Eosinophilic Esophagitis Presenting as Hiccups

Abstract

Purpose: A 24 year old woman was referred to our care in March 2011 with a 3 year history of persistent hiccups and mild, intermittent dyspepsia. Her symptoms began with occasional mild chest discomfort lasting one minute followed by bouts of hiccups but progressed to up to ten episodes per day. She had no prior medical history other than one admission for renal calculi and her only prescription was birth control pills. She had no history of allergy and no known family history of illness as she was adopted. Six months before our evaluation she was treated empirically with ranitidine with no relief in her symptoms. She underwent esophagogastroduodenoscopy (EGD), which demonstrated trachealization of the esophagus and biopsies from the distal esophagus showed significant eosinophilic infiltration. She was subsequently placed on a 6 week course of high-dose omeprazole (40 mg twice daily), with minimal relief of her symptoms. A follow-up EGD showed persistent esophageal eosinophilia (peak eosinophils count of 23 per high power field) consistent with a diagnosis of eosinophilic esophagitis (EoE) (Figure 1). The patient was started on topical fluticasone (440 mcg twice daily). Within 1 week of treatment her symptoms improved substantially, with hiccups occurring fewer than 2 times per week. After 6 weeks her chest discomfort and hiccups resolved entirely. A post-treatment EGD demonstrated resolution of trachealization and histological remission of EoE. In conclusion, hiccups may be associated with eosinophilic esophagitis. Thus, EoE should be considered in the differential diagnosis of patients with refractory hiccups.Figure: Hematoxylin and eosin from esophageal biopsy shows large numbers of intraepithelial eosinophils as well as multiple degranulated eosinophils.