Multiple drug and non-drug methods have been used to disrupt the hiccup reflex arc. When a patient's hiccups are protracted, home remedies are generally ineffective and other means must be employed.1 One non-drug method uses a nasogastric (NG) tube. Insert the NG tube into the stomach and immediately remove it. The hiccups should stop at once. If not, try a second time. It's postulated that the mechanism involved is irritation of the posterior nasal mucous membrane and lower esophageal sphincter.2
Another method of treating hiccups that is relatively benign, generally available, inexpensive, and simple to use is intravenous (IV) lidocaine. On multiple occasions, it has worked successfully when other medications have failed. Reported successful procedures with lidocaine doses, in both children and adults, have involved loading the patient with 1 to 2 mg/kg and then generally beginning a 2 mg/kg (sometimes up to 4 mg/kg) drip for 4 to 12 hours. This often had to be repeated within 24 hours.3-6 My personal experience with this technique was in a remote location with an adult who had had several severe and debilitating hiccup attacks over the prior decade. I used an infusion of 2 mg/kg lidocaine over 20 minutes, which stopped the hiccups as the infusion was ending. Although they did not recur, I gave him a 20-minute infusion of 1 mg/kg on each of the next 2 days. He did not have a recurrence over the next 5 months.
Treatments for the common complaint of nausea and vomiting vary around the globe. Some medications, such as the phenothiazines that are commonly used in some countries, are unavailable for this use in other countries. Other common treatments, such as metoclopramide and ginger root, are ineffective.7
Some generally available and inexpensive medications that have been shown to be effective for nausea and vomiting include dexamethasone, 5 to 10 mg IV (pediatric dose: 0.5 to 1.5 mg/kg); droperidol, 0.625 to 1.25 mg IV; dimenhydrinate, 1 to 2 mg/kg IV; and ephedrine, 0.5 mg/kg intramuscularly (IM).8 A side benefit of using dexamethasone is that it often relieves bowel obstruction along with the accompanying nausea and vomiting in cancer patients.9
Acupressure, as both a preventive (anesthesia and pregnancy) and a treatment, has shown mixed results. Acupressure may be more effective in controlling nausea symptoms than in preventing emesis.10 But, since it costs nothing, has no side effects, is simple to use, and is available in any situation, it is probably worth trying. The Pe6 Neiguan point where acupressure is applied can be located on the volar forearm about 2 inches proximal to the distal wrist crease (in adult males) between the tendons of the flexor carpi radialis and palmaris longus. For others, it is one-sixth the distance between the distal wrist crease and the elbow flexor crease (Fig. 31-1). Apply pressure to this site using a marble, ball bearing, or similar object placed beneath an armband, such as used for a venous tourniquet, or an elastic bandage. Begin by compressing the sphere intermittently for a few minutes; then apply the pressure constantly under the band.11
Acupressure site for nausea and vomiting.
Diarrhea afflicts nearly everyone at some point.
Among the Bataan prisoners of war (POWs), physician–prisoners "created pills for dysentery from cornstarch, guava leaves and charcoal."12 Pepto Bismol tablets are frequently used for symptomatic treatment of non-dysenteric diarrhea.
Probiotics (live nonpathogenic microorganisms, usually bacteria or yeast) may benefit patients with infectious and antibiotic-associated diarrhea, including Clostridium difficile-associated disease. Yogurt with Lactobacillus species and Saccharomyces boulardii has been shown to be effective.13,14
Irritable bowel syndrome (IBS) is characterized by mild to severe abdominal pain, discomfort, bloating, and alteration of bowel habits. In some adult patients with IBS, administering intrarectal lidocaine (300 mg) jelly may reduce rectal pain. It works within 15 minutes of administration and is reported to be safe and effective.15
Constipation is a common complaint, especially in postoperative and pregnant patients, the elderly, those on several types of medications, and those with diabetes, hypothyroidism, depression, and inflammatory bowel disease.
Treatment for constipation can either be mechanical (i.e., enema) or with oral agents. Table 31-1 lists some inexpensive, readily available oral agents that have been shown to be effective. There is good evidence to suggest that increased dietary fiber and increased physical activity can also reduce the incidence of constipation.
Table 31-1 Readily Available Oral Agents to Treat Constipation ||Download (.pdf)
Table 31-1 Readily Available Oral Agents to Treat Constipation
|Mechanism/Class||Agent||Typical Adult Dose||Time to Action (Hours)|
|Bulking or hydrophilic agents||Dietary fiber (most often, bran)||20-40 g*||12-72|
|Osmotic agents||Magnesium hydroxide (milk of magnesia)||15-60 mL||0.5-6|
|Sorbitol syrup (10.5 g/15 mL)||15-60 mL||0.5-3|
|Stimulant laxative||Senna (standardized concentrate)||15-60 mg||0.25-1|
|Cascara sagrada (fluid extract)||5 mL||0.25-1|
|Castor oil (ricinoleic acid)||30-60 mL||0.25-1|
|Lubricating agent||Mineral oil||15-30 mL||6-8|
Constipation can also be treated with enemas. Enemas, of course, may also be used to administer medications and to provide parenteral fluids, as described under "Rectal Hydration/Proctoclysis" in Chapter 11, Dehydration/Rehydration. Multiple types of improvised equipment can be used to give an enema. With an improvised connection, nearly any tubing can be attached to a tea or coffee pot, an IV bag, or a funnel.
Rectal pain from intermittent spasm is often a chronic condition. Patients can be taught to relieve the spasm by using a few ounces of warm water as an enema. The pain usually resolves within a minute.17
Common and painful, hemorrhoids are enlarged vascular cushions in the anal canal. They most commonly present with painless rectal bleeding, but patients often have pruritus, swelling, prolapse, discharge, or soiling. Hemorrhoids normally appear at 3 o'clock (left lateral when patients are in the lithotomy position), 7 o'clock, and 11 o'clock around the anus. Severe pain occurs when hemorrhoids are thrombosed or strangulated. Note that anal cancer presents very much like prolapsed hemorrhoids.
Those familiar with the technique can use rubber band ligation on all prolapsed hemorrhoids except those that cannot be reduced. Up to three hemorrhoids can be banded at each visit. Make the bands by cutting a Foley catheter into 1/16-inch-wide segments. Up to 150 bands (which also can be used to band esophageal varices) can be made from one catheter. Use thread seal to fasten the bands to the application cylinder on the scope.18 To minimize pain, banding should be done above the dentate line (transition from squamous to columnar epithelium). Most patients are happy with the outcome, but delayed bleeding 5 to 10 days after the procedure is possible.19
Submucosal injection of 5% oily phenol (sclerotherapy) is an inexpensive and easily performed alternative to treat first-degree and second-degree hemorrhoids. The difficulty is that this does not seem to have any better result than fiber supplementation, and it has a relatively high failure rate.20 Opening thrombosed hemorrhoids under less-than-ideal circumstances may initially relieve the pain but soon leads to bleeding, increased pain, and increased incidence of infection.
Painful anal fissures are often treated with surgery. They are thought to be due to increased internal sphincter pressure causing an ischemic ulceration distal to the dentate line. Usually, they lie in the posterior midline and can progress to chronic fissures. Acute anal fissures (ischemic ulcers) often persist because the pain causes spasm of the internal anal sphincter that results in more pain and bleeding. Without surgery, acute fissures can often be successfully treated with topical nitroglycerine or by using a "frozen finger."
Topical nitroglycerine cures about 60% of adult patients with acute fissures; it does less well treating chronic fissures. How well it works in infants and children is unknown. Make a 0.2% glyceryl trinitrate ointment by mixing 2 g glyceryl trinitrate (standard preparation) with 20 g fatty yellow petroleum jelly. Tell the patient to keep the ointment refrigerated. The patient should apply it to the anus and in the anal canal three times daily for 4 weeks.21
Another simple and effective treatment is to use a "frozen finger" to reduce the symptoms and promote healing.22 To make a frozen finger: fill an ordinary rubber exam glove with water and tie off the fingers with string. Empty the rest of the glove and cut off each of the fingers, leaving a generous margin of glove. Put them in a freezer and leave them there until needed.
To use a frozen finger, apply 5% lidocaine jelly to the anus and insert the frozen finger through the anal ring, leaving the strings used to tie it closed and a small part of the finger outside of the anus so that it can be removed easily. Leave it in place until it is no longer cold and stiff—about 7 minutes. Once shown how to do this, patients can place the fingers themselves once a day. Fingers work very well when accompanied by the standard patient recommendations to eat a high-fiber diet, hydrate well, and use anesthetic creams, laxatives, and sitz baths, as possible, for 3 months. They generally provide immediate temporary pain relief and significant ongoing pain relief within 2 weeks; 60% of the fissures heal within 2 weeks (as opposed to only 10% in the "non-finger" group).22 This technique also works well for symptomatic relief from thrombosed external hemorrhoids.23