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Chronic Burping and Belching

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Abstract and Figures

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 belching disorders 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 considered as the keystone in its management Summary The gold standard in the diagnosis of belching is impedance monitoring by which belching is classified into supragastric belching and gastric belching.
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Curr Treat Options Gastro (2020) 18:3342
DOI 10.1007/s11938-020-00276-0
Chronic Burping and Belching
M. Zad
1
A. J. Bredenoord
2,*
Address
1
Department of gastroenterology, Hervey Bay Hospital, Queensland, Australia
*,2
Department of Gastroenterology & Hepatology, Amsterdam UMC, location AMC,
Academic Medical Centre, Amsterdam, PO Box 22660, 1100 DD Amsterdam, the
Netherlands
Email: a.j.bredenoord@amc.uva.nl
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
fundoplication
Abstract
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
belching disorders
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.
Introduction
Belching or eructation is defined as a sudden escape of a
gaseous bolus from the esophagus to pharynx which
could be audible or silent [1]. It is considered as a
physiologic event which normally happens up to 30
times a day [2]. 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 [3]. There is no systematic study on
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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% [4]. It is estimated that
approximately 3.4% of patients referred to tertiary hos-
pitals for upper gastrointestinal problem suffer from
supragastric belching [5].
Pathophysiology
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 [6], speech [1,7], or during patientsdistraction[7]. 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
patients [3,10].
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 [1113]. 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 [11]. Gamma-aminobutyric acid, metabotropic glutamate re-
ceptors, cannabinoid receptor 1, nitric oxide, and cholecystokinin are
neurotransmitters that impact the amount of TLESRs [1417].
Belching in patients with gastroesophageal reflux disease
(GERD)
Proton-pump inhibitors (PPIs) which are commonly used in treatment
of GERD symptoms are considered effective in reducing the number of
34
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
belchesaswell[1922]. 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 [18].
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 [21].
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
[23,24••].
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].
Aerophagia
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 [18].
Thirdly, in aerophagia patients complain of bloating, abdominal distention,
Chronic Burping and Belching Zad and Bredenoord 35
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
and flatulence, while in supragastric belching, the primary symptom is belching
[29].
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 [30].
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)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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 [5]. 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 [9]. 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 spikesof intraesophageal air movement, notably absent during sleep [6].
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 [30].
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 [1]. The most described effective treatment for supragastric
belching is behavioral modification known as psychoeducation [32].
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
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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 [33]. 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 Boonesvoicefacilitatingsmaneuverto
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 patientscontrol 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 [35]. 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 [32]. 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
[34].
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
38
Neurogastroenterology and GI Motility (H Parkman and R Schey, Section Editors)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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 [36].
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 [37]. Baclofen is a
gamma-aminobutyric acid (GABA) receptor agonist which is commonly used
for muscle spasticity and also inhibits TLESRs [3842] .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 [37]. 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 [43].
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 [44].
Conclusion
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
failed.
Chronic Burping and Belching Zad and Bredenoord 39
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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.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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... [39] All these studies were rather small. Nevertheless, the available data and experts' opinion [40] suggest that psychological therapies are effective and represent the main treatment option in SGB. However, the major drawback in clinical practice is the availability of experts trained in speech therapy or CBT. ...
Article
Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It becomes pathologic if it is excessive and becomes bothersome. According to Rome IV diagnostic criteria, there is a belching disorder when one experiences bothersome belching (severe enough to impact on usual activities) more than 3 days a week. Esophageal impedance can differentiate between gastric and supragastric belching. The aim of this review was to provide data on pathogenesis and diagnosis of supragastric belching and study its relationship with gastroesophageal reflux disease and psychological factors. Treatment options for supragastric belching are also presented.
Article
Rumination syndrome is a functional disorder characterized by the involuntary regurgitation of recently swallowed food from the stomach into the mouth, from where it can be re-chewed or expelled. Clinically, it is characterized by repeated episodes of effortless food regurgitation. The most usual complaint is frequent vomiting. The physical mechanism that generates regurgitation events is dependent on an involuntary process that alters abdominal and thoracic pressures accompanied by a permissive oesophageal-gastric junction. The diagnosis of rumination syndrome is clinical, highlighting the importance of performing an exhaustive anamnesis on the characteristics of the symptoms. Complementary tests are used to corroborate the diagnosis or rule out organic pathology. Treatment is focused on behavioural therapies as the first line, reserving pharmacological and surgical therapies for refractory cases.
Article
Purpose: Belching is a common condition that frequently overlaps with other functional gastrointestinal disorders. While not associated with any increase in mortality, it is associated with impaired health-related quality of life. Management is challenging, as there are no pharmacologic therapies specifically targeted towards this disorder. This review covers pathogenesis, prevalence, and treatments for this condition, with specific emphasis on the evolving role of behavioral treatments in management. Key findings: The diagnosis of gastric and supragastric belching can usually be made clinically, without the need for invasive testing. If necessary, multichannel intraluminal impedance and pH testing can provide a more definitive diagnosis and can also be used to estimate the frequency of gastric and supragastric belching episodes, which each have a distinct appearance on impedance tracing. Belching disorders are commonly associated with gastroesophageal reflux disease and functional disorders of the gastrointestinal tract. Supragastric belching is also associated with behavioral disorders like anxiety and obsessive-compulsive disorder. Speech therapy, cognitive-behavioral therapy, and diaphragmatic breathing are all interventions that have recently shown promise in the management of this challenging disorder.
Article
Resumen El síndrome de rumiación es un trastorno funcional caracterizado por la regurgitación involuntaria de los alimentos recientemente ingeridos desde el estómago hacia la boca, donde puede ser remasticada o expulsada. Desde el punto de vista clínico, se caracteriza por episodios repetidos de regurgitación de alimentos sin esfuerzo, siendo la queja habitual los vómitos frecuentes. El mecanismo físico que genera los eventos de regurgitación es depende de un proceso involuntario que altera las presiones abdominal y torácica acompañado de una unión esofágo-gástrica permisiva. El diagnóstico del síndrome de rumiación es clínico, destacando la importancia de realizar una anamnesis exhaustiva sobre las características de los síntomas. Las pruebas complementarias se utilizan para corroborar el diagnóstico o descartar otra patología orgánica. El tratamiento está enfocado a terapias conductuales como primera línea, reservando las terapias farmacológicas y quirúrgicas para casos refractarios.
Article
Full-text available
The purpose of this study was to describe a newly developed speech therapy program as an innovating therapeutic approach and to assess the results of this intervention in patients with supragastric belching. This is a retrospective analysis of prospectively gathered data from 73 patients with supragastric belching who were treated with speech therapy between 2007 and 2017. Of these, 48 were included for evaluation of therapy. Thirty patients had supragastric belching proven by 24-h impedance measurements. Eighteen patients were diagnosed by an experienced speech language pathologist as having supragastric belching according to precise criteria. Speech therapy consists of explanation, creating awareness of esophageal air influx and exercises to discontinue the supragastric belching mechanism. Therapy effect was measured by comparing visual analogue scale (VAS) scores on belching and related symptoms. The median symptom duration at the start of therapy was 2 years. Supragastric belching symptoms decreased significantly with a total median VAS score of 406 (291–463) prior to treatment and a median VAS score of 125 (17–197) following treatment. Forty patients (83%) had a sufficient to major result with a median therapy duration of 3 months and ten sessions. Speech therapy was an effective treatment in the majority of patients with supragastric belching.
Article
Full-text available
Supragastric belching (SGB) is a phenomenon during which air is sucked into the esophagus and then rapidly expelled through the mouth. Patients often complain of severely impaired quality of life. Our objective was to establish the prevalence of ex-cessive SGB within a high-volume gastrointestinal physiology unit, and evaluate its association with symptoms, esophageal mo-tility and gastresophageal reflux disease. We established normal values for SGB by analyzing 24-hour pH-impedance in 40 healthy asymptomatic volunteers. We searched 2950 consecutive patient reports from our upper GI Physiology Unit (from 2010-2013) for SGB. Symptoms were re-corded by a standardized questionnaire evaluating for reflux, dysphagia, and dyspepsia symptoms. We reviewed the predom-inant symptoms, 24-hour pH-impedance and high-resolution esophageal manometry results. Excessive SGB was defined as > 13 per 24 hours. We identified 100 patients with excessive SGB. Ninety-five percent of these patients suffered from typical reflux symptoms, 86% reported excessive belching, and 65% reported dysphagia. Forty-one per-cent of patients with excessive SGB had pathological acid reflux. Compared to the patients with normal acid exposure these patients trended towards a higher number of SGB episodes. Forty-four percent of patients had esophageal hypomotility. Patients with hypomotility had a significantly higher frequency of SGB compared to those with normal motility (118.3 ± 106.1 vs 80.6 ± 75.7, P = 0.020). Increased belching is rarely a symptom in isolation. Pathological acid exposure and hypomotility are associated with more SGB frequency. Whether SGB is a disordered response to other esophageal symptoms or their cause is unclear.
Article
Background: Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns. Methods: Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n = 10, LTF vs. n = 10, LAF). Observed changes after surgery (∆) were compared between the two procedures. Results: Symptomatic reflux control as well as the reduction in the mean number of acid (∆ - 58.5 vs. - 66.5; P = 0.912), liquid (∆ - 17.0 vs. - 43.5; P = 0.247), and mixed liquid gas reflux episodes (∆ - 38.0 vs. - 40.0; P = 0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8-4) vs. 1.0 (0-3), P = 0.436). The reduction in proximal (P = 1.000), mid-esophageal (P = 0.063), and distal reflux episodes (P = 0.315) was comparable. Both procedures equally reduced the number of gastric belches (P = 0.278) and supragastric belches (P = 0.123), with no significant reduction in the number of air swallows after either procedure (P = 0.278). Conclusion: LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.
Article
Objectives: Excessive supragastric belching (SGB) manifests as troublesome belching, and can be associated with reflux and significant impact on quality of life (QOL). In some GERD patients, SGB-associated reflux contributes to up to 1/3 of the total esophageal acid exposure. We hypothesized that a cognitive-behavioral intervention (CBT) might reduce SGB, improve QOL, and reduce acid gastroesophageal reflux (GOR). We aimed to assess the effectiveness of CBT in patients with pathological SGB. Methods: Patients with SGB were recruited at the Royal London Hospital. Patients attended CBT sessions focused on recognition of warning signals and preventative exercises. Objective outcomes were the number of SGBs, esophageal acid exposure time (AET), and proportion of AET related to SGBs. Subjective evaluation was by patient-reported questionnaires. Results: Of 51 patients who started treatment, 39 completed the protocol, of whom 31 had a follow-up MII-pH study. The mean number of SGBs decreased significantly after CBT (before: 116 (47–323) vs. after 45 (22–139), P<0.0003). Sixteen of 31 patients were shown to have a reduction in SGB by >50%. In patients with increased AET at baseline, AET after CBT was decreased: 9.0–6.1% (P=0.005). Mean visual analog scale severity scores decreased after CBT (before: 260 (210–320) mm vs. after: 140 (80–210) mm, P<0.0001). Conclusions: Cognitive behavioral therapy reduced the number of SGB and improved social and daily activities. Careful analysis of MII-pH allows identification of a subgroup of GERD patients with acid reflux predominantly driven by SGB. In these patients, CBT can reduce esophageal acid exposure.
Article
Objectives: Both rumination syndrome and supra-gastric belching (SGB) have limited treatment options. We demonstrated (open-label) that baclofen reduces pressure flow events in these patients. We aimed to study the effect of baclofen in a placebo-controlled, double-blind, cross-over study in patients with clinically suspected rumination and/or SGB. Methods: Twenty tertiary-care patients (mean age 42 years (range 18-61), 13f) with clinically suspected rumination and/or SGB were randomized to receive baclofen (10 mg, t.i.d) or placebo for 2 weeks with cross-over to the alternative intervention after a 1 week wash-out period. At the end of each treatment period, patients underwent a solid-state high-resolution impedance manometry measurement, during which they registered symptoms. Patients received a solid meal and recordings continued for 1 h. They scored overall treatment evaluation (OTE) on a -3 to +3 scale. Results: Both the number of regurgitation event markers and rumination episodes were significantly decreased after baclofen (6 (0-19) vs. 4 (0-14), P=0.04; 13 (8-22) vs. 8 (3-11), P=0.004). The number of SGB episodes was similar in both groups. Lower esophageal sphincter (LES) pressure was significantly higher and the number of transient LES relaxations was significantly lower after baclofen (17.8 (12.7-22.7) vs. 13.1 (7.2-16.9) mm Hg, P=0.0002; 4(1-8) vs. 7(3-12), P=0.17). The number of reflux events decreased in the baclofen condition (4 (1-9) vs. 3 (0-6), P=0.03). Straining episodes were similar in both arms, but the rumination/straining ratio was significantly lower in the baclofen arm (0.06 (0-0.32) vs. 0.33 (0-0.51), P=0.0012). OTE was superior after baclofen compared to placebo (P=0.03). Conclusions: Baclofen is an effective treatment option for patients with rumination syndrome, probably through its effect on LES pressure.Am J Gastroenterol advance online publication, 5 December 2017; doi:10.1038/ajg.2017.441.
Rumination is a phenomenon characterized by retrograde flow of gastric contents into the mouth, otherwise known as regurgitation. Repetitive excessive occurrence of rumination is considered pathologic and is known as the rumination syndrome. Belching occurs occasionally in everyone and is often not related to a disease or a pathologic condition. Gastric belches are physiologic events caused by retrograde flow of air into the esophagus and mouth; however, supragastric belching is associated with belching disorders and is considered pathologic behavior.
Article
Excessive belching is a commonly observed complaint in clinical practice that can occur not only as an isolated symptom but also as a concomitant symptom in patients with gastroesophageal reflux disease (GERD) or functional dyspepsia. Impedance monitoring has revealed that there are two mechanisms through which belching can occur: the gastric belch and the supragastric belch. The gastric belch is the result of a vagally mediated reflex leading to relaxation of the lower esophageal sphincter and venting of gastric air. The supragastric belch is a behavioral peculiarity. During this type of belch, pharyngeal air is sucked or injected into the esophagus, after which it is immediately expulsed before it has reached the stomach. Patients who belch excessively invariably exhibit an increased incidence of supragastric, not of gastric belches. Moreover, supragastric belches can elicit regurgitation episodes in patients with the rumination syndrome and sometimes appear to induce reflux episodes as well. Behavioral therapy has been proven to decrease belching complaints in patients with isolated excessive belching, but its effect is unknown in frequently belching patients with GERD, functional dyspepsia or rumination.Am J Gastroenterol advance online publication, 8 July 2014; doi:10.1038/ajg.2014.165.
Article
Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utilization. This manuscript describes the role of a health psychologist in the treatment of esophageal disorders using behavioral medicine interventions. Observations over the course of a 1-year period indicate that the sample presents with a relatively low level of psychological distress but reports negative effects of their symptoms on health-related quality of life. Five case examples of commonly treated disorders (globus, non-cardiac chest pain, functional dysphagia, rumination syndrome, supragastric belching) are described to highlight how behavioral treatment can improve patients' symptoms, decrease health-care utilization, and improve overall quality of life in a timely and relatively simple manner. Successful treatment outcomes are associated with a collaborative working alliance between patient, health psychologist, and gastroenterologist. Results indicate the benefit of referring appropriate esophageal patients to a health psychologist with specialization in gastroenterology. © 2014 International Society for Diseases of the Esophagus.
Article
Objectives: The rumination syndrome is a behavioral disorder resulting in recurrent regurgitation of undigested food. The diagnosis of this syndrome is currently based on clinical features. We aimed to determine criteria for the rumination syndrome based on physiological measurements. Methods: We studied patients with clinically confirmed rumination syndrome and gastroesophageal reflux disease (GERD) patients with predominant symptoms of regurgitation. All patients underwent combined high-resolution manometry and pH-impedance measurement after a standardized meal. All reflux events extending to the proximal esophagus were analyzed. Furthermore, ambulatory measurements were performed in the majority of patients. Results: In the rumination group, the amplitude of the abdominal pressure increase during proximal reflux events and the esophageal pressure peaks were significantly higher compared with GERD patients. None of the GERD patients exhibited abdominal pressure peaks >30 mm Hg, whereas in the rumination patients 70% of the pressure peaks had an amplitude >30 mm Hg. Abdominal pressure patterns were also observed during ambulatory pH impedance-pressure monitoring in the rumination patients. pH-impedance monitoring alone could not differentiate between GERD and rumination, however, a higher percentage of reflux events reached the proximal esophagus in the rumination patients. Notably, three different mechanisms of rumination were observed: (i) primary rumination, in which the abdominal pressure increase preceded the retrograde flow, (ii) secondary rumination, consisting of an increase in abdominal pressure following the onset of a reflux event and (iii) supragastric belch-associated rumination, consisting of a supragastric belch immediately followed by a rumination event. Conclusions: The diagnosis of the rumination syndrome can be made when reflux events extending to the proximal esophagus that are closely associated with an abdominal pressure increase >30 mm Hg and an esophageal pressure increase are observed during combined pressure-impedance monitoring.
Article
In patients with repetitive and troublesome belching an organic cause is seldom found, indicating the presence of an acquired abnormal behavior. The aim of our study was to investigate the incidence and pattern of belching during a 24-hour period. Combined 24-hour pH and intraluminal impedance monitoring was performed in 14 patients (9 female; mean age: 43 y) with excessive belching and 10 patients (6 women, mean age 42 y; range 28 to 56) with noncardiac chest pain. Thereafter, we counted the number of belching events and differentiated the number of supragastric and gastric belches. During the 24-hour study, the hourly rate of belching was 38.7+/-6.0; rate of supragastric belches were significantly higher compared to gastric belches (37.7+/-6.0 vs 1.0+/-0.5, P<0.001). Patients with noncardiac chest pain showed a lower average hourly rate of belching (3.1+/-0.6, P<0.001). Dividing the recording into 2 periods (daily-upright and night-supine), there was a significant decrease in the hourly rate at night (37.8+/-6.1 vs. 0.9+/-0.5, respectively, P<0.001); mostly due to decrease in supragastric belches, where as the rate of gastric belches remained unchanged. None of the patients showed pathological acid reflux and none of the supragastric belches was associated with acid or nonacid reflux events. Supragastric belch is the prominent belching pattern in patients with excessive belching. Supragastric belches almost ceased at night suggesting the presence of a behavioral disorder. There were no diurnal changes in the rate of gastric belches.