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しゃっくり

著者: 伊藤裕司 中東遠総合医療センター 総合内科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正/監修レビュー済:2020/06/26
患者向け説明資料

概要・推奨   

  1. 48時間以上持続する場合、男性、睡眠中でもしゃっくりが発生する場合には、背景に原因疾患がある場合が多く、原因疾患の検索を行うことを強く推奨する(推奨度1)。
  1. 頭蓋内(脳幹)および求心路となる横隔神経・迷走神経・胸椎神経の走行経路(頭頸部、胸部、背部、腹部)に従った問診・診察を心がける。
  1. 48時間以上持続するしゃっくり患者に対して、頭蓋外疾患が除外されていれば明らかな神経学的異常がなくても、頭頸部MRI検査を次に行うことを推奨する(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
伊藤裕司 : 特に申告事項無し[2021年]
監修:山中克郎 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行い、推奨文について修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 「しゃっくり」は横隔膜のけいれんであり、横隔神経・迷走神経・胸椎の一部(第6~12胸椎の交感神経)からの刺激が『しゃっくり中枢(hiccup center)』である脳幹・頸椎を介して、横隔膜に伝わることで発生する。求心路のどこで問題が生じてもしゃっくりは起こる。
  1. ほとんどのしゃっくりが自然に消失する良性とされる。一方で、48時間以上続く場合を持続性あるいは難治性と呼び、背景に重大な基礎疾患が存在する可能性が高くなるので、そのような場合には原因検索を積極的に行うべきである[1]
  1. 持続性あるいは難治性しゃっくりの場合、基礎疾患による症状以外にも、持続すること自体での合併症が知られており、可能な範囲で対症療法も検討すべきである。
 
  1. 総論として有用な文献
  1. T. Walsh, Augusto Caraceni, et al.:Palliative Medicine 1st ed., Saunders, Chapter 163, 2008.[2]
  1. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med. 1991 May;20(5):565-73.[3]
  1. SAMUELS L. Hiccup; a ten year review of anatomy, etiology, and treatment. Can Med Assoc J. 1952 Oct;67(4):315-22.[4]
  1. Williamson BW, MacIntyre IM. Management of intractable hiccup. Br Med J. 1977 Aug 20;2(6085):501-3.[5]
問診・診察のポイント  
 
  1. 48時間以上続く場合には背景に重大な基礎疾患がある可能性が高くなる[1]ので、発症からの経過が重要である。特に外科手術に伴う影響は術後1~4日以内に発症するとされる[6]
  1. 特に、睡眠中にも続く場合は器質的疾患の可能性が高くなり、逆にしゃっくりがひどくて眠れない場合や起床後にしゃっくりが頻繁になる場合は心因性の可能性が高くなる[6]
  1. 「しゃっくり反射」の経路を考えれば、頭蓋内(脳幹)および求心路となる横隔神経・迷走神経・胸椎神経の走行経路(頭頸部、胸部、背部、腹部)に従った問診・診察を心がける。迷走神経は腹腔内にも入っているので、腹部の問診・診察を忘れないようにする。

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文献 

著者: Tyler Childs Cymet
雑誌名: J Natl Med Assoc. 2002 Jun;94(6):480-3.
Abstract/Text Hiccups are a physiologic phenomenon noted in animals and humans. There is little understanding of what makes hiccups occur and whether or not they have any productive purpose. A retrospective analysis of all patients seen in a community hospital over a 5 year period was conducted to see who is affected by hiccups, evaluate laboratory findings in people with hiccups, and to see what the currently accepted treatment is for hiccups. The vast majority of patients were male, older than 50 years of age, and with co-morbid conditions. Laboratory values appeared to be of little value in determining whether treatment interventions would be effective. Gastroenterology was the service most consulted and EGD the most common procedural intervention conducted, but with little success. No treatments showed a statistically significant effect.

PMID 12078929  J Natl Med Assoc. 2002 Jun;94(6):480-3.
著者: P W Kolodzik, M A Eilers
雑誌名: Ann Emerg Med. 1991 May;20(5):565-73.
Abstract/Text Hiccups are a common, and fortunately usually transient, benign malady. Occasionally, however, hiccups fail to resolve spontaneously, resulting in patient fatigue and incapacitation and the need for the affected individual to seek medical care for resolution of the problem. The approach to the management of these patients consists of the identification and treatment of serious underlying causes of the episode as well as therapeutic interventions to achieve hiccup resolution.

PMID 2024799  Ann Emerg Med. 1991 May;20(5):565-73.
著者: L SAMUELS
雑誌名: Can Med Assoc J. 1952 Oct;67(4):315-22.
Abstract/Text
PMID 13009550  Can Med Assoc J. 1952 Oct;67(4):315-22.
著者: B W Williamson, I M MacIntyre
雑誌名: Br Med J. 1977 Aug 20;2(6085):501-3.
Abstract/Text A patient who developed hiccups after laparotomy was treated with numerous drugs with limited success. A left phrenic nerve crush was eventually successful. A review of published work showed that the drugs most likely to succeed were chlorpromazine and metoclopramide, and that phrenic nerve injection and crush should be considered if these failed.

PMID 890370  Br Med J. 1977 Aug 20;2(6085):501-3.
著者: J V Souadjian, J C Cain
雑誌名: Postgrad Med. 1968 Feb;43(2):72-7.
Abstract/Text
PMID 5638775  Postgrad Med. 1968 Feb;43(2):72-7.
著者: K Marsot-Dupuch, V Bousson, J Cabane, J M Tubiana
雑誌名: AJNR Am J Neuroradiol. 1995 Nov-Dec;16(10):2093-100.
Abstract/Text PURPOSE: To look for central nervous system abnormalities as possible causes of intractable hiccups.
METHODS: Of a series of 50 patients with chronic (ie, lasting more than 48 hours) hiccups, a prospective study identified a subgroup of 9 patients with no clinical or gastroesophageal abnormalities (according to endoscopy, pH monitoring and manometry). We performed in all 9 patients brain and upper cervical cord MR examination with precontrast and postcontrast T1- and T2-weighted sequences. A study of the last cranial nerves was done with thin T2-weighted imaging (constructive interference in a steady state sequence). The cervical cord and parapharyngeal space were systematically explored using coronal T2- and sagittal T1-weighted imaging.
RESULTS: Five of these 9 patients had definite MR abnormalities located in the temporal lobe (3 cases), cerebellopontine angle (1 case), or areas of high signal intensity compatible with demyelination (1 case). The relationship between hiccups and infratentorial abnormalities in 2 cases was doubtful (vascular loop and prominent posterior condylar canal). MR findings in 2 cases were considered normal.
CONCLUSIONS: Brain MR is a useful investigation in patients with chronic hiccups when gastroesophageal lesions are either excluded or too mild to account for an intractable hiccup.

PMID 8585500  AJNR Am J Neuroradiol. 1995 Nov-Dec;16(10):2093-100.
著者: P Rousseau
雑誌名: South Med J. 1995 Feb;88(2):175-81. doi: 10.1097/00007611-199502000-00002.
Abstract/Text Hiccups result from a variety of causes and serve no known physiologic function. Although most episodes are time-limited, hiccups may become protracted, with serious consequences. Assessment of hiccups entails a focused history and physical examination coupled with selected laboratory tests. If a correctable malady is discovered, treatment should address the underlying disorder. However, if the cause remains unknown, therapeutic options include nonpharmacologic and pharmacologic measures. Since hiccups are common, this review provides a practical approach to the management of this bothersome symptom.

PMID 7839159  South Med J. 1995 Feb;88(2):175-81. doi: 10.1097/000076・・・
著者: M R Salem, A Baraka, C C Rattenborg, D A Holaday
雑誌名: JAMA. 1967 Oct 2;202(1):126-30.
Abstract/Text
PMID 6072000  JAMA. 1967 Oct 2;202(1):126-30.
著者: N Madanagopolan
雑誌名: Curr Med Res Opin. 1975;3(6):371-4. doi: 10.1185/03007997509114789.
Abstract/Text Metaclopramide has been observed to induce dramatic relief of intractable hiccup in 14 patients with diverse serious illnesses. When given orally or parenterally the effect was observed within 30 minutes, the relief lasting up to 8 hours, indicating a direct relation to the duration of action of the drug. This drug is recommended for symptomatic relief of hiccup associated even with serious organic illnesses, without any fear of undesirable effects.

PMID 1183218  Curr Med Res Opin. 1975;3(6):371-4. doi: 10.1185/030079・・・
著者: T Wang, D Wang
雑誌名: Intern Med J. 2014 Dec;44(12a):1205-9. doi: 10.1111/imj.12542.
Abstract/Text BACKGROUND: Limited data exist regarding the efficacy of metoclopramide in the treatment of intractable hiccups.
AIM: This study aimed to assess the feasibility efficacy of metoclopramide in the treatment of patients with intractable hiccups.
METHODS: A total of 36 patients with intractable hiccups was randomly assigned to arm A (n = 18) or arm B (n = 18) in a multicentre, double-blind, randomised, controlled pilot study. Participants in arm A received 10-mg metoclopramide thrice daily for 15 days, whereas those assigned to arm B received 10-mg placebo thrice daily for 15 days. The primary outcome measure was total efficacy against hiccups (including cessation and improvement of hiccups). Secondary outcome measures included a comparison of overall efficacy and adverse events between the two arms.
RESULTS: Of the 36 patients enrolled, 34 participants completed the study. The total efficacy was higher in arm A than in arm B (relative risk, 2.75; 95% confidence interval: 1.09-6.94, P = 0.03). Furthermore, comparison between the two arms revealed that overall efficacy was higher in arm A than that in arm B (P < 0.05). No serious adverse events related to the treatment were documented in either arm. The most common adverse events occurring in patients in arm A included fatigue, upset mood and dizziness.
CONCLUSION: Metoclopramide appears to be a promising candidate for the treatment of patients with intractable hiccups, with mild adverse events. However, further clinical trials are required to confirm these results.

© 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.
PMID 25069531  Intern Med J. 2014 Dec;44(12a):1205-9. doi: 10.1111/imj・・・
著者: C E FRIEDGOOD, C B RIPSTEIN
雑誌名: J Am Med Assoc. 1955 Jan 22;157(4):309-10.
Abstract/Text
PMID 13221413  J Am Med Assoc. 1955 Jan 22;157(4):309-10.
著者: Cornelius J Woelk
雑誌名: Can Fam Physician. 2011 Jun;57(6):672-5, e198-201.
Abstract/Text
PMID 21673211  Can Fam Physician. 2011 Jun;57(6):672-5, e198-201.
著者: F C Ramírez, D Y Graham
雑誌名: Am J Gastroenterol. 1992 Dec;87(12):1789-91.
Abstract/Text Four patients with intractable hiccup were treated in a double-blind, randomized, placebo, cross-over study with an analogue of gamma-aminobutyric acid, Baclofen. There was a consistent and statistically significant (p = 0.03) improvement in hiccup severity with Baclofen, both subjectively (p = 0.03) and by hiccup-free periods (p = 0.003). The actual frequency of hiccup was not significantly altered by the medication. We propose that the mechanical aspects of hiccup are reduced by Baclofen, leading to a perceptual blockage and a decrease in the reflex severity induced by the gamma-aminobutyric acid analogue. We conclude that this medication may be useful for the treatment of intractable hiccup.

PMID 1449142  Am J Gastroenterol. 1992 Dec;87(12):1789-91.
著者: Cuie Zhang, Ruifen Zhang, Shuangyan Zhang, Meiling Xu, Shuyan Zhang
雑誌名: Trials. 2014 Jul 22;15:295. doi: 10.1186/1745-6215-15-295. Epub 2014 Jul 22.
Abstract/Text BACKGROUND: The results of preclinical studies suggest that baclofen may be useful in the treatment of stroke patients with persistent hiccups. This study was aimed to assess the possible efficacy of baclofen for the treatment of persistent hiccups after stroke.
METHODS: In total, 30 stroke patients with persistent hiccups were randomly assigned to receive baclofen (n = 15) or a placebo (n = 15) in a double-blind, parallel-group trial. Participants in the baclofen group received 10 mg baclofen 3 times daily for 5 days. Participants assigned to the placebo group received 10 mg placebo 3 times daily for 5 days. The primary outcome measure was cessation of hiccups. Secondary outcome measures included efficacy in the two groups and adverse events.
RESULTS: All 30 patients completed the study. The number of patients in whom the hiccups completely stopped was higher in the baclofen group than in the placebo group (relative risk, 7.00; 95% confidence interval, 1.91-25.62; P = 0.003). Furthermore, efficacy was higher in the baclofen group than in the placebo group (P < 0.01). No serious adverse events were documented in either group. One case each of mild transient drowsiness and dizziness was present in the baclofen group.
CONCLUSIONS: Baclofen was more effective than a placebo for the treatment of persistent hiccups in stroke patients.
TRIAL REGISTRATION: Chinese Clinical Trials Register: ChiCTR-TRC-13004554.

PMID 25052238  Trials. 2014 Jul 22;15:295. doi: 10.1186/1745-6215-15-2・・・
著者: Giampiero Porzio, Federica Aielli, Lucilla Verna, Paolo Aloisi, Brigida Galletti, Corrado Ficorella
雑誌名: Clin Neuropharmacol. 2010 Jul;33(4):179-80. doi: 10.1097/WNF.0b013e3181de8943.
Abstract/Text AIM: To evaluate safety and efficacy of gabapentin in the treatment of severe chronic hiccups in patients with advanced cancer.
METHODS: Charts of all patients observed in the palliative care unit of a 4-bed hospital and at home by our Home Care Service were reviewed retrospectively.The presence of hiccups was routinely assessed. Patients with severe chronic hiccups were treated with gabapentin (300 mg t.i.d.). Doses of gabapentin were titrated based on the response to treatment.Gabapentin-related adverse effects were recorded.
RESULTS: Thirty-seven (3.9%) of 944 in-hospital patients and 6 (4.5%) of 134 patients observed at home presented severe chronic hiccups.We registered an improvement of hiccups, defined as complete resolution of hiccups, in 31 (83.8%) of 37 in-hospital patients and 4 (66.7%) of 6 patients observed at home.Four (10.8%) of the 37 in-hospital patients and 2 (33.3%) of the 6 patients observed at home experienced a reduction of hiccups.In 2 patients (5.4%), we registered a worsening of hiccups.Responses were observed in 32 patients (74.4%) with gabapentin at a dosage of 900 mg/d and in 9 patients (20.93%) at 1200 mg/d.In 2 patients (4.65%), grade 2 sleepiness was observed and in 10 patients (23.25%), grade 1 sleepiness was observed based on the Epworth Sleepiness Scale.
CONCLUSION: The results of the study allow suggesting gabapentin at least as a promising drug in the treatment of severe chronic hiccups in advanced cancer patients.

PMID 20414106  Clin Neuropharmacol. 2010 Jul;33(4):179-80. doi: 10.109・・・
著者: Rita Moretti, Paola Torre, Rodolfo M Antonello, Maja Ukmar, Giuseppe Cazzato, Antonio Bava
雑誌名: Neurologist. 2004 Mar;10(2):102-6.
Abstract/Text BACKGROUND: Persistent and intractable hiccups indicate multiple neurologic and extraneurologic disorders. Chronic hiccup is not so rare in patients suffering from stroke: its impact on quality of life and on rehabilitation management is substantial, and it may be closely related to aspiration pneumonia, respiratory arrest and nutritional depletion.
REVIEW SUMMARY: Intractable hiccups can be associated with potentially fatal consequences and safe management may require inpatient rehabilitation. It has been suggested that hiccups could be a form of myoclonus, caused by repeated and abnormal activity of the solitary inspiratory nucleus. Because of this cause we decided to treat intractable hiccups in patients with ischemic lesions of the medulla with a short course of gabapentin.
CONCLUSIONS: The results were promising, with the immediate disappearance of the hiccups, and the complete absence of side effects. The 36-months follow up was favorable to all the patients, who, after 6 days of treatment remain asymptomatic.

PMID 14998440  Neurologist. 2004 Mar;10(2):102-6.

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