Management of Intractable Hiccups from Ileus

Pharmacological Management

The National Comprehensive Cancer Network recommends dopamine receptor antagonists such as haloperidol, metoclopramide, prochlorperazine, or olanzapine as second-line options for intractable hiccups, titrating to maximum benefit and tolerance 1, 2
The National Comprehensive Cancer Network suggests adding a 5-HT3 antagonist, such as ondansetron, with or without an anticholinergic agent, such as scopolamine, if hiccups persist 1, 2
Consider adding a corticosteroid, such as dexamethasone, if no response to above therapies, as recommended by the National Comprehensive Cancer Network 1, 2
For refractory cases, the National Comprehensive Cancer Network recommends considering continuous IV/subcutaneous infusion of antiemetics 1, 2
Prokinetic agents, such as metoclopramide 10-20 mg PO four times daily, may be effective in treating intractable hiccups, according to the National Comprehensive Cancer Network 1

A multifaceted approach to resolve the underlying ileus is recommended, including optimizing fluid management, using opioid-sparing analgesia, encouraging early mobilization, removing nasogastric tubes as early as possible, and considering laxatives such as bisacodyl and magnesium oxide 3, 4, 5, 6, 7
Optimize fluid management by avoiding overhydration and aiming for weight gain <3 kg by postoperative day 3, as suggested by the World Journal of Emergency Surgery 3
Encourage early mobilization as soon as the patient's condition allows, according to the World Journal of Emergency Surgery 3, 4
Remove nasogastric tubes as early as possible, as recommended by the World Journal of Emergency Surgery 3
Consider laxatives such as bisacodyl and magnesium oxide, as suggested by the World Journal of Emergency Surgery 3
Early oral intake should be encouraged with small portions initially, especially after right-sided resections and small-bowel anastomosis, according to the World Journal of Emergency Surgery 7

Patients with intestinal ileus should not be given oral fluids until bowel sounds are audible, as recommended by the MMWR Recommendations and Reports 8, 9
If oral intake is inadequate (<50% of caloric requirement) for more than 7 days, consider early tube feeding or parenteral nutrition, according to the World Journal of Emergency Surgery 7
Water-soluble contrast agents and neostigmine may be considered for treating persistent postoperative ileus, as suggested by the World Journal of Emergency Surgery 7

Reassess the effectiveness of therapy daily and adjust medications accordingly, as recommended by the National Comprehensive Cancer Network 1