TEACHING CASE 3: HICCUPS

OBJECTIVES:

  1. Understand the pathophysiology of hiccups in palliative patients.
  2. Be able to identify risk factors for hiccups.
  3. Describe different treatment options for hiccups.

CASE

70yo male with prostate CA presents to his oncologist after returning from a trip to his hometown in Ireland with severe, acute back pain resulting in difficulty walking. He states he had nopain while traveling. He had eaten well until the past few days, when he noted his appetite had significantly declined. His past medical history is also significant for non-insulin-dependent diabetes and hypertension. He is a retired teacher, lives alone and has 2 daughters who live out of town. His oncologist immediately suspects spinal cord involvement and admits him to the hospital to start high dose steroids, get pain medications, and receive further imaging. On day 2 of his admission, hiccups develop. They impede his ability to eat and sleep and cause him great distress.

QUESTION 1

Which of the following is NOT a possible cause of hiccups in this patient?

  1. Alcohol use
  2. Myocardial infarction
  3. Steroids
  4. Psychogenic (stress)
  5. Gastroparesis
  6. None of the above (they are all possible causes).

QUESTION 2

If you HAD to choose one of the above possible causes, which would be MOST likely? Please explain.

______

CASE CONTINUES

The patient admits to some nausea but no emesis and is able to keep liquids down. Palliative team is consulted on hospital day #3, and they find out that patient has not had a bowel movement since before

hospitalization. They recommend low dose IV morphine to assist with his back pain. In addition, they recommend a bowel regimen.

QUESTION 3

For the patient’s hiccups, which of the following should the palliative team recommend?

  1. Metoclopramide 10mg IV Q6H prn
  2. Omeprazole 20mg po QAM
  3. Lorazepam 1mg IV Q4H prn
  4. Chlorpromazine 25mg po TID
  5. Discontinuation of the dexamethasone
  6. All of the above

Please explain. ______

QUESTION 4

The patient decides he doesn’t want any medications and requests non-pharmacologic therapy. Which of the following would you recommend?

  1. Acupuncture
  2. Phrenic nerve block
  3. Gargle with ice water
  4. Bite on a lemon
  5. Swallow a teaspoon of sugar
  6. Digital rectal stimulation
  7. Press on eyeballs
  8. Valsalva maneuver
  9. All of the above
  10. None of the above
  11. It depends…

Please explain. ______

RECOMMENDED READINGS

Calsina-Berna A, et al. Treatment of chronic hiccups in cancer patients: a systematic review. J Palliat Med. 2012 Oct; 15(10):1142-50.

Farmer C. Management of hiccups, 2nd edition. Fast Facts and Concepts. October 2007;81. Available at Accessed August 21, 2013.

Marinella MA. Diagnosis and management of hiccups in the patient with advanced cancer. J Support Onc.2009 July/August;7(4):122-130.

Krakauer EL, et al. Case6-2005: a 58-year-old man with esophageal cancer and nausea, vomiting, and intractable hiccups. N Engl J Med. 2005;352:817-25.