Other / General Medicine
Lillian D. Sidky, BS
Medical Student
Tufts University School of Medicine
Boston, Massachusetts, United States
Kyle Kinder, MD
Resident Physician
Department of Physical Medicine & Rehabilitation, University of California, Los Angeles (UCLA), Los Angeles, CA
Los Angeles, California, United States
Kavitha Swaminathan, DO
Physician
Department of Physical Medicine & Rehabilitation, University of California, Los Angeles (UCLA), Los Angeles, CA
Los Angeles, California, United States
Lillian Sidky
Tufts University School of Medicine
Boston, Massachusetts, United States
A 71-year-old male with a history of a gastrointestinal stromal tumor status post partial gastrectomy, gastroesophageal reflux disease, and right femoral neck fracture underwent right total hip arthroplasty. The patient developed postoperative hiccups and was started on metoclopramide with his baseline pantoprazole. Hiccups persisted in rehabilitation despite the addition of bowel medications, gabapentin, and chlorpromazine. After one week of refractory hiccups, baclofen was initiated and diagnostic workup pursued. Electrocardiogram was normal, but new leukocytosis prompted chest imaging, which revealed pneumonia. He was treated with levofloxacin, initially oral then intravenous due to gastrointestinal side effects. Further studies ruled out pulmonary embolism or intra-abdominal pathology. Despite escalation, hiccups persisted until gabapentin and baclofen were titrated to high doses, alongside intravenous antibiotics and as-needed chlorpromazine. Hiccups gradually improved, resolving completely two weeks postoperatively.
Discussions:
Intractable hiccups in the rehabilitation setting are rare, with most documented cases occurring after stroke. This case is notable because the patient had no neurologic insult. Hiccups result from sudden involuntary contractions of the diaphragm followed by abrupt closure of the glottis. Postoperative hiccups are commonly due to phrenic nerve or diaphragmatic irritation after anesthesia. However, hiccups may also be an unconventional symptom of cardiopulmonary, central nervous system, and gastrointestinal pathology or be an adverse effect of medications. Chlorpromazine is the only Food and Drug Administration (FDA) approved treatment for hiccups, yet in this case and other rehab reports, symptoms persisted. Relief was achieved only with off-label gabapentin and baclofen. These agents can be effective for refractory hiccups but should be used cautiously in older adults to minimize adverse effects.
Conclusions: Persistent hiccups cause significant discomfort, frustration, and decreased therapy participation, hindering patient progress towards functional goals. For postoperative patients, hiccups should be recognized as an important clinical symptom warranting evaluation for underlying pathology and initiation of appropriate treatment.
