Low-dose gabapentin for chronic hiccup and belching-like episodes with functional features in an elderly patient: a case report

Introduction: Hiccups are sudden, irregular myoclonic contractions of diaphragmatic and intercostal muscles [1]. Episodes exceeding 48 hours are ‘persistent’, while those over one month are ‘intractable’ [2]. Supragastric belching, a behavioural condition where pharyngeal air is drawn into oesophagus and expelled without swallowing or gastric involvement [3], coexists with recurrent hiccups [4]. Case series document gabapentin’s efficacy for persistent and intractable hiccups [2]. We report a multimorbid, elderly patient with refractory hiccups and belching who improved after detailed phenomenological assessment and low-dose gabapentin.

Case Presentation: An 81-year-old male presented with a five year history of chronic hiccup and belching-like attacks. Patient’s medical history is significant for coronary artery disease (post-CABG), hypertension, and right nephrectomy. Additionally, a permanent pacemaker was implanted to manage recurrent syncope. His current pharmacological regimen includes lercanidipine, atorvastatin, acetylsalicylic acid, esomeprazole, and isosorbide mononitrate. Patient is a non smoker and has no history of alcohol consumption. Patient presented with sudden, involuntary hiccup-like episodes occurring during wakefulness, approximately 20 times per minute. These characteristically disappeared during sleep, speech, or distraction. No meal-related exacerbation or loss of appetite/weight was reported. Each episode involved brief expiration and ‘eh-eh’ vocalisation followed by relief. Classic ‘hic’ sounds and diaphragmatic spasms were absent, though a belching component accompanied every episode. Consequently, phenomenology was evaluated between persistent hiccups and supragastric belching. Psychiatric history showed mild anxiety and death-related fears over four years. Multidisciplinary evaluations failed to identify organic aetiology. Endoscopy revealed erythematous gastritis and Forrest III duodenal ulcer, yet symptoms remained unresponsive to PPIs. Cranial imaging(CT/MRI) and EEG showed no organic pathology. Prior chlorpromazine 100 mg/day was ineffective and discontinued due to sedation. Gabapentin was initiated at 100 mg/day; after partial improvement and no adverse effects at two weeks, dose increased to 300 mg/day. Written informed consent was obtained from patient for publication of this case report.

Results: Ten-minute structured outpatient observations recorded hiccup/belching-like episodes. These decreased from 180 to 35 per 10 minutes (81% reduction). Assessments occurred at baseline and 6 weeks of gabapentin (300 mg/day) treatment. PHQ-9 scores decreased from 4 to 2. CGI-S scores improved from 6 (severely ill) to 3 (mildly ill), with CGI-I of 2 (much improved). HADS-A scores decreased from 8 to 6, and HADS-D from 2 to 0. Subjective distress (VAS) halved from 8 to 4. Furthermore, 0-10 numerical rating scales showed marked reductions in symptom related distress (8 to 4), appetite interference (3 to 1), and social/speech impairment (2 to 0). Overall, these findings demonstrate that gabapentin effectively reduced the frequency of hiccup/belching-like episodes and improved both symptom severity and patient functionality.

Conclusion: In patients with chronic hiccup-like complaints, functional/psychogenic and underlying anxiety symptoms require phenomenological evaluation. Symptom disappearance during sleep, speech, and distraction suggests functional or behavioural mechanisms. In this case, significant improvement occurred in episode frequency, VAS scores, CGI-S/CGI-I, and functionality following low-dose gabapentin (300 mg/day). Given limitations of chlorpromazine in elderly and comorbid patients due to sedation, low-dose gabapentin may be a safe, tolerable alternative in selected cases. However, gabapentin’s effectiveness within this phenomenological spectrum requires systematic studies.

References

1. Chang, F.Y., Lu, C.L., 2012. Hiccup: mystery, nature and treatment. J. Neurogastroenterol. Motil. 18 (2), 123-130.
2. Steger, M., Schneemann, M., Fox, M., 2015. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment. Pharmacol. Ther. 42 (9), 1037-1050.
3. Stanghellini, V., Chan, F.K., Hasler, W.L., Malagelada, J.R., Suzuki, H., Tack, J., Talley, N.J., 2016. Gastroduodenal Disorders. Gastroenterology 150 (6), 1380-1392.
4. Hopman, W.P., van Kouwen, M.C., Smout, A.J., 2010. Does (supra)gastric belching trigger recurrent hiccups? World J. Gastroenterol. 16 (14), 1795-1799.