Download hiccups - Coleman Palliative Medicine

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 no pain 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?
a.
b.
c.
d.
e.
f.
Alcohol use
Myocardial infarction
Steroids
Psychogenic (stress)
Gastroparesis
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.
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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?
a.
b.
c.
d.
e.
f.
Metoclopramide 10mg IV Q6H prn
Omeprazole 20mg po QAM
Lorazepam 1mg IV Q4H prn
Chlorpromazine 25mg po TID
Discontinuation of the dexamethasone
All of the above
Please explain.
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QUESTION 4
The patient decides he doesn’t want any medications and requests non-pharmacologic therapy. Which
of the following would you recommend?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Acupuncture
Phrenic nerve block
Gargle with ice water
Bite on a lemon
Swallow a teaspoon of sugar
Digital rectal stimulation
Press on eyeballs
Valsalva maneuver
All of the above
None of the above
It depends…
Please explain.
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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
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_081.htm. 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.