3 Hiccups, sore mouth and bad breath
Case
A 51-year-old post-menopausal woman consults because of a feeling of burning inside her mouth. The pain in her mouth is present every day and persists for most of the day. She also describes dryness of the mouth but no dryness of the eyes. She has otherwise been in excellent health. She denies any history of heartburn or acid regurgitation. Her sense of taste and smell is normal. She has not had any mouth ulcers or trauma. There is no history of arthritis or skin rashes. Her dental history is unremarkable. She has been using mouthwash but only occasionally. She denies symptoms of anxiety or feeling depressed.
Hiccups
Pathophysiology
A range of gastrointestinal stimuli can cause reflex excitation of visceral afferent vagal fibres. Vagal afferent receptors in the oesophagus can trigger the responsible medullary centres. This is the proposed mechanism for hiccups occurring during swallowed bolus impaction at the site of a benign stricture or ring, or in response to oesophageal distension by retained food and fluid in oesophageal achalasia, or in the context of pill-induced oesophageal ulceration or stricture. Similar vagal afferent stimuli might originate in cases of hiatus hernia or gastro-oesophageal reflux disease, but the evidence implicating reflux as a cause of hiccups remains inconclusive.
Aetiology of hiccups
The relatively common self-limiting bout of hiccups is frequently induced by gastric distension, emotion, alcohol ingestion or sudden change in temperature. However, most frequently the cause of transient hiccups is unknown. The cause of intractable hiccups can be classified into five groups (Box 3.1):
Box 3.1 Causes of intractable hiccups
Approach to the patient with intractable hiccups
A careful history should enquire about neurological symptoms, particularly headache and brainstem symptoms such as diplopia, vertigo, nausea, vomiting, hoarseness, ataxia or clumsiness, and disordered pain sensation. Chest pain, fever and cough are clues to cardiac, respiratory or mediastinal disease. Gastrointestinal causes may be suspected if heartburn, regurgitation, chest pain, dysphagia, vomiting or abdominal pain is reported. A history of metabolic disorders and drug enquiry are also important (Box 3.2).
Box 3.2 Approach to intractable hiccups
History
Physical examination should include examination of cranial nerve, long tract and cerebellar signs. Disordered cognitive function may relate to metabolic derangements or to central causes such as encephalitis. Cardiorespiratory examination should look for signs of pleural or pericardial disease and postural hypotension, which is present in Addison’s disease. The external auditory canals should be examined for foreign bodies. Abdominal examination should specifically look for signs of gastric stasis (e.g. succussion splash), bowel obstruction or tender hepatomegaly, which may indicate hepatic enlargement, or an intrahepatic lesion such as an abscess.
The priorities with respect to investigations will be dictated by the historical and physical findings. Serum electrolytes including sodium, calcium, blood sugar level and liver function tests should be done. A leucocytosis may indicate an underlying infective process. Chest x-ray and electrocardiogram are important to detect pericardial, plural or myocardial disease such as myocardial infarction. A thoracic computed tomography (CT) scan can be performed if mediastinal disease is suspected. Imaging of the abdomen is indicated if a subdiaphragmatic abscess is suspected. Endoscopy is indicated if oesophageal disease or gastric stasis is apparent clinically. The approach to intractable hiccups is outlined in Box 3.2.
