Intractable Hiccups: A Rare Presentation of Invasive Colon Adenocarcinoma

Abstract

Introduction: Hiccups are caused by a sudden onset of diaphragmatic and intercostal muscle contraction followed by laryngeal closure. Patients with GI malignancies get hiccups from many causes, such as chemotherapy agents, steroids, or metastases invading the hiccup reflex. However, hiccups as the presenting symptom of advanced cancer is uncommon, and is rarely found in the literature. We present a case of intractable hiccups as the presenting symptom of invasive colon adenocarcinoma. Case: A 67-year-old male with a history of diabetes and hypertension presented to the hospital with persistent hiccups for two months. Chlorpromazine moderately controlled the hiccups, however, they were sometimes severe enough to induce dyspnea. He denied any abdominal pain, nausea, or vomiting, but did report a 20-lb weight loss, decreased appetite, and increasing lower back pain over a two-week period. A CT scan of the abdomen/pelvis showed a 7-cm heterogeneous, ill-defined mass arising from the rectosigmoid colon with necrotic regions. Pelvic MRI localized the mass to the distal sigmoid with a left psoas muscle abscess. Colonoscopy showed a circumferential polypoid friable mass 20 cm from the anal verge, with a narrowed lumen. Subsequent biopsies revealed invasive adenocarcinoma. The patient had an ex-lap where a rectosigmoid mass adherent to the bladder and small bowel was resected, and a final diagnosis was moderately to poorly differentiated adenocarcinoma, stage III T4BN2A. The patient's hiccups decreased in intensity after his surgery. Discussion: Hiccups can be classified into three categories; self-limiting (due to gastric distention from overeating or aerophagia), that last for <48 hours, persistent, lasting for >48 hours, or, rarely, intractable, lasting for >1 month (due to CNS lesions, mediastinal disease, MI, TB, medications, or GI disorders). GI disorders including GERD, achalasia, gastric distention, SBO, and GI malignancies such as esophageal, pancreatic, and biliary cancers may cause intractable hiccups due to visceral afferent fiber stimulation of the vagus nerve in the hiccup reflex arc. GI malignancies may lead to intractable hiccups from cancer drugs such as cisplatin, which releases 5-HT from vagal afferents starting the hiccup reflex, and steroids, which have receptors within the efferent limb of the hiccup reflex. It is very rare for hiccups to develop in a patient with untreated colon adenocarcinoma. To our knowledge, this is the first case in the literature where invasive colon adenocarcinoma presented as intractable hiccups.