Hipo, un desafío diagnóstico / Hiccup, a diagnostic challenge

El hipo es una contracción espasmódica involuntaria del diafragma que desencadena una inspiración súbita y cierre abrupto de la glotis originando un sonido característico. Según su duración se clasifica en ataque de hipo, hipo persistente o hipo intratable o rebelde. Presentamos el caso de un varón de 75 años de edad con hipo rebelde que le impedía conciliar el sueño, diurno y nocturno, asociado a eructos, de tres años de evolución, refractario al tratamiento con clorpromazina. Luego de una extensa evaluación se llegó al diagnóstico de tumor en seno etmoidal derecho. Se efectuó la resección del tumor y posterior radioterapia local con desaparición del hipo. Consideramos ésta una causa rara de hipo rebelde que generó un desafío diagnóstico y terapéutico.

Hiccup is a spasmodic involuntary contraction of the diaphragm which triggers a sudden inspiration and an abrupt closure of the glottis with a characteristic sound. Regarding its duration, it is classified as hiccup attack, persistent hiccup or rebellious or intractable hiccup. We present the case of a 75 old male with rebellious hiccup which prevented him to fall asleep by day or by night, associated with belches lasting for three years, refractory to chlorpromazine. An extensive evaluation led to the diagnosis of right ethmoid sinus tumor. The tumor resection was performed and after subsequent local radiotherapy the hiccup disappeared. We consider this a rare cause of rebellious hiccup that generated a diagnostic and therapeutic challenge.

Hiccup: Mystery, Nature and Treatment

Hiccup is the sudden onset of erratic diaphragmatic and intercostal muscle contraction and immediately followed by laryngeal closure. The abrupt air rush into lungs elicits a "hic" sound. Hiccup is usually a self-limited disorder; however, when it is prolonged beyond 48 hours, it is considered persistent whereas episodes longer than 2 months are called intractable. A reflex arc involving peripheral phrenic, vagal and sympathetic pathways and central midbrain modulation is likely responsible for hiccup. Accordingly, any irritant in terms of physical/chemical factors, inflammation, neoplasia invading the arc leads to hiccups. The central causes of hiccup include stroke, space occupying lesions and injury etc, whereas peripheral causes include lesions along the arc such as tumors, myocardial ischemia, herpes infection, gastroesophageal reflux disease and applied instrumentations on human body etc. Besides, various drugs (eg, anti-parkinsonism drugs, anesthetic agents, steroids and chemotherapies etc) are the possible etiology. An effective treatment of persistent hiccup may be established upon the correct diagnosis of lesion responsible for the serious event. The pharmacotherapy of hiccup includes chlorpromazine, gabapentin, baclofen, serotonergic agonists, prokinetics and lidocaine. Non-pharmacological approaches such as nerve blockade, pacing, acupuncture and measures to hold breathing are also successful. Finally, alternative medicines and remedies are convenient to treat hiccups with uncertain effect. In conclusions, hiccup is likely to result from lesions involving the hiccup reflex arc. The lesion may need to be localized correctly for ablative treatment in patients with intractable hiccup. Apart from lesion ablation, drugs acting on reflex arc may be effective, while some other conventional measures may also be tried.

Establishing an artificial reflex arc restore controlled micturition of flaccid bladder after spinal cord injury: a preliminary report / 中华显微外科杂志

Objective To explore the establishment of an new artificial bladder reflex arc for controlled micturition function in the conical spinal cord injury(SCI). Methods One conical SCI patients were included by lateral microanastomosis of the L6 ventral root to S2 ventral root. After several months of axonal regeneration, the function of bladder were examined clinically and urodynamically. Results Stimulation of the new artificial reflex are could inuduce controlled voiding, and could cause detrusor contraction when following 55 months of one patient. Conclusions Establishing of an new artificial reflex arc may effective for controlled micturition in conical SCI.

Experimental and clinical studies on artificial bladder reflex arc after spinal cord injury / 中华显微外科杂志

Objective To establish an artificial reflex arc to reinnervate the nerropathic bladder and restore bladder function after spinal cord injury. It involves a somatic reflex are with a modified efferent branch which passes the somatic motor impulses to the bladder and initiate autonomic bladder detrusor contraction. Methods This is achieved by intradural microanastomosis of the right L5 ventral root to S2 ventral root in canines. After a-conal regeneration,the pateller ligament-spinal cord center-bladder new artificial bladder reflex pathway was extablished. The early and final function of the reflex are was observed by electrophysiological experiments, bladder pressure tests and detrusor electromyograms (EMG)' Surgical operation of bilateral intradural microanastomosis of the L5 ventral roots to the S2 ventral roots was done in a 20 years old male patient with upper thoracispinal paraplegia. Results Single stmuli (115 mV, 1. 0 ms) of the right L, dorsal root resulted in evoked potentials recorded from the right S2 ventral root distal to the anastomosized site in all 6 canines. In 4 canines 6 months postoperation and 48 hours after spinal cord was transected, bladder contraction was very quickly initiated by trains of stimuli (l 000 mV, 10 Hz, 2 s) of the right L5 dorsal root and bladder pressures increased rapidly to average 65% of normal compared to controls' Bladder contraction induced by knocking the right pateller ligament increased to average 51 % of controls througt the new reflex arc. In 2 canines 18 months postoperation,bladder pressures increased by the same stimuli to average 84% of controls and to average 62% of controls by knocking the pateller ligament. Stimuli (3. 8 mA, 1' 0 Hz) of the right L5 dorsal root and femoral nerve resulted in EMG recorded from the detrusor in 2 canines 18 months postoperation. The patient achieved controllable micturition by calcaneus tendon-spinal cord center-bladder new artificial bladder reflex pathway at 14 months postoperation. Micturition was very quickly initiated by passive dorsalflexion of either lateral ankle joint,and the results of bladder function was excellent at postoperation. Conclusion The somatic motor a-cons can regenerate into the parasympathetic endoneurial tubes of autonomic nerve. Using the survived somatic reflex under the horizon of spinal cord injury to reconstruct the bladder autonomic reflex arc by intradural microanasto- mosis of ventral root is successful in the first patient and have a potential of clinical application.