound; sometimes a symptom of indigestion, its causes, symptoms and treatment.

        Causes of benign, self-limited hiccups include gastric distention (carbonated beverages, air swallowing, overeating), sudden temperature changes (hot then cold liquids, hot then cold shower), alcohol ingestion and states of heightened emotion (excitement, stress, laughing). There are over 100 causes of recurrent or persistent hiccups, grouped into the following categories:

        Central nervous system: Neoplasms, infections, cerebrovascular accident, trauma.

        Metabolic: Uremia, hypocapnia (hyperventilation).

        Irritation of the vagus or phrenic nerve: (i) Head, neck: Foreign body in ear, goiter, neoplasms. (ii) Thorax: Pneumonia, empyema, neoplasms, myocardial infarction, pericarditis, aneurysm, esophageal obstruction, reflux esophagitis. (iii) Abdomen: subphrenic abscess, hepatomegaly, hepatitis, cholecystitis, gastric distention, gastric neoplasm, pancreatitis, or pancreatic malignancy.

        Surgical: General anesthesia, post-operative.

        Psychogenic and idiopathic.

        Clinical findings:

        Evaluation of the patient with persistent hiccups should include a detailed neurologic examination, serum creatinine, liver chemistry tests, and a chest radiograph. When the cause remains unclear, CT of the head, chest, and abdomen, echo cardiography, bronchoscopy, and upper endoscopy may help. On occasion, hiccups may be unilateral: chest fluoroscopy will make the diagnosis.

        Treatment:

        A number of simple remedies may be helpful in patients with acute benign hiccups. (1) Irritation of the nasopharynx by tongue traction, lifting the uvula with a spoon, catheter stimulation of the nasopharynx, or eating 1 tsp of dry granulated sugar. (2) Interruption of the respiratory cycle by breath holding. Valsalva's manoeuvre, sneezing, gasping, (fright stimulus), or re-breathing into a bag. (3) Stimulation of the vagus, carotid massage. (4) Irritation of the diaphragm by holding knees to chest or by continuous positive airway pressure during mechanical ventilation. (5) Relief of gastric distention by belching or insertion of a nasogastric tube.

        A number of drugs have been promoted as being useful in the treatment of hiccups. Chlorpromazine, 25-50 mg. Orally or intramuscularly, is most commonly used. Other agents reported to be effective include anticonvulsants (phenytoin, cabamazepine), benzodiazepines (lorazepam, diazepam) metoclopramide, baclofen and occasionally general anesthesia.