Log in to view full text. If you're not a subscriber, you can:. Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. Its contribution to numerous other gastrointestinal disorders is beginning to be appreciated. Improved knowledge of its pathophysiology has enabled identification of therapeutic goals, some of which have been subject to formal study and demonstrated good outcomes. This review sets out to present and discuss new findings related to the improved understanding of the relationship between supragastric belching and other gastrointestinal disorders, as well as fresh concepts in terms of management.

Patients with supragastric belching experience higher frequency of belching events if they have concurrent esophageal hypomotility. Gum chewing and sleeve gastrectomy have no impact on supragastric belching. Pediatric studies suggest an overlap with aerophagia that is not observed in adults.

Successful treatments trialed recently include psychoeducation and behavioral therapy delivered by a health psychologist with expertise in gastroenterology. Further study is justified to uncover additional therapeutic options for this benign but disabling condition. You may be trying to access this site from a secured browser on the server.

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Previous Abstract Next Abstract. Article as EPUB. Your Name: optional. Your Email:. Colleague's Email:. Separate multiple e-mails with a .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 excessive SGB within a high-volume gastrointestinal physiology unit, and evaluate its association with symptoms, esophageal motility and gastresophageal reflux disease.

We established normal values for SGB by analyzing hour pH-impedance in 40 healthy asymptomatic volunteers. Symptoms were recorded by a standardized questionnaire evaluating for reflux, dysphagia, and dyspepsia symptoms. We reviewed the predominant symptoms, hour pH-impedance and high-resolution esophageal manometry results. We identified patients with excessive SGB. Forty-one percent of patients with excessive SGB had pathological acid reflux.

supragastric belching

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 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. Excessive belching is a commonly reported symptom.

It may occur in the context of gastroesophageal reflux symptoms, with dyspepsia, or can be an isolated symptom. The most common cause of belching is a physiological venting mechanism. Accumulated gas in the proximal stomach stimulates stretch receptors in the gastric wall, initiating a vago-vagal reflex culminating in a transient lower esophageal sphincter relaxation.

Patients with SGB often complain of excessive belching with a severe impact on quality of life, and belching can occur hundreds of times per day.

SGB is considered to be a behavioral disorder, and in some cases a response to an unpleasant sensation originating from the esophagus or the abdomen. It may be initially performed consciously but at consultation the patient usually has no control over the symptom.

SGB has been studied in selected patients attending gastrointestinal physiology units.Belching is the expulsion of air from the upper GI tract.

It occurs in everyone and is a normal physiologic process that decreases the volume of gas in the upper stomach. With each swallow, or when drinking a carbonated beverage air is ingested and conveyed to the stomach. The swallowed air stays in the stomach because there is a muscle called the lower esophageal sphincter LES at the esophagogastric junction EGJwhich remains contracted most of the time.

This closes the passage between the esophagus and stomach so air cannot go back up the esophagus. Accumulation of gastric air stretches the top of the stomach and sets off a reflex that causes a relaxation of LES.

Gastric air can then move back up into the esophagus. When it distends the top of the esophagus, a second reflex is triggered that relaxes a muscle called the upper esophageal sphincter UESwhich partitions the throat from the esophagus.

The air then leaves the esophagus to fill the mouth and be expelled. This type of belch is called the gastric belch. Transient LES relaxations are also important because when they are too frequent they are a major cause of gastroesophageal reflux disease. This type of belching is usually solitary, not bothersome and can usually be diagnoses by history.

The gastric belch is seen using this technique as air moving up the esophagus from the stomach.

Gas, Bloating, and Belching: Approach to Evaluation and Management

Ways to decrease this type of belching include eating and drinking more slowly, avoiding chewing gum and hard candies, not drinking carbonated beverages, stop smoking and treat gastroesophageal reflux disease when it is present. Some patients complain of episodes of repeated belching. The belches might occur every few seconds for varying lengths of time.

Supragastric Belching

During consultation with the doctor, it is often observed. It usually stops while the patient is talking, or if they are distracted from the belching. Patients who suffer from this type of belching almost always have what is called supragastric belching. This type of belch is often associated with anxiety disorder and frequently worsens under stress.

During episodes of supragastric belching the patient repeatedly uses the diaphragm to pull air into the esophagus. The air does not enter the stomach because the LES muscle does not relax.

Instead, it is pushed back up the esophagus and is expelled. Supragastric belching is seen as repeated episodes of air moving in and out of the esophagus. Esophageal manometry is a test that measures pressures along the inside of the esophagus. With manometry, supragastric belching is seen as repeated episodes of decreased followed by increased pressure in the esophagus, which correlate with repeated movement of air in and out of the esophagus.

Supragastric belching is a learned behavior. There is little information available about treatment and there are no large controlled trials of therapy. Most doctors who see these patients start by trying to explain the mechanism by which this belching occurs, and that it is a learned response to something.

Patients often are resistant to this explanation. There is some evidence that speech language pathologists knowledgeable on this topic might help retrain the patient.

The same might be true of behavioral therapists.Rumination syndrome is characterized by the effortless, often repetitive regurgitation of recently ingested food into the mouth; it results from contraction of the abdominal muscles and a subsequent increase in intragastric pressure that pushes the stomach contents upward, into the esophagus.

In patients with supragastric belching, air is either sucked into the esophagus by decreasing the intrathoracic pressure or pushed into the esophagus by contracting the pharyngeal muscles during glottis closure.

Afterward the air is rapidly expelled, which might be initiated by abdominal straining. Rumination and excessive belching are troublesome and can severely reduce quality of life. Patients are often diagnosed with gastroesophageal reflux disease GERDbut then do not respond to therapy with proton pump inhibitors PPIs. During rumination, the increased intragastric pressure overcomes the pressure provided by the lower esophageal sphincter LES, a barrier between the stomach and the esophagusand the gastric contents move upward.

Low LES pressure after meals, or straining during transient LES relaxation, has been proposed to facilitate rumination and might be targeted therapeutically. It reduces all types of reflux by increasing the basal LES pressure and decreasing the number transient lower esophageal sphincter relaxations, which contribute to regurgitation of gastric contents in patients with GERD.

Kathleen Blondeau et al. Patients were then treated with baclofen 10 mg 3 times daily for 1 week, and the process was repeated. A A liquid reflux event, identified by high-resolution manometry impedance recording. B A rumination episode. The impedance recording shows a liquid reflux event that is associated with an increase in intragastric pressure straining on the high-resolution manometry recording.

What to know about excessive burping

The arrows indicate the direction of flow on the impedance tracings. Analysis of the 12 patients who completed the study showed that baclofen reduced symptoms and flow events—particularly in patients with rumination, but also in those with supragastric belching. The beneficial effects of baclofen seemed to be associated with an increase in basal LES pressure observed in 7 of the 12 patients and reduced swallowing frequency.

Baclofen also significantly reduced the number transient lower esophageal sphincter relaxations and straining events. The degree of LES pressure increase but not the number of reductions in transient lower esophageal sphincter relaxations correlated with the overall reduction of flow events.

In an editorial that accompanies the article, John Clarke and John Pandolfino say that these findings are important because they identify a pharmacologic treatment for rumination, which is currently treated with only behavioral therapy.

They also identify a subset of patients who do not respond to PPIs who might benefit from therapies designed to alter LES pressure, transient lower esophageal sphincter relaxation, swallowing frequency, and possibly other reflexes.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 excessive SGB within a high-volume gastrointestinal physiology unit, and evaluate its association with symptoms, esophageal motility and gastresophageal reflux disease.

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We established normal values for SGB by analyzing hour pH-impedance in 40 healthy asymptomatic volunteers. We searched consecutive patient reports from our upper GI Physiology Unit from ? Symptoms were recorded by a standardized questionnaire evaluating for reflux, dysphagia, and dyspepsia symptoms. We reviewed the predominant symptoms, hour pH-impedance and high-resolution esophageal manometry results. We identified patients with excessive SGB. Forty-one percent 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 Increased belching is rarely a symptom in isolation. Pathological acid exposure and hypomotility are associated with more SGB frequency.

Belching Disorders

Whether SGB is a disordered response to other esophageal symptoms or their cause is unclear. Excessive belching is a commonly reported symptom. It may occur in the context of gastroesophageal reflux symptoms, with dyspepsia, or can be an isolated symptom. The most common cause of belching is a physiological venting mechanism. Accumulated gas in the proximal stomach stimulates stretch receptors in the gastric wall, initiating a vago-vagal reflex culminating in a transient lower esophageal sphincter relaxation.

supragastric belching

Patients with SGB often complain of excessive belching with a severe impact on quality of life, and belching can occur hundreds of times per day. SGB is considered to be a behavioral disorder, and in some cases a response to an unpleasant sensation originating from the esophagus or the abdomen.Background: Patients with aerophagia are believed to have excessive belches due to air swallowing. Intraluminal impedance monitoring has made it possible to investigate the validity of this concept.

Methods: The authors measured oesophageal pH and electrical impedance before and after a meal in 14 patients with excessive belching and 14 healthy controls and identified patterns of air transport through the oesophagus. The size of the gastric air bubble was measured radiographically.

In four patients prolonged oesophageal manometry was performed simultaneously. Results: In all subjects, impedance tracings showed that a significant amount of air is propulsed in front of about a third of the swallow induced peristaltic waves. Two types of retrograde gas flow through the oesophagus belch were observed. The incidence of air-containing swallows and gastric belches was similar in patients and controls but supragastric belches occurred exclusively in patients.

There was no evidence of lower oesophageal sphincter relaxation during supragastric belches. Gastric air bubble size was not different between the two groups. Conclusions: In patients with excessive belching the incidence of gaseous reflux from stomach to oesophagus is similar to that in healthy subjects. Their excess belching activity follows a distinct pattern, characterised by rapid antegrade and retrograde flow of air in the oesophagus that does not reach the stomach. Air swallowing during eating and drinking is a normal physiological event: in a study in healthy subjects, swallowing a 10 ml liquid bolus was found to be accompanied by ingestion of 8—32 ml of air.

It has been shown that distention of the proximal stomach elicits transient relaxations of the lower oesophageal sphincter LOS allowing the ingested air to be vented. Postprandial belching is normal, with three to four belches per hour occurring with a normal diet.

Belching is a common symptom in patients with gastro-oesophageal reflux disease and functional dyspepsia 11 but can also occur as an isolated symptom. In many patients with troublesome repetitive belching the eructation appears to be the result of a behavioural disorder in which excessive air swallowing is the primary event.

This poorly defined disease entity is referred to as aerophagia. Until recently, technical limitations stood in the way of an adequate analysis of the events associated with belching and aerophagia.

With the advent of the intraluminal impedance recording technique, it has become possible to monitor the passage of air through the oesophagus, either in aboral or oral direction. We studied 14 healthy volunteers eight males and six females; mean age Extensive diagnostic testing in the patients revealed no organic abnormalities. Written informed consent was obtained from all subjects and the protocol was approved by the medical ethics committees of the University Medical Center Utrecht and the Catholic University of Leuven.

After an overnight fast, radiographs of the upper abdomen were made in anteroposterior and lateral orientation while subjects were standing. Thereafter a routine oesophageal manometry was performed to determine the distance from nostrils to the LOS. After the manometry, the impedance catheter and the pH catheter were introduced transnasally and positioned based on the manometric findings see below.

In four of the 14 patients with excessive belching we also introduced a manometric catheter and this catheter recorded pressures for the duration of the study.

Subjects were in an upright position and after an adaptation period of at least 10 minutes, recording was started and subjects were asked to minimise head movements and to breathe normally.Belching is a physiological process, defined as the audible expulsion of air from the stomach or oesophagus into the pharynx 1. The cause of excessive belching can be often attributed to lifestyle choices, gastrointestinal disease, behavioural causes or a combination of these factors.

Determining the cause of excessive belching on an individual basis is important not only in treating this troublesome symptom, but also to help restore a better quality of life for the patient. Belching can present in two different patterns, depending on the origin of the gas. It is important to identify the cause of belching to help guide treatment, and this may not be clear on clinical assessment alone 2.

Intraluminal impedance monitoring is imperative in determining the belching pattern and cause of this troublesome symptom. Gastric belching can be identified on intraluminal impedance accompanied by high-resolution manometry HRM-Z as a retrograde movement of gas accompanied by relaxation of the LOS and upper oesophageal sphincter UOS Figure 1b. Impedance first increases in the antegrade direction as air is sucked into the oesophagus from the pharynx.

When is it quickly expelled from the oesophagus this causes the impedance to increase in the retrograde direction Figure 2a. Figure 2b above — repetitive SGB. Aerophagia is a behavioural condition where excessive air swallowing can lead to symptoms of bloating and distension. When aerophagia is accompanied by the primary symptom of belching, this is considered excessive belching 3.

This may occur when the anti-reflux barrier is compromised and instead of swallowed air being trapped in the abdomen, contributing to distension, it breaches the LOS as a belch. These increased number of transient relaxations of the LOS may increase levels of gastroesophageal reflux.

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There is evidence to show that patients with functional dyspepsia have a significantly greater number of air swallows and gastric belches than healthy controls 4. Utilising ambulatory impedance monitoring to identify aerophagia and educating patients on this behaviour may be the first step in reducing these events. Lifestyle modifications such as taking time when eating meals, avoiding fizzy drinks and ceasing chewing gum may reduce the volume of air swallowed.

With an estimated 3. Patients with pathological SGB may also present with rumination type symptoms or initiate this behaviour following anti-reflux surgery 6,7. Figure 3— Acidic reflux episode and patient-reported regurgitation preceded by SGB. Why patients supragastric belch is somewhat unclear, however, it is thought to begin as a voluntary action to relieve discomfort, which in time becomes subconscious 8. Stress is also thought to exacerbate the frequency of SGB 9.

There is limited evidence for medical therapy for SGB.

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One trial demonstrated the efficacy of baclofen in the treatment of SGB and rumination, reducing both symptoms and postprandial flow events Speech therapy centred around making the patient aware of their behaviour is efficacious in reducing SGB Cognitive behavioural therapy has also been shown to significantly reduce belching, acid exposure time and improve quality of life in patients with pathological SGB When excessive belching shown by impedance is not accompanied by excessive air swallowing or SGB, investigations to evaluate small bowel disease may be useful.

In small intestinal bacterial overgrowth SIBOover proliferation of microflora in the small bowel can lead to premature fermentation of ingested food and drink.

supragastric belching

Waste products of this fermentation include water, short chain fatty acids and gases. Production of these waste products can induce symptoms of bloating, abdominal discomfort, belching, flatulence and altered bowel habit.

In the case of a positive diagnosis, treating SIBO with antibiotic therapy may reduce belching. Excessive belching may often present as a primary complaint or be associated with other gastrointestinal symptoms. Physiological testing is key in determining the aetiology of belching on an individual patient basis.


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