Anesthesia as Therapy for Persistent Hiccups
Peter Lierz, MD*, and Peter Felleiter, MD†
*Department of Anaesthesiology and Intensive Care Medicine, Marienkrankenhaus Soest, Germany; and †Department of
Intensive Care Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
iccups are repeated abrupt contractions of the
diaphragm and the external intercostal muscles.
The glottis closes to prevent inspiration 35 ms
Discussion
Long-lasting hiccups may be a symptom of various
diseases but may also appear without any detectable
reason. If hiccups last for days, sleep disorders and
alimentary problems arise and can be physically and
psychologically stressing to the patient. Even pulmo-
nary edema because of the negative pressure has been
described (3). Diagnostic exclusion of several neuro-
logical, gastrointestinal, thoracic, and metabolic disor-
ders is required. Besides direct mechanical causes,
such as dislocation of a pacemaker electrode or ner-
vous compression by a tumor, central nervous prob-
lems that have similarities with convulsive disorders
must be also considered. The nucleus of the phrenic
nerve, the medulla reticularis, and the hypothalamus
are particularly involved (4). In the literature, various
medical therapies are suggested (5):
H
after electrical activity rises above the baseline in the
diaphragm and external intercostal muscles (1). Usu-
ally hiccups terminate spontaneously within hours,
but they may also persist for longer and lead to serious
therapeutic problems (2).
Case Report
A 60-yr-old patient presented in our medical department
suffering from hiccups for 3 days. The hiccups did not
respond to simple measures, such as drinking cold fluids,
holding the breath, or Valsalva maneuvers. The patient had
a history of repeated hiccup episodes, especially after alcohol
consumption, that had always been self-terminating after sev-
eral hours. Clinical examination, as well as otorhinolaryngo-
logical and neurological examinations, a gastroscopy, and a
computed tomography-scan of the thoracic region showed no
abnormalities.
•
•
•
Baclofen 15–25 mg/d orally
Carbamazepine 600–1200 mg/d orally
Valproate 5 mg/kg bw/day, with weekly in-
creases of 250 mg until hiccups are terminated
Lidocaine bolus 1 mg/kg IV, than 2 mg/min IV
until hiccups are terminated
The hiccups had a frequency of 20 per minute, and the
patient’s contractions were so intense that he suffered from
regurgitation during his meals. Diazepam 20 mg was given
IV, but no effect was seen. Oral medication with 15 mg of
baclofen and 20 mg of pantoprazole daily did not change the
situation. An additional medication with gabapentin, start-
ing with 300 mg and increasing the dosage to 900 mg daily,
decreased the hiccup rate and even terminated the hiccups
for several hours, but they reappeared.
•
Recent publications have shown that not only ba-
clofen, but also gabapentin, have had positive effects
in patients with chronic hiccups (6). Thirty-eight per-
cent of 29 patients suffering from chronic hiccups
were healed, and 24% had a decreased intensity when
they were treated with a combination of cisapride,
omeprazole, and baclofen. Patients not responding to
baclofen were treated with 1200 mg/d of gabapentin,
leading to a further improvement of the response rate.
The investigators concluded that replacing baclofen
with gabapentin is useful in the treatment of patients
with persisting hiccups (7). Ataractic drugs (8), such as
haloperidol and chlorpromazine (9) as well as atro-
pine (10), have also had therapeutic value in otherwise
intractable hiccups. Friedgood and Ripstein (9) report
an 82% permanent cure rate with 50 mg of chlorprom-
azine IV. In one case, the hiccups had been present
nine months. Our patient refused further attempts of
conservative therapy, therefore other drugs could not
be tested. There is also one case report that showed a
After 12 days, we decided to perform general anesthesia.
The patient (176 cm and 88 kg) received IV 2 mg of cisatra-
curium, 100 g of remifentanil, 200 mg of propofol, and
1
00 mg of succinylcholine. Respiration was maintained via a
facial mask with an air/oxygen mixture containing 60%
oxygen and 0.4% enflurane. After 15 min, the enflurane was
stopped, and the patient regained consciousness. The hic-
cups were gone and did not reappear within the last 12 wk,
although the oral medication was terminated.
Accepted for publication April 23, 2002.
Address correspondence and reprint requests to Peter Lierz, MD,
Department of Anaesthesiology and Intensive Care, Marienkran-
kenhaus Soest, Widumgasse 5, 59494 Soest, Germany. Address
e-mail to anaesthesie@marienkrankenhaus-soest.de.
DOI: 10.1213/01.ANE.0000021365.55302.F2
©
2002 by the International Anesthesia Research Society
0003-2999/02
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94 Anesth Analg 2002;95:494–5
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