Symptom finder - The causes of hiccups
Symptom finder - The causes of hiccups
Why do we have hiccups? Hiccups usually occur as a distinct sound due to the contraction of the diaphragm which is involuntary in nature and terminated by closure of the glottis suddenly. Hiccups are mostly self limiting in nature. However, further investigations and evaluations are required in cases of chronic persistent hiccup which interfere with daily living to rule out any underlying serious disorders.
The causes of hiccups are central nervous system condition such as encephalitis, brainstem stroke, tumors, meningitis and intracranial hemorrhage, irritation of the phrenic nerve such as during thoracic surgery, lung tumor and esophageal tumor, irritation of the diaphragm such as a result of gastric distention after ingestion of air, fluid or food rapidly, diaphragmatic hernia, subphrenic abscess, empyema and lower lobe pneumonia. Other causes of hiccups are hysterical, uremic or toxic reaction.
History taking should focus on neurological history, abdominal history and respiratory history.
Neurological history may include identification of signs such as loss of facial sensory, dysarthria and difficulty in swallowing or diplopia due to the effect of any infarction or tumor on the distribution of the lower cranial nerves. (Variable symptoms due to complex anatomical structures of the brainstem). The effect of infarction and tumor are differentiated based on the speed of onset. Tumor develop progressively, infarction or stroke develop suddenly. Meningitis tends to present with neck stiffness, photophobia and headache as well as pyrexia. Encephalitis may present with seizures, alteration in consciousness and confusion. Hemiplegia , visual field defects and aphasia are associated with cortical lesion due to hemorrhage and infarction.
Abdominal evaluation will focus on the development of intra abdominal abscess which is most commonly present on the subphrenic region( subphrenic abscess /collection of pus). The subphrenic abscess is associated with appendicitis or cholecystitis which is a localized inflammatory condition. The symptoms tend to occur after abdominal surgery. The symptoms are malaise, pyrexia, pain referred to the neck, scapula, shoulder, pleural effusion and intractable hiccups. Diaphragmatic hernia is asymptomatic in adult and its present is detected incidentally on a chest x ray. Diaphragmatic hernia is associated with respiratory distress if occurred at birth.Esophageal carcinoma may present as rapid onset of progressive dysphagia which is painless in nature.
Empyema ma leads to hiccup. Empyema occurs as a result of thoracic surgery or pneumonia. Patient with pneumonia may suffer from cough, purulent sputum, rigors and high temperature as well as pleuritic chest pain and pyrexia. Lung tumor or bronchogenic carcinoma may also cause hiccup and present with signs such as weight loss, hemoptysis and smokers. Uremia is also associated with hiccup during sleep with bizarre associated symptoms and inconsistencies in the evaluation or history.
Patient with hiccup may present with pyrexia. Swinging pyrexia or swinging fever commonly due to subphrenic abscess and empyema. Subphrenic abscess is caused by cholecystitis or appendicitis. Therefore it is vital to perform abdominal examination to localized the site of tenderness. Abdominal abscess may also present as tenderness on the lower chest wall or on the skin surface. Bronchogenic carcinoma may present with pleural effusion, empyema or tracheal deviation. Elevation of the diaphragm due to diaphragmatic hernia may produce a clinical features similar to pleural effusion. Dullness on percussion is associated with areas of empyema, pleural effusion and consolidation. Pneumonia is associated with an area of consolidation which produces a coarse crepitation when auscultated.
Why do we have hiccups? Hiccups usually occur as a distinct sound due to the contraction of the diaphragm which is involuntary in nature and terminated by closure of the glottis suddenly. Hiccups are mostly self limiting in nature. However, further investigations and evaluations are required in cases of chronic persistent hiccup which interfere with daily living to rule out any underlying serious disorders.
The causes of hiccups are central nervous system condition such as encephalitis, brainstem stroke, tumors, meningitis and intracranial hemorrhage, irritation of the phrenic nerve such as during thoracic surgery, lung tumor and esophageal tumor, irritation of the diaphragm such as a result of gastric distention after ingestion of air, fluid or food rapidly, diaphragmatic hernia, subphrenic abscess, empyema and lower lobe pneumonia. Other causes of hiccups are hysterical, uremic or toxic reaction.
History taking should focus on neurological history, abdominal history and respiratory history.
Neurological history may include identification of signs such as loss of facial sensory, dysarthria and difficulty in swallowing or diplopia due to the effect of any infarction or tumor on the distribution of the lower cranial nerves. (Variable symptoms due to complex anatomical structures of the brainstem). The effect of infarction and tumor are differentiated based on the speed of onset. Tumor develop progressively, infarction or stroke develop suddenly. Meningitis tends to present with neck stiffness, photophobia and headache as well as pyrexia. Encephalitis may present with seizures, alteration in consciousness and confusion. Hemiplegia , visual field defects and aphasia are associated with cortical lesion due to hemorrhage and infarction.
Abdominal evaluation will focus on the development of intra abdominal abscess which is most commonly present on the subphrenic region( subphrenic abscess /collection of pus). The subphrenic abscess is associated with appendicitis or cholecystitis which is a localized inflammatory condition. The symptoms tend to occur after abdominal surgery. The symptoms are malaise, pyrexia, pain referred to the neck, scapula, shoulder, pleural effusion and intractable hiccups. Diaphragmatic hernia is asymptomatic in adult and its present is detected incidentally on a chest x ray. Diaphragmatic hernia is associated with respiratory distress if occurred at birth.Esophageal carcinoma may present as rapid onset of progressive dysphagia which is painless in nature.
Empyema ma leads to hiccup. Empyema occurs as a result of thoracic surgery or pneumonia. Patient with pneumonia may suffer from cough, purulent sputum, rigors and high temperature as well as pleuritic chest pain and pyrexia. Lung tumor or bronchogenic carcinoma may also cause hiccup and present with signs such as weight loss, hemoptysis and smokers. Uremia is also associated with hiccup during sleep with bizarre associated symptoms and inconsistencies in the evaluation or history.
Patient with hiccup may present with pyrexia. Swinging pyrexia or swinging fever commonly due to subphrenic abscess and empyema. Subphrenic abscess is caused by cholecystitis or appendicitis. Therefore it is vital to perform abdominal examination to localized the site of tenderness. Abdominal abscess may also present as tenderness on the lower chest wall or on the skin surface. Bronchogenic carcinoma may present with pleural effusion, empyema or tracheal deviation. Elevation of the diaphragm due to diaphragmatic hernia may produce a clinical features similar to pleural effusion. Dullness on percussion is associated with areas of empyema, pleural effusion and consolidation. Pneumonia is associated with an area of consolidation which produces a coarse crepitation when auscultated.
Vocal resonance will diminished with empyema and effusion and increase with consolidation. Crepitation may present in the area of consolidation by pneumonia.
Any neurological abnormalities and the deficit anatomical sites of lesions are identified while performing neurological examination. Brudzinski’s sign or flexion of the hip and knee while flexing the neck as well as Kernig’s sign (pain on extension of the knee when the knee and hip in a flexed position ) are important in diagnosing meningitis.
The investigations require are full blood count, urea and electrolytes, ESR, chest x ray, EEG, CT scan/ MRI scan of the head, US abdomen, CT thorax, bronchoscopy and mediastinoscopy, lumbar puncture and upper GI endoscopy and biopsy.
Full blood count may reveal raised white cell count due to malignancy and infection. Urea and electrolytes may indicate renal failure by raised in urea and creatinine level. Raised ESR is associated with infection and malignancy. Chest X ray may reveal any consolidation due to pneumonia. Chest x ray may also reveal elevation of hemi diaphragm due to diaphragmatic hernia or infiltration of carcinoma which lead to phrenic nerve palsy. Subphrenic abscess , effusion as a result of malignancy and empyema may present as fluid with meniscus on the chest x ray. Carcinoma is detected on the chest x ray by the present of hilar mass, peripheral shadow with cavitation and lobar collapse.
EEG is useful to detect the present of encephalitis by slowing background rhythm and formation of periodic complex. CT scan/ MRI scan of the head is useful to identify any high density area due to intracranial bleeding or low density area due to tumor or infarction. Midline shifting is caused by bleeding or mass effect due to the present of tumor. CT scan /MRI scan is also useful to identified raised intracranial pressure or cortical swelling in case of encephalitis. Lumbar puncture is useful in identifying encephalitis as high lymphocytes counts and meningitis. Ultrasound of the abdomen may detect the present of subphrenic abscess and facilitate the drainage and aspiration. CT scan of the thorax may identified the location of the empyema and guided biopsy for bronchogenic carcinoma. Bronchoscopy and mediastinoscopy may provide biopsy for bronchial carcinoma and esophageal carcinoma is clarified with upper GI endoscopy and biopsy.
Any neurological abnormalities and the deficit anatomical sites of lesions are identified while performing neurological examination. Brudzinski’s sign or flexion of the hip and knee while flexing the neck as well as Kernig’s sign (pain on extension of the knee when the knee and hip in a flexed position ) are important in diagnosing meningitis.
The investigations require are full blood count, urea and electrolytes, ESR, chest x ray, EEG, CT scan/ MRI scan of the head, US abdomen, CT thorax, bronchoscopy and mediastinoscopy, lumbar puncture and upper GI endoscopy and biopsy.
Full blood count may reveal raised white cell count due to malignancy and infection. Urea and electrolytes may indicate renal failure by raised in urea and creatinine level. Raised ESR is associated with infection and malignancy. Chest X ray may reveal any consolidation due to pneumonia. Chest x ray may also reveal elevation of hemi diaphragm due to diaphragmatic hernia or infiltration of carcinoma which lead to phrenic nerve palsy. Subphrenic abscess , effusion as a result of malignancy and empyema may present as fluid with meniscus on the chest x ray. Carcinoma is detected on the chest x ray by the present of hilar mass, peripheral shadow with cavitation and lobar collapse.
EEG is useful to detect the present of encephalitis by slowing background rhythm and formation of periodic complex. CT scan/ MRI scan of the head is useful to identify any high density area due to intracranial bleeding or low density area due to tumor or infarction. Midline shifting is caused by bleeding or mass effect due to the present of tumor. CT scan /MRI scan is also useful to identified raised intracranial pressure or cortical swelling in case of encephalitis. Lumbar puncture is useful in identifying encephalitis as high lymphocytes counts and meningitis. Ultrasound of the abdomen may detect the present of subphrenic abscess and facilitate the drainage and aspiration. CT scan of the thorax may identified the location of the empyema and guided biopsy for bronchogenic carcinoma. Bronchoscopy and mediastinoscopy may provide biopsy for bronchial carcinoma and esophageal carcinoma is clarified with upper GI endoscopy and biopsy.
