Table 21

Investigation and management of hiccups

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Short-term hiccups	Reassure patient.
	Long-term hiccups	Investigate as outlined below.
Medication findings9	Corticosteroids Benzodiazepines Barbiturates Opioids Methyldopa	Discuss possible alternative medications.
First line
Routine blood tests	Infection with vagal irritation: ▸ Pleuritis ▸ Pharyngitis	Treat infection as appropriate.
	Metabolic: ▸ Diabetes ▸ Hypokalaemia ▸ Hypercalcaemia ▸ Uraemia	Treat underlying condition.
Physical examination	Meningitis	This is an emergency. Refer immediately to the acute medicine on-call team.
CT chest/abdomen	Acute gastric distension	This is an emergency. Discuss immediately with an upper GI surgeon.
	Small bowel obstruction	This is an emergency. Discuss immediately with GI surgeon.
	Malignancy/tumour recurrence	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Chest pathology	Discuss with supervising clinician within 24 hours.
	Intra-abdominal infection	This is an emergency. Discuss immediately with the on-call surgical team.
Second line
OGD	GORD	Start PPI or H2 antagonist. If following oesophagectomy, consider promotility agents (see p. 26).
Third line
If normal investigations/no response to intervention		Consider empirical baclofen, PPI, chlorpromazine, haloperidol, gabapentin, pregabalin. Ask for support from palliative care team. Refer to ENT team. Reassure.

CT, computerised tomography; ENT, ear, nose and throat; GI, gastrointestinal; GORD, gastro-oesophageal reflux disease; H2, histamine -2; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PPI, proton pump inhibitor.