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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 10  |  Page : 1356-1360

The effect of gender differences in protracted hiccups


Department of Emergency Medicine, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey

Date of Acceptance12-Jun-2018
Date of Web Publication8-Oct-2018

Correspondence Address:
Dr. O Eroglu
Department of Emergency Medicine, Kirikkale University, Faculty of Medicine, Kirikkale 71850
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_101_18

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   Abstract 


Background: Although little importance is attached to hiccups, they may be associated with several diseases. The purpose of this study was to investigate the effects of gender differences on types of hiccups and the relation with diseases involved in the etiology. Materials and Methods: Patients presenting to the Kirikkale University Medical Faculty Hospital with hiccups were investigated retrospectively. Patients' age, sex, duration of hiccups, additional diseases, advanced imaging results, laboratory tests, and clinical follow-up were recorded. Patients were divided into two groups; Group transient hiccup (TH) consisted of subjects with a duration of hiccups less than 48 h, and Group protracted hiccup (PH) of patients with a duration exceeding 48 h. The Chi-square test was used for comparisons, and P < 0.05 were regarded as significant. Results: Eighty-four patients were enrolled, 44.1% (n = 37) in Group TH, and 55.9% (n = 47) in Group PH. Male patients comprised 67.5% (n =25) of Group TH and 89.4% (n = 42) of Group PH (P = 0.027). The conditions most associated with hiccups were gastrointestinal system (GIS) diseases. Correlation was determined between GIS diseases and male gender (P = 0.034), no relation between other system diseases and gender. Correlation was determined between GIS diseases and protracted hiccups (P = 0.037), but no relation between other system diseases and type of hiccups. Conclusion: Protracted hiccups are more common in males. This gender variation applies particularly to hiccups of GIS origin.

Keywords: Gastrointestinal system, gender, hiccup, male


How to cite this article:
Eroglu O. The effect of gender differences in protracted hiccups. Niger J Clin Pract 2018;21:1356-60

How to cite this URL:
Eroglu O. The effect of gender differences in protracted hiccups. Niger J Clin Pract [serial online] 2018 [cited 2018 Nov 15];21:1356-60. Available from: http://www.njcponline.com/text.asp?2018/21/10/1356/242828




   Introduction Top


Hiccup is an involuntary, intermittent, and spasmodic contraction of the diaphragm and intercostal muscles that many people experience at least once in their lives.[1] These contractions are uncomfortable and may number between 4 and 60/min.[1],[2] Hiccups may lead to problems such as malnutrition, dehydration, weight loss, insomnia, listlessness, mental stress, and a decreased quality of life, and maybe a precursor of diseases involving several systems.[3],[4] Hiccups generally assume the form of transient attacks not exceeding 48 h. Attacks exceeding that duration are considered as protracted hiccups. Those exceeding 48 h are classified as “persistent,” and those exceeding 1 month as “intractable.”[5],[6],[7] Transient attacks generally derive from causes such as alcohol intake, stress, excitement, excessive and fast eating, spicy foods, and gastric distension, while persistent/intractable hiccups may derive from several diseases of different organs and systems.[1],[6],[8] To be able to diagnose these diseases, pathologies of the gastrointestinal system (GIS), central nervous system (CNS), cardiovascular system, and the thorax should particularly be investigated, and various causes of vagus or phrenic nerve or diaphragmatic irritation should be considered, in addition to bleeding, thrombus, mass, infection, and toxic and metabolic causes.[1],[6],[8],[9],[10],[11] Few of these causes may be known in patients presenting to the emergency department with hiccups. However, identification and treatment of underlying causes are of the utmost importance.[1],[9],[12] Detailed history, physical examination, and investigation accompanied by appropriate tests should, therefore, be performed in cases presenting with protracted (persistent/intractable) hiccups.[8] Although hiccups have frequently been observed in elderly men in previous studies, the cause of hiccups and the relation between types of hiccups and gender are still unclear.[3],[10]

The purpose of this study was to investigate the effects of gender differences on type of hiccups and the relation with diseases involved in the etiology.


   Materials and Methods Top


Study design

Following receipt of Ethical Committee Approval (No. 2017-20/01), this retrospective study was performed with patients presenting to the Kirikkale University Medical Faculty Emergency Department due to hiccups between January 1, 2013, and January 1, 2018.

Patient evaluation and group constitution

All data were obtained from the hospital computer system and archive records. ICD-10 code “R.06.6” was investigated to identify patients presenting with hiccups. Patients' demographic data (age, sex, body weight, height, history of disease, drugs used, duration of hiccups, numbers of attacks or recurrences, number of hospital presentations due to hiccups, and treatments administered), physical examination findings, laboratory results, polyclinic records, chest X-ray findings, and confirmed endoscopy, computerized tomography, and magnetic resonance imaging reports were recorded. Patients were divided into two groups based on duration of hiccups, and were also investigated regarding whether the causes originated from the CNS or not (non-CNS).

  • Group TH: Duration of hiccups <48 h (transient hiccups)
  • Group PH: Duration of hiccups >48 h (protracted hiccups).


Patients undergoing advanced diagnostic tests at other health centers after discharge from the emergency department, not attending follow-up visits, with missing data or aged under 18 were excluded from the study.

Statistical analysis

Statistical analysis was performed on SPSS 21.0 (IBM SPSS Statistics 21.0, IBM Corporation, Armonk, NY, USA) software. Normality of data was evaluated using the Shapiro–Wilk test. Parametric data were expressed as the mean ± standard deviation, and categorical variables as number (n) and percentage (%). The Chi-square test was used for comparisons between the groups. Relations between age and sex in the groups were analyzed using analysis of ANOVA. Values of P < 0.05 were considered as statistically significant.


   Results Top


Two hundred and thirty-nine patients with hiccups were identified during the study period. One hundred and fifty-five patients meeting the exclusion criteria were subsequently excluded, and the study was completed with 84 patients. Duration of hiccups attack was <48 h in 44.1% (n = 37) of patients, between 48 h and 1 month (persistent) in 36.9% (n = 31), and longer than 1 month (intractable) in 19% (n = 16). Accordingly, Group TH contained 44.1% (n = 37) of patients, and Group PH 55.9% (n = 47) [Table 1].
Table 1: Age and gender data of hiccup patients

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The mean age of all patients was 52.2 ± 21.3 years (range: 19–84). Mean age in Group TH was 51.2 ± 22.8, and mean age in Group PH was 52.9 ± 20.2 (P = 0.601). Men constituted 79.8% (n = 67) of all patients, 67.5% (n = 25) of those in Group TH, and 89.4% (n = 42) of those in Group PH (P = 0.027). The mean age of the women in the total patient group was 41.7 ± 19.7 years and that of the men 54.8 ± 20.9 years. Mean ages in Group TH were 54.7 ± 23.2 years for men and 43.9 ± 20.9 for women (P = 0.180). Mean ages in Group PH were 54.9 ± 19.8 years for men and 36.4 ± 17.1 for women (P = 0.042). Analysis of the relation between types of hiccups and gender revealed that protracted hiccups were more common in men (P = 0.027) [Table 1].

The most common cause of hiccups was GIS diseases (n = 39), followed by psychiatric diseases (n = 35) and neurological diseases (n = 19). In addition, 89.8% (n = 35) of GIS diseases involved gastritis and gastroesophageal reflux disease (GERD). Eighteen patients with hiccups had diagnoses of cancer; 27.8% (n = 5) were newly diagnosed cancer patients, and 22.2% (n = 4) were receiving chemotherapy for cancer treatment. CNS-related causes of hiccups were determined in 46.4% (n = 39) of patients, and nonCNS-related causes in 53.6% (n = 45). No difference was determined between hiccups types (groups TH and PH) regarding whether or not causes were CNS-related (P = 0.337) [Table 2].
Table 2: Distribution of causes associated with hiccups and polyclinic presentations

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At analysis of relations between diseases causing hiccups and gender, the correlation was observed between GIS diseases and male gender (P = 0.034), but none was determined between other system diseases and gender [Table 3]. Examination of the relation between diseases causing hiccups and types of hiccups revealed a correlation between GIS diseases and types of hiccups (P = 0.027), but not with other system diseases [Table 4].
Table 3: Correlation between diseases responsible for hiccups and gender

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Table 4: Correlation between diseases responsible for hiccups and hiccup types

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   Discussion Top


Our results show that protracted hiccups are more common in men and are closely associated with GIS diseases. Previous studies of hiccups have reported no relation between transient hiccup attacks and gender, and that protracted hiccups generally occur in men.[8],[9],[13],[14],[15] Liaw et al. reported that men constituted 76.5% of patients under monitoring due to hiccups. In their study, the great majority of which consisted of patients with long-term hiccups, Cymet reported a male gender rate of 91%.[11],[13] Lee et al. performed perhaps the most comprehensive investigation of the relation between hiccups and gender and reported a male gender dominance of 90%.[9] The incidence of hiccups is lower in women than in men, and onset is also later.[8],[9] Male patients comprised 789.8% of patients in our study. The predominance of male gender was pronounced in both short-term and long-term hiccups and was particularly statistically significant in protracted hiccups. Variation was also determined between the sexes regarding age. Mean age in women was lower than that in men, and the age difference between the sexes was particularly statistically significant in protracted hiccups. These findings are compatible with previous studies reporting a predominance of the male gender, and also provide new information showing that protracted hiccups are more common among older men.

Irrespective of duration, hiccups is an uncomfortable symptom that generally drives from the GIS.[1] Cymet also reported that hiccups frequently derives from the GIS, and that most patient consultations involve the Gastroenterology Department.[11] GIS-related hiccups may derive from simple causes such as excessive or rapid eating, spicy foods, or aerophagia, or from fatal diseases such as cancers of the GIS. Gastritis, GERD, and peptic ulcer are the patients of the main focus on this subject.[1],[8] Cabane et al. emphasized the importance of GERD in the development of hiccups and showed that the condition could be resolved in these patients with antacid or proton pump inhibitor use.[5] Orr et al. in their study reported that hiccups were triggered by acid overproduction caused by Helicobacter pylori, erosion of esophageal mucosa, and vagal irritation.[16] This association between hiccups and the GIS may also be linked to the gender factor. Studies have reported that the development of hiccups in male gender is not associated with diseases involving the (CNS) and that hiccups derive from non-CNS causes. In women, the situation is different, and hiccups have been linked to such diseases of the CNS as neuromyelitis optica.[9] Rey et al. focused on GERD, reporting that this condition caused hiccups in 7.9% of women and 10% of men.[17] Several diseases previous linked to hiccups were present in our patients. These may include diseases of the CNS such as Parkinson's disease and cerebrovascular hemorrhage/stroke, oncological diseases with or without chemotherapy (cisplatin and dexamethasone), and psychiatric diseases such as anxiety disorder and depression. However, GIS diseases, and particularly gastritis and GERD, were present in a large proportion of cases. Discharged patients were also determined to subsequently present most frequently to the Gastroenterology Department. In addition, when we examined the relation between these causes of hiccups and gender and type of hiccups, we determined an association between GIS diseases and both male gender and protracted hiccups. Our findings are compatible with previous studies showing that hiccups in men derive from nonCNS causes, and are important in showing that they derive from the GIS.

Limitations

There are some limitations to this study. The first is the study's retrospective nature. Second, since hiccups are frequently overlooked as a symptom, these patients' ICD codes may have been entered with different diagnoses, and patients' reports may not have been entirely accurate. Third, no patients presenting to the emergency department due to hiccups subsequently underwent polyclinic follow-up (particularly those with complete resolution after transient attacks), and this may have affected the case number, and thus the statistical analysis results.


   Conclusion Top


Protracted hiccups are more common in men. This gender difference also applies to GIS-related hiccups. Further prospective studies are needed to confirm our findings.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Steger M, Schneemann M, Fox M. Systemic review: The pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015;42:1037-50.  Back to cited text no. 1
    
2.
Kolodzik PW, Eilers MA. Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991;20:565-73.  Back to cited text no. 2
    
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Payne BR, Tiel RL, Payne MS, Fisch B. Vagus nerve stimulation for chronic intractable hiccups. Case report. J Neurosurg 2005;102:935-7.  Back to cited text no. 3
    
4.
Demirci H, Gulsen M. Singultus. Güncel Gastroenterol 2014;18:277-84.  Back to cited text no. 4
    
5.
Cabane J, Bizec JL, Derenne JP. A diseased esophagus is frequently the cause of chronic hiccup. A prospective study of 184 cases. Presse Med 2010;39:e141-6.  Back to cited text no. 5
    
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Chang FY, Lu CL. Hiccup: Mystery, nature and treatment. J Neurogastroenterol Motil 2012;18:123-30.  Back to cited text no. 6
    
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Becker DE. Nausea, vomiting, and hiccups: A review of mechanisms and treatment. Anesth Prog 2010;57:150-6.  Back to cited text no. 7
    
8.
Schuchmann JA, Browne BA. Persistent hiccups during rehabilitation hospitalization: Three case reports and review of the literature. Am J Phys Med Rehabil 2007;86:1013-8.  Back to cited text no. 8
    
9.
Lee GW, Kim RB, Go SI, Cho HS, Lee SJ, Hui D, et al. Gender differences in hiccup patients: Analysis of published case reports and case-control studies. J Pain Symptom Manage 2016;51:278-83.  Back to cited text no. 9
    
10.
Souadjian JV, Cain JC. Intractable hiccup. Etiologic factors in 220 cases. Postgrad Med 1968;43:72-7.  Back to cited text no. 10
    
11.
Cymet TC. Retrospective analysis of hiccups in patients at a community hospital from 1995-2000. J Natl Med Assoc 2002;94:480-3.  Back to cited text no. 11
    
12.
Mercadante S, Porzio G, Valle A, Fusco F, Aielli F, Adile C, et al. Orphan symptoms in advanced cancer patients followed at home. Support Care Cancer 2013;21:3525-8.  Back to cited text no. 12
    
13.
Liaw CC, Wang CH, Chang HK, Wang HM, Huang JS, Lin YC, et al. Cisplatin-related hiccups: Male predominance, induction by dexamethasone, and protection against nausea and vomiting. J Pain Symptom Manage 2005;30:359-66.  Back to cited text no. 13
    
14.
Miwa H, Kondo T. Hiccups in parkinson's disease: An overlooked non-motor symptom? Parkinsonism Relat Disord 2010;16:249-51.  Back to cited text no. 14
    
15.
Takahashi T, Miyazawa I, Misu T, Takano R, Nakashima I, Fujihara K, et al. Intractable hiccup and nausea in neuromyelitis optica with anti-aquaporin-4 antibody: A herald of acute exacerbations. J Neurol Neurosurg Psychiatry 2008;79:1075-8.  Back to cited text no. 15
    
16.
Orr CF, Rowe DB. Helicobacter pylori hiccup. Intern Med J 2003;33:133-4.  Back to cited text no. 16
    
17.
Rey E, Elola-Olaso CM, Rodríguez-Artalejo F, Locke GR 3rd, Díaz-Rubio M. Prevalence of atypical symptoms and their association with typical symptoms of gastroesophageal reflux in spain. Eur J Gastroenterol Hepatol 2006;18:969-75.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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