Curr Treat Options Gastro (2020) 18:33–42
Chronic Burping and Belching
A. J. Bredenoord
Department of gastroenterology, Hervey Bay Hospital, Queensland, Australia
Department of Gastroenterology & Hepatology, Amsterdam UMC, location AMC,
Academic Medical Centre, Amsterdam, PO Box 22660, 1100 DD Amsterdam, the
Published online: 23 January 2020
*The Author(s) 2020
This article is part of the Topical Collection on Neurogastroenterology and GI Motiliy
Keywords Supragastric belching ISpeech therapy ICognitive behavioral therapy IBaclofen
Abbreviations SGB Supragastric belching _GB Gastric belching _UES Upper esophageal sphincter _LES Lower
esophageal sphincter _TLESR Transient lower esophageal sphincter relaxation _GERD Gastroesophageal reflux dis-
ease _CBT Cognitive behavioral therapy _AET Acid exposure time _GABA Gamma-aminobutyric acid _LTF Toupet
Belching is a physiological event that allows venting of swallowed gastric air. Excessive
belching is a common presentation to gastroenterology clinics and could be isolated
complains or associated with other gastrointestinal problems.
Purpose of this Review It is to describe the presentation, diagnosis, and treatment of
Recent Findings These demonstrate that learned abnormal behaviors in response to
unpleasant feeling in the abdomen are the driving causes for excessive belching and
addressing these behaviors by speech pathology and cognitive behavior therapy consid-
ered as the keystone in its management
Summary The gold standard inthe diagnosis of belching is impedance monitoring by which
belching is classified into supragastric belching and gastric belching.
Belching or eructation is defined as a sudden escape of a
gaseous bolus from the esophagus to pharynx which
could be audible or silent . It is considered as a
physiologic event which normally happens up to 30
times a day . However, excessive belching can become
reason for consultation when it is repetitive and inter-
feres with day-to-day activity and affects the quality of
life of patients . There is no systematic study on
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
epidemiology of belching, but in one study, up to 50%
of patients with dyspepsia also complained of excessive
belching. In this group, belching was interfering with
their social life in 20% . It is estimated that
approximately 3.4% of patients referred to tertiary hos-
pitals for upper gastrointestinal problem suffer from
supragastric belching .
There are two different types of belching: supragastric belching and gastric
belching. Supragastric belching is considered as an unintentional reaction to
unpleasant feeling in the abdomen and/or retrosternal region which does not
happen during sleep , speech [1,7], or during patient’sdistraction. There
are two primary mechanisms for supragastric belching which consist of air
suction and air injection. In air suction, patients subconsciously contract the
skeletal muscle part in the diaphragm which results in negative pressure in the
esophagus. In this situation, when the upper esophageal sphincter relaxes, the
pressure difference between pharynx and atmosphere results in therapid inflow
of air into the esophagus. Subsequently, the air in the esophagus forces out of
the esophagus again during straining which is perceived as belching [1,8••,9].
In the air injection mechanism of supragastric belching, voluntary contraction
of the base of the tongue results in elevated pharyngeal pressure and unchanged
esophageal pressure which results in pushing of air from the pharynx to the
esophagus. Again, air is expelled from the esophagus during straining. In both
mechanisms, air does not enter the stomach; the reason it is called supragastric
belching. Although supragastric belching is initially considered as an voluntary
response of patients to unpleasant feeling in the upper abdomen or chest, it is
through activation of voluntary muscle and over time becomes a firmly
established habit in patients. There is not enough evidence to support the cause
and effect relation between supragastric belching and psychological disorders
such as anxietyand depression, but these conditions are associated with it. Also,
supragastric belching results in a significant reduction in the quality of life of
Gastric belching occurs with impetuous release of air from the stom-
ach through transient relaxation of the lower esophageal sphincter
(TLESR); this is a gastric venting mechanism that prevents excessive
abdominal distention by swallowed air [11–13]. It is a physiological
mechanism and triggers by gastric extension which happens in average
of 30 times in 24 h, more frequently after consumption of carbonated
beverages . Gamma-aminobutyric acid, metabotropic glutamate re-
ceptors, cannabinoid receptor 1, nitric oxide, and cholecystokinin are
neurotransmitters that impact the amount of TLESRs [14–17].
Belching in patients with gastroesophageal reflux disease
Proton-pump inhibitors (PPIs) which are commonly used in treatment
of GERD symptoms are considered effective in reducing the number of
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
belchesaswell[19–22]. Perhaps this can be explained by the notion
that PPIs reduce the unpleasant abdominal or retrosternal sensation that
triggers the behavior and leads to supragastric belching.
The study with ambulatory impedance monitoring by Hemmink
et al. showed that about 50% of patients with GERD also presented
with supragastric belches. The mechanism of reflux and its temporal
association with supragastric belching revealed two association patterns;
18% of the supragastric belches occurred very soon after acid reflux and
responded well to proton-pump inhibitors which treat reflux symptoms.
However, in 30% of patients, supragastric belching happened prior to
acid reflux. It is believed that supragastric belching in this group trig-
gered the reflux, and these patients did therefore not respond to proton-
pump inhibitors .
Belching in patient with functional dyspepsia
Belching is a common complaint in patients who are suffering from other
functional upper gastrointestinal diseases besides GERD. Conchillo et al. found
that patients with functional dyspepsia have more frequent gas reflux symp-
toms. However, the author does not specifically assess supragastric belching in
this small study .
Belching and rumination syndrome
Rumination syndrome is defined as a recurrent unintentional regurgitation of
recently consumed food. The mechanism of rumination syndrome is the ha-
bitual contracture of voluntary abdominal muscle which result in increasing the
intragastric pressure which drives gastric contents into the esophagus and higher
A study by Kessing et al. revealed that supragastric belching could induce
rumination in a subgroup of patients with rumination syndrome. In this group,
supragastric belching triggers the sharp increase in the intragastric pressure
which forces out the gastric content within the esophagus and results in regur-
gitation of food [25,26•].
The term aerophagia is sometimes confused with supragastric belching. In
aerophagia excessive air is swallowed and transported to the intestines and
colon. Patients complain of bloating and flatulence. There are three major
differences between aerophagia and supragastric belching. Firstly, in aerophagia
the air is swallowed and transported distally by peristalsis, while in supragastric
belching, this is done by air suction or pharyngeal air pushing [8••,27,28].
Secondly, in aerophagia the air is mainly found in the intestines and colon,
while in supragastric belching, the air stays proximal of the stomach .
Thirdly, in aerophagia patients complain of bloating, abdominal distention,
Chronic Burping and Belching Zad and Bredenoord 35
and flatulence, while in supragastric belching, the primary symptom is belching
Clinical evaluation and diagnostic approach
The first step in the clinical evaluation of the patient with excessive belching is a
comprehensive history and physical examination. This helps to ensure that red
flags for organic disorders, such as weight loss and dysphagia, do not exist and
also to better understand the clinical pattern including the frequency and timing
of belching .
Impedance monitoring is the gold standard in the diagnosis of belching and
aerophagia and helps to identify the underlying cause of belching and to
differentiate supragastric belching from gastric belching [29,31]. Impedance
allows the presence and movement patterns of air in the esophagus. It helps to
study belching by providing objective evidence of supragastric belching events.
Intraluminal esophageal impedance monitoring is also helpful in the detection
of esophageal transit of fluid boluses and gastroesophageal reflux. Gastric
belching is characterized by an increase in impedance level starting in the distal
channel and progressing to the most proximal channel (Fig. 1). Criteria for
diagnosis of supragastric belching is a rapid antegrade movement of gas (im-
pedance of 1000 Ω), followed by retrograde expulsion back to the baseline
impedance level (Fig. 2)[8••]. Up to 13 events of supragastric belching in 24 h
have been demonstrated to be physiologic in asymptomatic patients which
Fig. 1. Gastric belching during liquid reflux episode. In this figure, impedance monitoring shows a decrease in impedance starting
distally and moving in proximal direction (blue arrow) and an increase in impedance level starts during the liquid reflux episode
spreading in proximal direction
36 Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
considered as an upper limit of normal; we therefore assume this can go unno-
ticed in healthy subjects as well. Patients with symptomatic supragastric belching
have average of 101 events in 24 h (ranging from 7 to 510) which is much higher
even when compared to the patients with gastric belching . In another study,
on 90-min impedance monitoring, the median number of belching events
captured for patients with gastric belching was 1, compared with 36 for those
with supragastric belching . This helps experienced gastroenterologist to spot
the diagnosis of supragastric belching on a quick overview of impedance mon-
itoring based on characteristic day-time density of symptom markers and imped-
ance “spikes”of intraesophageal air movement, notably absent during sleep .
High-resolution manometry (HRM) is not commonly recommended in
diagnosis of supragastric belching, but if combined with impedance, monitor-
ing helps to differentiate between supragastric belching, gastric belching, and
rumination syndrome. It also allows to distinguish the underlying manometric
technique, air suction, or pharyngeal air pushing, although it is not clear if this
helps treatment .
Treatment of belching
The keystone for treating patients with supragastric belching and gastric
belching is a comprehensive clarification of the etiology of these symptoms
which makes the patient aware that this is a behavioral disorder. It is often
challenging for the patient to accept that there is no pathological explanation
for their disease . The most described effective treatment for supragastric
belching is behavioral modification known as psychoeducation .
Fig. 2. Supragastric belching. In this figure, the impedance monitoring shows an increase of impedance level form the proximal
channel to the most distal impedance channel
Chronic Burping and Belching Zad and Bredenoord 37
Speech therapy is the most described treatment in supragastric belching. A
report by Ten Cate et al. on 48 patients revealed 83% of patients with
supragastric belching responded well to behavioral modification with a signif-
icant reduction of the total median visual analogue scale (VAS) from 406 to
125. In this method, an experienced speech pathologist provided care in ten
sessions with average of 60 min for the first three sessions followed by 30 min
of training for the remaining sessions. The treatment gives the patients insight
into the underlying behavioral problem related to excessive swallowing of air
and strategies to tackle it. These strategies include changing the unconscious act
of breathing and swallowing to more conscious and purposeful movement by
retraining of respiratory muscle with tight glottal/laryngeal contraction and
mouth closure, paying more attention to the pathophysiology of supragastric
belching and controlling of air influx during breathing. Abdominal breathing
was also beneficial in the reduction of belching symptoms. In severe cases,
patients were encouraged to retrain their breathing, while they put their finger
between their mouth and breath by open mouth . Katzka also described
that supragastric belching is not possible when asking the patient to use a pencil
between the teeth [34•]. Speech therapy also improves the coordination be-
tween the lingual, laryngeal, and cricopharyngeal muscles by relaxation of the
maxilla, laryngeal manipulation, and Boone’svoicefacilitating’smaneuverto
prevent any unusual movement of the tongue, larynx, and upper esophageal
sphincter which cause supragastric belching. The response rate was assessed by
VAS which considers the effect of belching on both personal and social life of
affected patients and also the degree of patients’control on their symptoms.
This technique should be practiced on a daily basis until the patients picks up
the new habits. The previous study by Hemmink et al. also confirmed that
speech therapy is helpful in patients with supragastric belching. In this study, 6
out of 11 patients had more than 30% improvement in their VAS score, and the
rest of them showed some degree of improvement . Speech therapy has
been tried differently in different studies. Riehl et al. examined a two-session
protocol, based on their pilot study of a psychologist delivering
psychoeducation and instructions on relaxed open-mouth breathing. They
achieved 75% reduction in symptom at 3 months . Also, one education
session on sustained glottal opening showed complete improvement in
supragastric belching at 1 month in 80% of patients as demonstrated by Katzka
Cognitive behavioral therapy (CBT) was also effective in the treatment of
supragastric belching as shown in the study by Glasinovic et al. In this inter-
ventional study, the severity of symptoms was assessed pre- and posttreatment.
The intervention involved five CBT sessions which have three components: a
cognitive part, a behavioral component, and an assessment of treatment and
outcome. In the first session, patients were separately assessed by gastroenter-
ologist and psychologist, and the contributing psychosocial factors were iden-
tified. In the following sessions, the treatment was initiated with a focus on
assisting the patient how to recognize the etiology of the disease, triggering
factors and explanation of how treatment could improve their symptoms. The
critical component of CBT was to recognize the warning signs which most
patients described as abnormal tension or uncomfortable pressure-like feeling
in the retrosternal area just before the supragastric belching starts. Following
this warning sign, they were encouraged to practice awareness training
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
technique to stop belching with diaphragmatic breathing, mouth opening, and
tongue positioning. The patients were assessed based on MII-pH pre- and
posttreatment at 8 weeks. Cognitive behavioral therapy resulted in more than
50% reduction in belching symptoms in more than 50% of patients. It was also
effective in decreasing the esophageal acid exposure time in the patients with
elevated acid exposure time at baseline and declining of mean VAS score from
260 to 140. CBT also decreased the frequency of supragastric belching and
associated esophageal acid reflux, but it was not effective in reducing the
frequency of gastric belching .
A randomized double-blinded placebo-controlled study was performed by
Pauwels et al. on the effect of baclofen on 25 patients with supragastric belching
and rumination syndrome who did not respond to PPIs . Baclofen is a
gamma-aminobutyric acid (GABA) receptor agonist which is commonly used
for muscle spasticity and also inhibits TLESRs [38–42] .Regurgitation was the
main symptom in 16 patients; belching was predominant in 5. The patients
were commenced on 10-mg baclofen, three times a day for 2 weeks, and were
then assessed by high-resolution manometry. This study showed that baclofen
significantly decreases the number of rumination episodes and the ratio of
rumination to straining. However, it was not effective in the treatment of
supragastric belching. In patients treated with baclofen, the pressure of post-
prandial lower esophageal sphincter was considerably higher than the placebo
group which resulted in the reduction of the number of rumination symptoms.
However, the frequency of postprandial TLESRs was considerably less than the
placebo group . Another study on a small number of patients revealed
improvement in symptoms and reduction in postprandial flow events in pa-
tients with rumination and SBG who treated with baclofen .
In a study by Oor et al., upper gastrointestinal endoscopy, esophageal
manometry, and 24-h pH impedance were used to compare the effectiveness
of different methods of partial fundoplication in controlling reflux symptoms
and also post-operation gastric belching and SGB. Two partial fundoplication
methods include the laparoscopic 270° posterior or Toupet fundoplication and
180° anterior fundoplication. This study showed that Toupet fundoplication
and anterior fundoplication controlled reflux symptoms equally and resulted in
a similar reduction in the number of belching and supragastric belching .
Belching is a common physiological symptom in general population which can
happen isolated or associated with other gastrointestinal complains such as
GERD, rumination syndrome, or functional dyspepsia. Impedance monitoring
helped to better understand the pathophysiology of belching and to divide
belching to gastric or supragastric belching based on its mechanism.
Psychoeducation is considered as the most effective strategy for treatment of
supragastric belching and consists of speech pathology and cognitive behavioral
therapy. Baclofen effectiveness in symptoms management varied in different
studies, and it is recommended to use baclofen only if other treatment options
Chronic Burping and Belching Zad and Bredenoord 39
Compliance with Ethical Standards
Conflict of Interest
AZ does not have anything to disclose. AJB received research funding from Nutricia, Norgine, and Bayer and received
speaker and/or consulting fees from Laborie, EsoCap, Diversatek, Medtronic, Dr. Falk Pharma, Calypso Biotech,
Thelial, Robarts, Reckett Benkiser, Regeneron, Celgene, Bayer, Norgine, AstraZeneca, Almirall and Allergan.
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