University of Alabama at Birmingham School of Medicine Birmingham, AL
Introduction: Chronic hiccups can be distressing and may substantially reduce quality of life. Gastroesophageal acid reflux is in the differential for underlying non-neuroleptic and non-respiratory causes of intractable symptoms. However, proton pump inhibitor (PPI) therapy is often underdosed or mistimed, promoting medication abandonment or polypharmacy. Alternative pharmaceutical therapies are associated with side effects that may lead to eventual patient intolerance.
Case Description/Methods: A 67-year-old male presented to gastroenterology clinic with two years of hiccups and frequent nocturnal awakening. Additional symptoms included intermittent oral regurgitation without pyrosis, nausea, vomiting, or chest/abdominal pain. Prior therapies consisted of chlorpromazine and once daily pantoprazole without benefit. In addition, the patient was previously prescribed baclofen, which provided incomplete relief. Initial CBC, CMP, and thyroid function tests were unremarkable. Index radiographic imaging showed a patulous esophagus.
High resolution esophageal manometry (HREM) was nondiagnostic due to hiccups occurring during the study. Ambulatory pH/impedance testing, performed off acid suppression therapy, demonstrated elevated DeMeester score of 49.8, Acid Exposure Time (AET) of 13.2%, an elevated proportion of weakly acidic refluxate, and low mean nocturnal baseline impedance, consistent with reflux. Next, the patient underwent EGD, where a 1 cm hiatal hernia, regular Z-line, and Los Angeles Grade D esophagitis were discovered. Non-bleeding erosions were found in the distal stomach, and gastric biopsies returned negative for intestinal metaplasia or Helicobacter pylori. He was recommended to continue baclofen, start colestipol 1 gm daily, and start omeprazole 40 mg twice daily for 3 months.
Five months after his initial visit, the patient reported improved symptoms with resolution of nocturnal episodes. He was planned for a surveillance EGD after 3 months of twice daily PPI therapy.
Discussion: Chronic hiccups are atypical symptoms of gastroesophageal acid reflux. Important diagnostic steps include ruling out alternative etiologies, in order to tailor specific therapy. PPI are frequently prescribed but are often underdosed or lower potency options (eg. pantoprazole) are utilized. Our case suggests a limited trial of high-potency twice daily PPI therapy is effective and should be initially considered for chronic hiccups from an acid reflux etiology.
