Hiccups, dyspepsia and reflux

Please be aware - this information is for healthcare professionals

Gastric problems such as hiccups (also known as hiccoughs), dyspepsia and reflux are common and most people will experience them at some point in their life. They can usually be treated with simple remedies. However, at the end of life, hiccups, dyspepsia (indigestion) and reflux (acid leaking up into the throat) may be disease-related. So they might need to be managed differently.

Understanding the patient’s medical history, and the cause of their discomfort, will help you to offer more effective care and support.

As well as keeping your own record of symptoms and treatments, you may also find it helpful to ask the patient, or their carer, family or friend, to keep a diary of symptoms. This may help you and the patient work out when symptoms are worse or identify triggers and whether anything seems to help.

You may also find it helpful to ask the patient, or their family member or friend, these questions:

  • When did it start?
  • Is it new or have you had it before? When? How often?
  • How bad is it? What impact is it having on you? Is it interfering with sleep?
  • Is it getting worse?
  • Does anything make it better or worse?
  • If you’ve had it before, what has helped or has anything made it worse?

Although there are some simple steps you can suggest that may help, it’s also important you speak to the multidisciplinary team if you have any concerns. If you aren’t able to manage the condition, you can also seek advice from the palliative care team, GP or district nurse. For example, if you can’t get hiccups under control, or if the patient’s reflux or dyspepsia does not respond to treatment.

Hiccups

Although hiccups are a common minor inconvenience, they can cause distress and exhaustion if they continue for a long period of time. At the end of life, there are a number of possible causes of hiccups.

Causes of hiccups:

  • gastric distention (stomach bloated with air) and stasis (when the stomach empties more slowly than normal)
  • gastric reflux
  • metabolic disturbances, such as uraemia (excess urea in the blood) , high or low calcium, low magnesium, potassium or sodium
  • infection
  • irritation of the diaphragm or the nerve running to it (the phrenic nerve)
  • liver disease, including tumours
  • ascites (fluid in the abdomen), abdominal distention (swelling or bloating) or bowel obstruction
  • tumours in the brain, meninges (membranes covering the brain and spinal cord) , central nervous system , diaphragm or mediastinal area (in the centre of the chest between the lungs)
  • renal failure
  • Addison’s disease (when the adrenal glands do not produce enough hormones).

What might help?

Hiccups usually stop on their own, so treatment is only needed if they are prolonged, excessive or happen often. It is best to ask the patient what they want to do. They may feel that they are managing, or it may be that they are getting tired and need relief.

Not enough research has been done to be able to recommend a specific treatment for hiccups. However, there are a few anecdotal remedies that you may want to discuss with the patient, such as:

  • quickly eating two heaped teaspoons of granulated sugar
  • rubbing the soft palate with a swab
  • holding the breath
  • breathing into a paper bag, particularly if the patient is hyperventilating.

There are medicines that can be prescribed for stubborn and persistent hiccups. These can include:

  • medicines to suppress the hiccup reflex – such as metoclopramide, chlorpromazine or haloperidol
  • muscle relaxants – such as baclofen, nifedipine or midazolam
  • proton pump inhibitors to reduce gastric distension and reflux – such as lansoprazole.

Most patients with fluid in the abdomen (ascites) will feel more comfortable if the fluid is drained off. This may be recommended if the ascites is severe or has not responded to other treatments. The Palliative Care Guidelines explain more about this.

Dyspepsia and gastric reflux

Causes of gastrointestinal symptoms:

  • tumour in the upper abdomen
  • ascites (fluid in the abdomen)
  • medication – including NSAIDs, steroids , SSRI antidepressants , iron supplements , some antibiotics and too much coffee
  • oesophageal problems – such as thrush, spasm and incompetence of gastric sphincter at entrance to stomach hiatus hernia
  • stomach and/or oesophageal cancer
  • stomach ulcer
  • H. pylori infection 
  • heart problems may present as indigestion.

What might help?

  • Treatment for dyspepsia and gastric reflux will depend on the cause
  • These simple approaches may help ease the patient’s symptoms and provide relief
  • repositioning the patient to be sitting or sleeping in a more upright position
  • raising the head of the bed
  • mild antacids available without a prescription – such as Gaviscon
  • making changes to the patient’s diet, including the timing of meals and portion size.

Medicines may also be prescribed. These can include:

  • medicines to speed up stomach emptying and relieve distention – such as metoclopramide
  • proton pump inhibitors for moderate to severe reflux – such as lansoprazole
  • diuretics for ascites – such as spironolactone.

If the measures listed above do not help, your GP, district nurse or specialist nurse will be able to offer more advice. You should also talk to other members of the multidisciplinary team if the patient is distressed or exhausted, or if you suspect that their symptoms are caused by a medical issue that hasn’t been diagnosed, such as a heart condition.

Who else should I talk to?

  • The patient’s GP
  • A district nurse
  • The specialist palliative care team.

Points to remember

  • Many people experience gastric symptoms at some point. However, at the end of life the causes may be disease-related and so need a different approach
  • Understanding your patient’s medical history will help you provide the best support possible
  • Sometimes simple measures can help to ease symptoms
  • Speak to colleagues if you think symptoms are unmanageable or if you think they are caused by an undiagnosed medical issue.

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