Rhinorrhea and Hiccups After Bariatric Surgery: Exploring Associations with Psychological and Behavioral Factors

Abstract

In our surgical center, we have observed a high occurrence of hiccups and rhinorrhea following bariatric surgery. This retrospective study aimed to assess the frequency of post-prandial hiccups and rhinorrhea following bariatric surgery and explore potential behavioral and clinical associations. The study was performed at Cannizzaro Hospital (Catania, Italy), an institution accredited by SICOB (Italian Society for Bariatric and Metabolic Surgery) as a national referral center. The cohort included bariatric patients who completed a preoperative psychological evaluation and adhered to a one-year post-surgical follow-up between October 2022 and November 2023. Data on eating behaviors, mental status and dietary habits were collected for each patient before surgery, while clinical records, including the recurrence of hiccups and rhinorrhea, were acquired at the following time points: baseline and 1, 3, 6 and 12 months post-surgery. Post-prandial hiccups and/or rhinorrhea were reported by 49.5% of patients at 1 month and persisted in 46.8% after 12 months. No significant associations were found between the symptoms and weight loss, BES score, or psychological traits, except for slight associations with smoking and carbonated beverage intake. In our cohort, the etiology of hiccups and rhinorrhea appears unrelated to behavioral or psychological factors and may instead reflect vagal hyper-responsiveness after gastric fundus resection.

1. Introduction

Metabolic bariatric surgery (MBS) is currently one of the most effective treatment options for achieving significant long-term weight loss, especially when previous attempts with both diet and medical therapy have given suboptimal clinical response [1,2,3]. According to the latest 2022 guidelines of the International Federation for the Surgery of Obesity and Metabolic Disorder (IFSO), published jointly with ASMBS (American Society for Metabolic and Bariatric Surgery), weight-loss surgery is mainly indicated in individuals with class II obesity or higher, regardless of associated diseases, or for those with class I obesity in the presence of at least one metabolic comorbidity [4]. In addition, the same IFSO/ASMBS guidelines designate bariatric surgery as a more effective way to lose weight rather than non-surgical treatments, and many studies in the literature have already shown the remarkable improvement in associated medical problems and mortality risk to which MBS can lead [5,6,7,8,9,10]. Despite the benefits, the bariatric approach was historically considered as a last resort to attempt noteworthy weight loss, taking into account all the possible surgery-related risk factors. As it is also stated in the IFSO/ASMBS 2022 guidelines, a patient who consents to this kind of treatment must be evaluated in a multidisciplinary manner, with the collaboration of an expert team [4]. It is thus recommended for the candidate to undergo several diagnostic preoperative investigations: according to the 2023 SICOB (Italian Society for Bariatric and Metabolic Surgery) guidelines, esophagogastroduodenoscopy (EGD) and obstructive sleep apnea syndrome (OSAS) screening are particularly indicated (albeit not mandatory) in order to reduce the incidence of perioperative complications [11]. A psychological-psychiatric preoperative interview should be carried out as well: IFSO/ASMBS 2022 guidelines consider this evaluation essential to improve surgical outcomes, determine the patient’s ability to deal with post-operative lifestyle and body image changes, and assess for possible mental health, eating, or substance abuse disorders that may interfere with optimal surgical outcomes. [4,12,13,14,15,16,17,18].

Hiccups are defined as involuntary diaphragm spasms triggered by a reflex arc involving phrenic, vagal, and sympathetic nerves, often related to belching and aerophagia. These symptoms may be exacerbated by the consumption of certain types of food, carbonated drinks and smoking [19]. Rhinorrhea, on the other hand, refers to excessive nasal mucus discharge, most frequently associated with allergy, respiratory infections, cold exposure and head trauma [20,21,22]. Less often, it results from gustatory rhinitis, caused by the ingestion of specific foods that stimulate trigeminal nerve endings and activate parasympathetic nasal reflexes [23]. In our surgical center, we have observed a relatively high occurrence of atypical symptoms such as hiccups and rhinorrhea following bariatric surgery.

Eating behaviors can be identified not as isolated events but as the result of complex neurobiological processes that involve specific neural circuits implicated in inhibitory control and emotion regulation. Furthermore, psychological factors can interfere with these homeostatic mechanisms, potentially influencing autonomic responses. As symptoms such as hiccups and rhinorrhea are directly mediated by the sympathetic vagal arc, it is clinically relevant to explore whether eating behavioral patterns can alter these neurophysiological reflexes [18,24].

Therefore, the aim of this study is to analyze the frequency of hiccups and rhinorrhea in a cohort of patients undergoing metabolic and bariatric surgery and to investigate potential associations and underlying mechanisms related to these phenomena.

2. Materials and Methods

2.1. Study Group

This retrospective study involved a sample of MBS candidates at Cannizzaro Hospital (Catania, Italy) who underwent sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB) from October 2022 to November 2023. All patients in the cohort satisfied the following inclusion criteria: (1) MBS indication; (2) class II obesity or higher; (3) patients from 18 to 65 years of age; (4) preoperative psychological-psychiatric interview; (5) adherence to one-year post-bariatric follow-up.

2.2. Preoperative Psychological-Psychiatric Interview

In accordance with SICOB guidelines, all MBS candidates included in this study underwent a preoperative psychological-psychiatric evaluation. Several psychological features, including emotional eating, anxiety, and body image disturbance, were assessed using clinical judgment during the psychological interview.

The process began with a general clinical anamnestic interview assessing spontaneous speech, openness to dialogue, personal background, and mental status. Several areas were explored, including: (1) family and marital status; (2) working habits; (3) free time and physical activity; (4) obesity familiarity; (5) weight-related medical problems; (6) psychiatric history and psychopharmaceutical usage, and (7) eating disorders.

The clinician then investigated the patient’s weight and dietary history, with attention to weight fluctuations during different life stages, previous weight-loss attempts, and the type of diets followed (professionally prescribed or self-managed). Use of anorectic drugs and awareness of their effects were also addressed. Eating behaviors were explored in detail, focusing on eating patterns, food types, meal frequency, intake for meal and possible emotional overeating. Additionally, consumption of cigarettes, coffee, and carbonated drinks was recorded.

Given that surgical outcomes depend mostly on patient compliance, the evaluation also assessed motivation, awareness of the surgical process and its long-term effects, expectations about weight loss, and ability to adhere to follow-up and treatment protocols. Body image perception was explored, especially in terms of emotional distress, self-esteem, and the association between appearance and self-worth, to identify any underlying body image disorder.

Afterwards, all patients filled in a standardized eating behavior survey called the Binge Eating Scale (BES), a self-administered 16-item questionnaire to appraise the presence of binge eating disorder. All questions were multiple choice, and each of the answers had its own numerical value, referencing an overall score range from 0 to 46. Based on the test, the patient may be found to be a non-binge eater (BES < 17), a moderate binge eater (17 ≤ BES ≤ 26) or a severe binge eater (BES ≥ 27) [25].

Absolute exclusion criteria to MBS included: (1) Major Psychiatric Disorder or Axis-I disorders according to DSM-V-TR (e.g., dementia, psychosis, schizophrenia, major depression, bipolar disorder), (2) eating disorders related to Bulimia Nervosa, and (3) Personality Disorder or Axis-II disorders according to DSM-V-TR, especially when related to suicidal instincts, serious impulsiveness or inability to follow rules or provide informed consent.

Patients who met the inclusion criteria were deemed eligible to undergo the procedure and participate in the post-bariatric follow-up.

2.3. Surgical Procedures

All candidates in the cohort were treated with one of the following MBS laparoscopic procedures: sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). In both cases, patients underwent general anesthesia and were given preoperative and perioperative antibiotics following the hospital protocol. All patients in the cohort underwent a preoperative gastroscopy to identify any lesions related to gastroesophageal reflux disease (GERD). When such pathological findings were detected, appropriate treatment was administered. To confirm the resolution of GERD and ensure eligibility for surgery, a second preoperative control gastroscopy was then performed in patients previously found to have reflux-related lesions.

SG is a mini-invasive laparoscopic bariatric technique that aims to reduce the size of the stomach by approximately 80%, leaving only a sleeve-shaped gastric stump [26]. SG was performed through a first mobilization of the greater curvature, separating it anatomically from omental attachments and gastric vessels, extending up to the fundus, near the cardia and the angle of His. The vertical resection was started at 4–6 cm proximal to the pyloric sphincter, obtaining a 36 French bougie. After the tubulization, the dissected surgical piece was then removed irreversibly.

In comparison, OAGB is meant to limit the nutrients the body assimilates by setting up a bypass of a portion of the small intestine [27]. The procedure was conveyed at the level of the lesser curvature. At the beginning, the surgeon opened access to the lesser sac, releasing the anatomic relation with the small omentum and the gastric vessels and carefully moving the posterior wall of the stomach away from the pancreas. Subsequently, a small gastric pouch was created (~150–200 mL in volume, enough to secrete gastric juice through the pylorus) and then anastomosed with a jejunal loop located at about 150–200 cm downstream of the Treitz ligament. This gastro-jejunostomy allows food to bypass the antrum and a significant part of the small intestine, reducing its absorption and assimilation. Unlike the SG, in OAGB, no portion of the digestive tract was removed, as the resected part remained in place and was excluded.

2.4. Post-Bariatric Follow-Up

Medical evaluation through clinical and laboratory data collection was performed for each patient at five different stages: preoperative and 1, 3, 6 and 12 months post-surgical treatment. At every follow-up visit, patients’ assessments were conducted as follows:

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General interview to appraise candidates’ quality of life, weight variations, dietary history and habits, possible postoperative complications and changes in medication and pharmacological therapy.

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Assessment of post-prandial hiccups and rhinorrhea through the following standardized questions: “Do you experience hiccups and/or rhinorrhea after meals?” and, if yes, “How frequently do these symptoms occur: more or less than two times per day?”

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Recommendations to reduce food intake by chewing and eating more slowly were provided to all patients at every follow-up visit.

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Blood sampling, with hematological analysis.

The post-surgical outcomes of MBS, including BMI value, %TWL (percentage of total weight loss) and course of obesity-linked medical problems, were recorded according to standard guidelines from the IFSO and the ASMBS [4].

The occurrence and frequency of hiccups and rhinorrhea were recorded for all participants of the study. In order to be classified as having post-prandial hiccups or rhinorrhea, patients needed to report recurrent symptoms occurring at least once per day. Episodic events were not considered. A high frequency was defined as the presence of more than two episodes per day, whereas a low frequency indicated less than two episodes per day.

All data from the one-year post-bariatric follow-up were reported into an organized database and analyzed with statistical methods.

2.5. Statistical Analysis

Descriptive statistics were used to analyze clinical data. Normality was assessed using the Shapiro–Wilk and Kolmogorov–Smirnov tests. Continuous variables were expressed as mean ± SD or median (IQR) depending on their distribution; whereas categorical variables were expressed as counts and percentages. Comparisons between groups were performed using the unpaired t-test or Mann–Whitney test, as appropriate. Associations between categorical variables were assessed with the chi-square or Fisher’s exact test. Changes across time points were analyzed using Repeated Measures One-Way ANOVA or the Friedman test, followed by appropriate multiple-comparisons tests. Correlations were evaluated using Pearson’s or Spearman’s coefficients. A p-value < 0.05 was considered statistically significant. Analyses were performed with GraphPad Prism version 10.4.1 for macOS (GraphPad Software, Boston, MA, USA).

3. Results

3.1. Study Group

The study included 109 patients, of whom 88.1% (96) underwent SG and 11.9% (13) OAGB surgery. Among the study group, 80.73% (88) were female, and 19.26% (21) were male. The median age was 40 with a range of 30–49 (25th–75th percentile). No complications were observed during the post-operative follow-up.

Following the preoperative psychological-psychiatric assessment, all 109 patients met the inclusion criteria, were considered eligible for bariatric surgery, and were therefore included in the study cohort.

The categorical data collected from the psychological-psychiatric evaluation are reported in

Table 1. Outcomes of the preoperative psychological-psychiatric assessment, reported as numbers and percentages of the total cohort.

Psychological Outcome	N	% of Total Population
Emotional eating	49	44.95
Anxiety	26	23.85
Body image disturbance	48	44.03
Worker	54	49.54
Specialized diet	93	85.32
Childhood obesity	46	42.20
Adolescent obesity	57	52.20
Weight cycling	61	55.96
Post-pregnancy obesity	50	56.81 (% of female population)
Large-volume meals	86	78.89
Snacking	81	74.31
Carbonated drinks	68	62.38
Coffee	68	62.38
Smoke	32	29.36

as absolute numbers and the percentage of the total cohort.

The mean and standard deviation BES scores observed in this study cohort were 9.94 ± 8.21. The number and percentage of patients falling into the different severity categories of BED (none to mild, moderate, and severe) are reported in

Table 2. Distribution of the patient cohort across BED (binge eating disorder) severity categories.

BES Score	Binge Eating Disorder Symptoms	N	% of Total Population
BES ≤ 17	None to mild	90	82.57
18 ≤ BES ≤ 26	Moderate	15	13.76
BES ≥ 27	Severe	4	3.66

.

3.2. Weight Loss

Throughout the follow-up period, a progressive and sustained improvement in weight-related parameters was observed. Specifically, there was a gradual decrease in body weight and BMI and an increase in ΔBMI and %TWL across the different time points, as reported in

Table 3. Weight-related parameters, including absolute body weight, BMI, ΔBMI and %TWL at the different time points of post-bariatric follow-up. BL: baseline; 1M: one month; 3M: three months; 6M: six months; 12M: twelve months; BMI: body mass index; ΔBMI: change in BMI; %TWL: percentage of total weight loss.

Weight Parameter	BL	1M	3M	6M	12M
Body weight in kg (Mean ± SD)	112.79 ± 17.21	100.72 ± 16.03	91.28 ± 15.39	80.73 ± 14.57	72.47 ± 14
BMI (Mean ± SD)	41.73 ± 5.03	37.27 ± 4.87	33.77 ± 4.83	29.83 ± 4.67	26.76 ± 4.41
ΔBMI (Mean ± SD)	-	4.46 ± 1.15	7.97 ± 1.6	11.89 ± 2.49	15.02 ± 3.59
%TWL (Mean ± SD)	-	10.78 ± 2.56	19.21 ± 3.68	28.55 ± 5.36	35.89 ± 7.25

. The Friedman test and the Repeated Measures One-Way ANOVA highlighted a statistically significant difference (p < 0.0001) between the time points for, respectively, BMI and %TWL.

3.3. Hiccups and Rhinorrhea

During follow-up visits, patients described the onset and frequency of hiccups and/or rhinorrhea after surgery, commonly experienced during meals or in the postprandial phase. These symptoms were generally associated with rapid eating or insufficient mastication.

After one month, 49.54% of patients reported one or both symptoms; at 3 months, 44.95%; at 6 months, 42.20%; and at 12 months, 46.79%. A comprehensive overview of the number of patients experiencing only hiccups, only rhinorrhea, or both symptoms at each follow-up time point is reported in

Table 4. Number of patients affected by hiccups, rhinorrhea or both symptoms at each time point. 1M: one month; 3M: three months; 6M: six months; 12M: twelve months.

Timepoint	Hiccups	Rhinorrhea	Hiccups and Rhinorrhea	Total Symptomatic
1M	40	19	5	54
3M	17	36	4	49
6M	19	32	5	46
12M	31	27	7	51

. Symptomatic patients were further stratified according to symptom frequency, based on the criteria described above. The distribution of high and low frequency hiccups and/or rhinorrhea at each follow-up time point is presented in

Table 5. Distribution of patients with hiccups and/or rhinorrhea according to symptom frequency at each time point. High frequency was defined as more than 2 episodes/day and low frequency as less than 2 episodes/day. 1M: one month; 3M: three months; 6M: six months; 12M: twelve months.

Timepoint	High Frequency	Low Frequency	Total Symptomatic
1M	39	15	54
3M	27	22	49
6M	21	25	46
12M	13	38	51

.

Analyses were conducted considering the total number of symptomatic patients (i.e., those presenting hiccups and/or rhinorrhea), without distinguishing between individuals experiencing only one of the two symptoms.

Statistical analysis was performed to assess whether the prevalence of these symptoms varied significantly over time. Fisher’s exact test showed no statistically significant difference between time points. Although the prevalence of hiccups and rhinorrhea did not significantly change over time, the proportions of patients with high frequency symptoms decreased from 72.2% (39) at 1 month to 27.78% (15) at 12 months.

Stratification by bariatric procedure and gender was also performed, as reported respectively in

Table 6. Number and percentage of patients reporting hiccups and/or rhinorrhea at each time point, stratified by bariatric procedure. Percentages are calculated based on the total number of patients in each procedure subgroup. SG: sleeve gastrectomy; OAGB: One-Anastomosis Gastric Bypass; 1M: one month; 3M: three months; 6M: six months; 12M: twelve months.

Timepoint	SG (n = 96)		OAGB (n = 13)
	N	%	N	%
1M	51	53.12	3	23.07
3M	46	47.91	3	23.07
6M	42	43.75	4	30.77
12M	45	46.87	6	46.15

and

Table 7. Number and percentage of patients reporting hiccups and/or rhinorrhea at each time point, stratified by gender. Percentages are calculated based on the total number of patients in each gender subgroup. 1M: one month; 3M: three months; 6M: six months; 12M: twelve months.

Timepoint	Males (n = 21)		Females (n = 88)
	N	%	N	%
1M	6	28.57	48	54.54
3M	5	23.81	44	50
6M	6	28.57	40	45.45
12M	9	42.85	43	48.86

. Fisher’s exact test was performed at each time point to assess whether the prevalence of symptoms differed significantly between SG and OAGB groups or between genders. No significant differences were observed between SG and OAGB at any time point. Regarding gender, a slight statistically significant difference was observed at 3 months between males and females (p = 0.0491).

3.4. Association with Clinical and Behavioral Parameters

The association between rhinorrhea and/or hiccups and several clinical and behavioral parameters was explored. First, no significant association was found between the presence of symptoms and weight loss, assessed through the ΔBMI at all time points, using the Mann–Whitney test. The chi-square or Fisher’s exact test was performed, as appropriate, to analyze any associations of rhinorrhea and/or hiccups at 1 month and 12 months with behavioral factors measured at baseline, including emotional eating, anxiety, employment status, consumption of large-volume meals, intake of carbonated beverages, history of weight cycling, smoking, coffee consumption, body image disturbance, and history of post-pregnancy obesity. All results were non-significant, except for slight statistical significance observed for rhinorrhea and/or hiccup symptoms at 1 month with smoking (p = 0.034) and consumption of carbonated beverages (p = 0.048).

In addition, the potential association between rhinorrhea and/or hiccups and binge eating was assessed using the Binge Eating Scale (BES). When considering a BES score above 17 as the threshold for the presence of binge eating symptoms, no significant associations were found at any time point, using Fisher’s exact test. Similarly, no significant associations emerged when using BES as a continuous variable and performing the Mann–Whitney test.

The association between BES, as a continuous variable, and selected behavioral parameters was also explored. Statistically significant associations were observed with emotional eating (p = 0.0006), body image discomfort (p = 0.0005), and anxiety (p = 0.0491), as determined by the Mann–Whitney test.

Further analyses were conducted to assess the relationship between BES scores and weight-related outcomes. Spearman correlation tests revealed no significant associations between BES scores (as continuous values) and BMI at baseline, ΔBMI at 12 months, or percentage of total weight loss (%TWL) at 12 months. Likewise, when considering BES as a categorical variable (BES score >17), no significant associations were found with BMI at baseline, ΔBMI or %TWL at 12 months using the Mann–Whitney and unpaired t-tests.

4. Discussion

Our single-center analysis indicates that post-prandial hiccups and rhinorrhea occur with appreciable frequency following bariatric surgery in our cohort; nevertheless, patients almost uniformly describe symptoms as brief and only mildly troublesome. The modest clinical impact contrasts with the high frequency of the phenomenon and invites exploration of underlying mechanisms.

Indeed, the aim of this investigation was to investigate the possible causes of these symptoms, which are not commonly reported in the literature as postoperative outcomes of bariatric surgery. To this end, we performed association analyses to evaluate potential correlations between the occurrence of hiccups and rhinorrhea and several clinical and psychological variables, including gender, the type of bariatric procedure performed and the amount of weight loss. Because autonomic symptoms can be modulated by behavioral and psychological traits, we examined associations with dietary habits, emotional eating and anxiety [18,24]. Particular attention was given to the presence of binge eating disorder (BED), a condition in which individuals tend to ingest large amounts of food in a short period of time, compulsively and without control. These episodes often occur even in the absence of hunger or appetite and are typically followed by an uncomfortable sense of fullness [28].

However, our analysis did not reveal any correlations between hiccups and rhinorrhea and the variables assessed, except for a slight but statistically significant association with smoking and the consumption of carbonated beverages.

The retrospective design and the limited size of some subgroups, together with the low average BES score and the limited prevalence of severe binge eating disorder, may explain the absence of statistically significant associations observed in the present study. Therefore, the lack of statistically significant results should be interpreted as an absence of evidence of association rather than evidence of no relationship.

The occurrence of the symptoms observed in our cohort might be instead related to specific aspects of the surgical technique.

In our center, the staple line is intentionally placed within one centimeter of the cardia, and the gastric fundus is removed en bloc. Complete fundus excision is intended to prevent the “retained fundus” pouch, which has been linked to postoperative regurgitation, nausea and vomiting in revision reports. However, this approach also removes the region that harbors the greatest density of mechanosensitive vagal afferents and leaves a small proximal pouch that is rapidly distended by food intake. Animal models in which the fundus is resected demonstrate long-term increases in the excitability of surviving gastric vagal fibers, supporting the hypothesis of a hyper-afferent state after fundectomy surgery.

A first possible explanation for our findings is a hyper-vagal reflex in which sudden distension of the proximal gastric pouch triggers a parasympathetic response to the nasal glands, resulting in rhinorrhea, similar to what is observed in gustatory rhinitis. A second, not mutually exclusive hypothesis involves the activation of the hiccup reflex arc; case reports show that therapeutic vagus nerve stimulation can abolish otherwise intractable hiccups, underscoring the central role of vagal activity in this reflex. Finally, hormonal adaptations following fundus resection may also modulate brainstem autonomic circuits. Sleeve gastrectomy consistently lowers fasting ghrelin while augmenting post-prandial GLP-1 and PYY, peptides known to influence vagal tone.

Another possible explanation for the occurrence of hiccups and rhinorrhea could be gastroesophageal reflux. However, this hypothesis seems unlikely since, as mentioned in the Materials and Methods Section, all patients undergo preoperative gastroscopy to identify any GERD-related lesions, which are treated before surgery if present. Moreover, after bariatric surgery, patients receive proton pump inhibitor (PPI) therapy, further reducing the likelihood that hiccups or rhinorrhea could be associated with reflux.

The study presents some limitations that should be acknowledged. First, its retrospective design relies on the accuracy of previously recorded medical records, which may have introduced bias or missing information. Second, the lack of a control group substantially limits causal inference and prevents any conclusions regarding causality between the observed symptoms and their possible etiologies. Small subgroup sizes may also have interfered with finding statistically significant differences. The categorization of symptom frequency into “high” and “low” groups using a cut-off of two episodes per day was adopted for exploratory purposes and is not based on validated thresholds, representing an additional limitation that may have influenced subgroup comparisons. In addition, multiple association analyses were performed without formal correction for multiple comparisons, increasing the risk of type I error, particularly for borderline statistically significant results. Lastly, the findings are based on observations within a specific clinical context, which may not reflect broader patient populations or clinical practices.

5. Conclusions

In conclusion, while post-prandial hiccups and rhinorrhea are generally underreported in the context of bariatric surgery, our findings suggest that these symptoms may occur more frequently than previously recognized, albeit with limited clinical impact. The absence of strong associations with psychological or behavioral factors points toward a plausible physiological mechanism linked to surgical technique, particularly the extensive resection of the gastric fundus. These observations underscore the need for further studies to better characterize the prevalence, pathophysiology, and potential clinical relevance of these autonomic symptoms in post-bariatric patients, and to determine whether subtle technical variations during surgery might mitigate their occurrence.