Hiccups, dyspepsia and reflux in palliative care
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Hiccups, dyspepsia (indigestion) and reflux (stomach acid going into the oesophagus) can affect anyone. For people living with a terminal illness, they may be more difficult to manage. There are medicines that can help manage these symptoms, and things that you can do to help people feel more comfortable.
On this page:
Understanding hiccups
Hiccups are sudden, involuntary contractions of the muscles in the chest that are involved in breathing, including the diaphragm. When we hiccup air rushes into the lungs against closed vocal cords, making the characteristic hic sound.
Most hiccups are harmless and stop within minutes or hours. An episode of hiccups might last up to 48 hours and not be a sign of anything serious. Hiccups that last between 48 hours and one month are referred to as persistent hiccups. Hiccups that last for more than one month are called intractable hiccups.
Almost 1 in 10 people with terminal cancer will have hiccups that are distressing or have a significant impact on their quality of life. Persistent and intractable hiccups also occur in people with non-cancer terminal illness, including stroke, Parkinson's disease and multiple sclerosis.
The effect that hiccups can have on a person's life
Persistant (sometimes called protracted), or intractable hiccups can be very frustrating and distressing. They can disrupt a person's normal life by interfering with talking, eating, drinking and sleeping. They can also affect their mood and make their pain feel worse.
Serious complications of hiccups include:
- malnutrition
- fatigue
- dehydration
- disrupted sleep
- stress, anxiety or depression
- decreased quality of life.
What causes hiccups?
There are many different causes of hiccups and someone with a terminal illness might have more than one risk factor. Causes include, but are not limited to:
- distention (stretching) of the stomach
- gastro-oesophageal reflux – stomach acid going into the oesophagus (gullet)
- altered blood levels of calcium, magnesium, sodium or potassium
- infection
- damage to the nerve that supplies the diaphragm (the phrenic nerve) – this could be caused by a stroke, compression by a tumour or shingles
- liver disease, including tumours
- medicines including opioids, benzodiazepines and steroids
- stress and anxiety.
Distension and gastro-oesophageal reflux are the most common causes of hiccups.
Medicines rarely causes hiccups, so don’t stop someone taking their medicines unless you’re advised to by their doctor or specialist nurse.
What can I do to help someone with hiccups?
If you think there may be an underlying cause for the hiccups, speak to the person's doctor or nurse and follow their advice. If there is no underlying cause, you can help the person identify if anything seems to make the hiccups start (triggers), such as overeating or drinking alcohol. They may want to avoid these things, depending on their own priorities.
There are some practical things you can do to try to stop an episode of hiccups, especially if it has started in the last 48 hours. There isn’t much evidence to show that they work but lots of people still find that some of these techniques work well for them. Different techniques might work for different people, so you might want to try these different things to see if any of them can help:
- gargling cold water or swallowing crushed ice
- breathing into a paper bag
- interrupting normal breathing – for example holding their breath
- drinking water from the far side of a cup
- pulling on their tongue
- drinking peppermint water
- swallowing a teaspoon of dry granulated sugar
- compressing the diaphragm by pulling their knees up to their chest
- swallowing water while closing their nose
- having a sudden fright.
Some people find complementary therapies such as acupuncture and hypnosis helpful.
When should I ask for help with managing hiccups?
If hiccups last for more than 48 hours, or if you’re concerned about what’s causing them or the effects that they’re having, speak to the person’s GP or specialist. They can help assess and treat any reversible causes.
If no cause is found, they may be prescribed peppermint water, anti-sickness medicines or proton pump inhibitors (PPIs) to reduce stomach acid, such as omeprazole.
Treatments should be reviewed after three days and if there’s no improvement a specialist palliative care professional can assess and prescribe other medicines, including dopamine antagonists. Peppermint water should not be used if the person is taking medicines such as metoclopramide as they work in opposite ways.
If someone is in their last few days or hours of life a sedative such as midazolam can ease hiccups and make them feel more comfortable.
What are dyspepsia and reflux?
Dyspepsia (indigestion) isn’t one disease but describes a range of symptoms that affect the upper gastrointestinal tract (the stomach and the oesophagus). The symptoms are:
- pain or discomfort in the upper part of the abdomen (tummy)
- heartburn
- reflux
- nausea or vomiting
- feeling full quickly after eating
- bloating
- belching.
Dyspepsia can be very uncomfortable and have a significant negative effect on someone’s quality of life.
Reflux (stomach acid going backwards into the oesophagus) can occur as part of dyspepsia or might be a symptom on its own.
What causes dyspepsia?
Dyspepsia is very common, affecting up to 10% of the populaton, and can affect anyone at any age. People with a terminal illness may be more likely to have dyspepsia.
Dyspepsia might not have any obvious cause. This is called primary or functional dyspepsia.
Secondary dyspepsia is when the symptoms occur as a result of an underlying condition, including:
- gastro-oesophageal reflux disease (GORD)
- peptic ulcer (an ulcer in the stomach or small intestine)
- inflammatory conditions such as Crohn’s disease
- cancer in the stomach or oesophagus
- infection with Helicobacter pylori (H. pylori) bacteria
- lymphoma affecting the stomach
- the stomach muscles not working properly (gastroparesis) caused by diabetes, renal failure or hypothyroidism
- medicines causing gastroparesis, including opioids, iron supplements, antibiotics and steroids.
What can I do to help someone with dyspepsia?
If you suspect someone has dyspepsia, speak to their GP or specialist nurse who can arrange further assessment to look for underlying causes and/or prescribe treatment. They might recommend proton pump inhibitors (PPIs) such as omeprazole or H2 antagonists such as ranitidine if someone has pain or heartburn. Prokinetics such as metoclopramide help the stomach to work faster so can be helpful with symptoms of bloating and feeling full. A community pharmacist may be able to give advice on medication, eating and drinking, although most of them will not yet be able to prescribe medication themselves.
If there are no underlying causes (functional dyspepsia), the person might not need any treatment. There are things you can suggest to help them manage their symptoms. They could:
- eat smaller portions more frequently to avoid feeling full early
- sit up during meals
- raise the head of the bed or use pillows to be propped up in bed
- avoid foods that make their symptoms worse such as fatty foods and spicy foods
- avoid eating immediately before bed.
Useful resources
NICE Clinical Knowledge Summary: Hiccups
Scottish Palliative Care Guidelines: Hiccups
Palliative Care Adult Network Guidelines Plus: Gastro-oesophageal reflux and dyspepsia
Key points
- Hiccups and dyspepsia can affect anyone but may be harder to manage in people with a terminal illness.
- Speak to the person’s GP or specialist nurse if hiccups last for more than 48 hours, or if you’re concerned about what’s causing them or the effect that they’re having.
- Speak to their GP or specialist nurse if you suspect they have dyspepsia as further investigation and medicines might be required.
- There are practical things you can do to ease symptoms.
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Disclaimer
This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
