Monday, September 08, 2003
Copyright © Las Vegas Review-Journal

ANNOYING PROBLEM: What's up with hiccups?

Bouts, which normally last a couple of minutes, can sometimes endure for months

Illustration by Anton. The diaphragm is is the main muscle for breathing. It separates the chest above from the abdomen below. When it suffers spasms, hiccups can result.

No part of humanity is exempt from hiccups.

Medical researchers have studied the subject, yielding several discoveries: Hiccups happen more in the evening than early in the day. They often dissipate once a person falls asleep. Men are more likely than women to have extremely long bouts of hiccups. They have been observed even in fetuses.

Hiccups occur in series, anywhere from four to 60 per minute, according to research. A bout can last several minutes, on the normal end, to weeks or months, in the extreme.

The vast majority of cases of hiccups are benign.

"A doctor probably sees more hiccups in his own family than in patients," notes Dr. Ellis Samols of the University of Nevada School of Medicine. As chairman of the internal medicine department, he specializes in metabolic disorders as well as nuclear medicine.

"If the episode happens and goes away, if it doesn't happen again, forget about it. Don't call the doctor," says Dr. Joseph Fayad, a gastroenterologist who also is on the medical school faculty.

On the other hand, recurrent or long-lasting hiccups are occasionally a clue to underlying serious illness, the physicians note.

The hiccup phenomenon comes from a twitchy diaphragm muscle, which results in a sudden intake of air -- or amniotic fluid, in the case of a fetus with the hiccups -- which is stopped reflexively by an opening in the throat that flaps shut, culminating in a "hic" sound.

The diaphragm is a large, horizontal, dome-shaped muscle that effectively divides the chest, or thorax, from the abdomen below. Its primary role is in breathing.

The diaphragm and the nearby intercostal muscles that wrap the chest exert pressure on the lungs, which have little muscle content and "don't move spontaneously" on their own, Samols explains. When the diaphragm goes down, the lungs can inhale and expand. When the diaphragm rises, the lungs exhale and deflate.

When the diaphragm starts to spasm, leading to hiccups, three parts of the nervous system may be involved: the phrenic nerve, which runs through the diaphragm; the vagus nerve, which runs through the throat as well as many chest and abdominal organs including the lungs, heart and stomach; and thirdly, the brain itself.

Hiccups can happen when any of these three parts of the nervous system gets irritated, or when an adjacent organ physically touches -- such as through inflammation -- and irritates the diaphragm. That covers a lot of diagnostic ground.

The stereotype of the hiccuping drunkard has a basis in fact. Stomach or throat irritation can come from drinking too much alcohol.

But hiccup-producing irritation also can come from overeating, excess stomach acid, hypersensitivity to stomach acid as well as acid "reflux," in which stomach acid is not confined to the stomach, but inadvertently leaks up into the esophagus, where the tissue is not acid-resistant.

While eating less or drinking less can prevent some hiccups, other times the spasms are, Fayad says, a "reflection of a pathological process in the brain, sinus, neck, chest or abdomen," requiring medical intervention.

Medical annals note some fluke causes for the hiccups. A stray hair resting on the eardrum and an insect that worked its way into the ear canal, and ended up dead, touching the eardrum, have both been documented as causes. When the irritants were removed, the hiccups stopped, Samols says the literature reports.

But more than 100 serious medical conditions are linked with hiccups, Samols says, cautioning that while there is "an association," the diseases do not always, or necessarily, cause the hiccups.

Among the serious conditions in which hiccups can be present -- from the top down, speaking anatomically -- are brain or sinus cancer, stroke, pneumonia, asthma, lung cancer, heart attack, inflammation of the heart's membrane, pancreatitis, hernia and colon cancer.

Diabetes and kidney function problems sometimes also can be indicated by hiccups. And anesthesiologists must monitor patients after chest or abdominal surgery, to make sure their anesthesia drugs don't induce hiccups, which could increase pain.

Though the two physicians don't want to encourage hypochondria in patients with simple hiccups that dissipate on their own, they do recommend that people with recurrent or protracted hiccups see a doctor for an appropriate workup. If an underlying condition is identified and treated, the hiccups can go away.

Even so, a workup may not always reveal a cause. "I've had cases," Fayad admits, "where the hiccups stay six months, and we can't find anything."

Even without a serious underlying condition, extended hiccups can pose a health problem, both in terms of patient fatigue and what Samols calls "psychological annoyance."

He estimates he sees several such cases yearly, particularly among the elderly, who do not all have the physical stamina to face an extended hiccups bout.

For such extreme cases, there are several types of hiccups treatment. Certain medications can reduce the incidence. A surgical nerve block of the phrenic nerve in the diaphragm also can be appropriate.