Intractable Hiccups and Gastroesophageal Reflux Disease Attributable to Brain Tumor: A Case Report

Abstract

Introduction: Intractable (lasting more than 2 months) hiccups have various etiologies including vagus or phrenic nerve irritation, toxic-metabolic disorders, central nervous system (CNS) disorders, and psychogenic causes. The aim of this study was to report a child with intractable hiccups resulting from probable infiltrating astrocytoma at brainstem and cervical spinal cord. Case description: A 6-year-old girl had hiccups, snoring, and anemia for 2 months. Hiccups persisted throughout day and night. She also had epigastric pain with nausea. Her BW was 19.6 kg and height was 109 cm. Her general medical examination revealed pallor and unremarkable otherwise. There was no papilledema. Motor, sensory, and cerebellar function were intact. Gastroesophageal reflux disease was assumed as the cause of her symptoms, therefore she was put on 20 mg of omeprazole daily. One month later, she had hematemesis. EGD revealed an esophageal ulcer and erosion at distal esophagus. Her symptoms continued even she was on 60 mg of lansoprazole and iron supplement. Esophageal pH monitoring revealed a reflux index of 59% and impedance study demonstrated 65 episodes of acid reflux. Upper GI series was unremarkable. Because of unremitting hiccups, brain imaging was conducted, and magnetic resonance imaging demonstrated enhancing infiltrative lesion involved floor of forth ventricle, posterior aspect of lower pons, entire medulla, cervicomedullary junction and extended down to dorsal portion of C7 cord. Biopsy revealed reactive gliosis. Brainstem and intramedullary astrocytoma was supposed. Her symptoms improved with radiotherapy. This report emphasizes brain tumor as the etiology of intractable hiccups. When encountering a patient with intractable hiccups, appropriate CNS imaging studies should be included in the evaluation protocol.