Simple office-based behavioral approach to patients with chronic belching

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

Management advice for patients with reflux-like symptoms: an evidence-based consensus

Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.

Roles of swallowing and belching in different phenotypes of gastroesophageal reflux disease

BACKGROUND

The contributions of swallowing and belching to specific gastroesophageal reflux disease (GERD) phenotypes are unclear.

METHODS

This study retrospectively analyzed esophageal pH/impedance studies, comparing reflux events preceded by gastric belching (GB), supragastric belching (SGB), air swallowing, and liquid/solid swallowing based on reflux position, lower esophageal sphincter (LES) pressure, and acid exposure time (AET).

KEY RESULTS

20 GERD patients and 10 controls were studied. Upright GERD patients and controls had a higher proportion of reflux events with a preceding swallow or belch (0.64, 0.64) than the supine group (0.38, p = 0.043). The upright group and controls trended toward a higher proportion of reflux events preceded by overall swallowing (0.61, 0.50) and air swallowing (0.55, 0.48) than the supine group (0.32, 0.31 p = 0.064, p = 0.11), but the three groups had similar rates of liquid/solid swallowing (0.032, 0.024, 0.017, p = 0.69). LES pressure did not correlate with reflux events preceded by swallowing (R2  = 0.021, p = 0.44). There was a higher rate of events preceded by gastric belching in the control group (0.14) than in the upright (0.032) and supine groups (0.066, p = 0.049). LES pressure did not correlate with the rate of events preceded by belching (R2  = 0.000093, p = 0.96). Normal AET patients had a higher rate of events preceded by GB (0.12) than those with increased acid exposure (0.030, p = 0.0083), but the two groups had similar rates of preceding air (0.43, 0.47, p = 0.68), liquid/solid (0.018, 0.032, p = 0.30), and overall swallowing (0.44, 0.53, p = 0.38).

CONCLUSIONS AND INFERENCES

Swallowing more than belching is a dominant mechanism for reflux irrespective of GERD position, LES pressure, and AET.

Supragastric belching: Pathogenesis, diagnostic issues and treatment

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.

Management of supragastric belching

Increased SGB is currently more often recognized not only in patients with belching as a main symptom, but also in patients with reflux like symptoms that are refractory to PPI treatment or patients with reflux hypersensitivity. Detection of increased SGB during analysis of impedance-pHmetry can help to better understand the pathophysiology of symptoms in individual patients and to provide more focused and specific treatment. At the moment, the most efficient treatments for increased SGB are CBT and Speech therapies, pharmacological treatment being less effective and prone to mild secondary effects. In this issue of Neurogastroenterology and Motility, Punkinnen et al demonstrate, in controlled clinical trial, that behavioral therapy was superior to follow-up without intervention in patients with SGB. We present a critical review of the different treatment modalities currently available for patients with pathological SGB.

Belching: Pathogenesis, Clinical Characteristics, and Treatment Strategies

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.

Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial

INTRODUCTION

Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls.

METHODS

Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day.

RESULTS

On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015.

DISCUSSION

In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.

Belching in Gastroesophageal Reflux Disease: Literature Review

Belching is a common phenomenon. However, it becomes bothersome if excessive. Impedance–pH monitoring can classify the belching into two types: gastric belching and supragastric belching (SGB). The former is a physiological mechanism to vent swallowed air from the stomach, whereas the latter is a behavioral disorder. Gastroesophageal reflux disease (GERD) is the most relevant condition in both types of belching. Recent findings have raised awareness that excessive SGB possibly sheds light on the pathogenesis of a part of proton pump inhibitor (PPI) refractoriness in GERD. SGB could cause typical reflux symptoms such as heartburn, regurgitation or chest pain in two ways: SGB-induced gastroesophageal reflux or SGB-induced esophageal distension. In PPI-refractory GERD, it is important to detect hidden SGB as a cause of reflux symptoms since SGB requires psychological treatment instead of high dose PPIs or pain modulators. In the case of PPI-refractory GERD with excessive SGB, recent studies imply that the combination of a psychological approach and conventional treatment can improve treatment outcome.

Chronic Burping and Belching

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.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Management of supragastric belching with cognitive behavioural therapy: factors determining success and follow-up outcomes at 6-12 months post-therapy

BACKGROUND

Supragastric belching (SGB) has a significant behavioural component. We recently used cognitive behavioural therapy (CBT) to treat SGB. We demonstrated that CBT significantly reduces symptoms and improves quality of life in 50% of patients who had completed treatment.

AIMS

To investigate factors associated with successful CBT for SGB and to assess symptoms 6-12 months after completion of CBT METHODS: Records of 39 patients who had completed the CBT protocol were analysed. Per cent pre- to post-treatment change in symptoms was assessed using a visual analogue scale (VAS) score. We evaluated the association between 'pre-treatment' factors and 'during-treatment' factors, and symptomatic outcomes. Symptoms were also assessed 6-12 months after treatment.

RESULTS

From 'pre-treatment factors', a lower number of SGBs (P < .01) and lower hypervigilance score (P < .04) were significantly associated with a better outcome. From 'during-treatment factors' a higher CBT 'proficiency score' ([a] acceptance of the explanation that SGB is a behavioural phenomenon [b] detection of a warning signal before belching [c] adherence to the exercises treatment) was associated with a better outcome (P = .001). Multiple regression analysis found that number of SGBs, hypervigilance score and CBT proficiency score were independently associated with outcome (P < .01, P = .01, P < .01). VAS score before CBT (267 ± 79) decreased to 151 ± 88 soon after CBT (P < .001), and the effect persisted at 6-12 months follow-up (153 ± 82).

CONCLUSIONS

Lower number of SGBs, lower hypervigilance score and higher proficiency during CBT were associated with better CBT outcome. CBT positive effect lasted for at least 6-12 months post-treatment.

Diagnosis and Treatment of Rumination Syndrome

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. The disorder appears uncommon, although only limited epidemiologic data are available. Awareness of the characteristic symptoms is essential for recognizing the disorder, and thus avoiding the long delay in diagnosis, that many patients experience. Although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers, a clinical diagnosis can be made in most patients. The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing. This clinical practice update reviews the pathophysiology, diagnosis, and treatment of rumination syndrome. Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting. Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely. Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up. Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome. Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique. Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations. Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients.

Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux

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.

Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms

BACKGROUND & AIMS

In patients with gastroesophageal reflux disease (GERD) and excessive belching, most belches are supragastric, and can induce reflux episodes and worsen GERD. Supragastric belching (SGB) might be reduced with diaphragmatic breathing exercises. We investigated whether diaphragmatic breathing therapy is effective in reducing belching and proton pump inhibitor (PPI)-refractory gastroesophageal reflux symptoms.

METHODS

We performed a prospective study of 36 consecutive patients with GERD refractory to PPI therapy and a belching visual analogue scale (VAS) score of 6 or more, seen at a gastroenterology clinic at a tertiary hospital in Singapore from April 2015 through October 2016. Patients underwent high-resolution manometry and 24-hour pH-impedance studies while they were off PPIs. Fifteen patients were placed on a standardized diaphragmatic breathing exercise protocol (treatment group) and completed questionnaires at baseline, after diaphragmatic breathing therapy, and 4 months after the therapy ended. Twenty-one patients were placed on a waitlist (control subjects), completed the same questionnaires with an additional questionnaire after their waitlist period, and eventually received diaphragmatic breathing therapy. The primary outcome was reduction in belching VAS by 50% or more after treatment. Secondary outcomes included GERD symptoms (evaluated using the reflux disease questionnaire) and quality of life (QoL) scores, determined from the Reflux-Qual Short Form and EuroQoL-VAS.

RESULTS

Nine of the 15 patients in the treatment group (60%) and none of the 21 control subjects achieved the primary outcome (P < .001). In the treatment group, the mean belching VAS score decreased from 7.1 ± 1.5 at baseline to 3.5 ± 2.0 after diaphragmatic breathing therapy; in the control group, the mean VAS score was 7.6 ± 1.1 at baseline and 7.4 ± 1.3 after the waitlist period. Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19% in control subjects (P = .001). Treatment significantly reduced symptoms of GERD (the mean reflux disease questionnaire score decreased by 12.2 in the treatment group and 3.1 in the control group; P = .01). The treatment significantly increased QoL scores (the mean Reflux-Qual Short Form score increased by 15.4 in the treatment group and 5.2 in the control group; P = .04) and mean EuroQoL-VAS scores (15.7 increase in treatment group and 2.4 decrease in the control group). These changes were sustained at 4 months after treatment. In the end, 20 of the 36 patients who received diaphragmatic breathing therapy (55.6%), all with excessive SGB, achieved the primary outcome.

CONCLUSIONS

In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching-especially those with excessive SGB.

Rumination syndrome: pathophysiology, diagnosis, and treatment

BACKGROUND

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by either re-swallowing or spitting. Rumination is thought to occur due to a reversal of the esophagogastric pressure gradient. This is achieved by a coordinated abdominothoracic maneuver consisting of a thoracic suction, crural diaphragm relaxation and an increase in intragastric pressure. Careful history is important in the diagnosis of rumination syndrome; patients often report "vomiting" or "reflux" and the diagnosis can therefore be missed. Objective testing is available with high resolution manometry or gastroduodenal manometry. Increase in intra-gastric pressure followed by regurgitation is the most important characteristic to distinguish rumination from other disorders such as gastroesophageal reflux. The mainstay of the treatment of rumination syndrome is behavioral therapy via diaphragmatic breathing in addition to patient education and reassurance.

PURPOSE

The purpose of this review was to critically appraise recent key developments in the pathophysiology, diagnosis and therapy for rumination syndrome. A literature search using OVID (Wolters Kluwer Health, New York, NY, USA) to examine the MEDLINE database its inception until May 2016 was performed using the search terms "rumination syndrome," "biofeedback therapy," and "regurgitation." References lists and personal libraries of the authors were used to identify supplemental information. Articles published in English were reviewed in full text. English abstracts were reviewed for all other languages. Priority was given to evidence obtained from randomized controlled trials when possible.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.

Supragastric belching

PURPOSE OF REVIEW

Supragastric belching has recently gained recognition as a belching disorder of behavioral origin that can be accurately diagnosed on esophageal impedance monitoring. 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.

RECENT FINDINGS

Supragastric belching is now shown to be associated with globus, as well as reflux symptoms in proton pump inhibitor nonresponders. 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.

SUMMARY

With the foreseeable increase in recognition and diagnosis of pathological supragastric belching, there is a clear need to better understand its pathophysiology, especially in terms of its emerging importance in relation to other gastrointestinal disorders. Further study is justified to uncover additional therapeutic options for this benign but disabling condition.

Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action

BACKGROUND

While high resolution esophageal manometry combined with impedancometry has demonstrated that gastric pressurizations lead to rumination, the contribution of upper esophageal sphincter (UES) and esophagogastric junction (EGJ) function to rumination is unclear. Behavioral therapy with diaphragmatic breathing (DB) can reduce rumination. We aimed to evaluate the pressures in the stomach, EGJ and UES during rumination and the effects of DB augmented with biofeedback therapy.

METHODS

Sixteen patients with rumination were studied with manometry and impedancometry before and after a meal. The postprandial assessment comprised three periods: before, during, and after DB augmented with biofeedback therapy.

KEY RESULTS

All patients had postprandial rumination, which was associated (p < 0.001) with increased gastric pressure and reversal of the postprandial gastroesophageal pressure gradient from -4 (-43 to 18) before to 20 (7-79) mmHg during rumination. The EGJ pressure was lower (p < 0.001) during gastric pressurizations that were associated with rumination vs those that were not. The UES also relaxed, almost completely, during rumination. Patients had a median (range) of 5 (2-10) rumination episodes before, 1 (0-2) (p < 0.001) during, and 3 (1-5) after (p < 0.001 vs during) diaphragmatic breathing. During manometry and impedancometry, DB was well-tolerated and learned within 5 min. Diaphragmatic breathing increased EGJ pressure (p < 0.001) and restored a negative gastroesophageal pressure gradient (-20 mmHg [-80 to 7]).

CONCLUSIONS & INFERENCES

Diaphragmatic breathing aided with high resolution esophageal manometry is well-tolerated, effective and averts the gastroesophageal pressure disturbance that leads to rumination.

EFFECT OF GUM CHEWING ON AIR SWALLOWING, SALIVA SWALLOWING AND BELCHING

BACKGROUND

Eructation is a physiologic event which allows gastric venting of swallowed air and most of the time is not perceived as a symptom. This is called gastric belching. Supragastric belching occurs when swallowed air does not reach the stomach and returns by mouth a short time after swallowing. This situation may cause discomfort, life limitations and problems in daily life.

OBJECTIVE

Our objective in this investigation was to evaluate if gum chewing increases the frequency of gastric and/or supragastric belches.

METHODS

Esophageal transit of liquid and gas was evaluated by impedance measurement in 16 patients with complaint of troublesome belching and in 15 controls. The Rome III criteria were used in the diagnosis of troublesome belching. The esophageal transit of liquid and gas was measured at 5 cm, 10 cm, 15 cm and 20 cm from the lower esophageal sphincter. The subjects were evaluated for 1 hour which was divided into three 20-minute periods: (1) while sitting for a 20-minute base period; (2) after the ingestion of yogurt (200 mL, 190 kcal), in which the subjects were evaluated while chewing or not chewing gum; (3) final 20-minute period in which the subjects then inverted the task of chewing or not chewing gum. In gastric belch, the air flowed from the stomach through the esophagus in oral direction and in supragastric belch the air entered the esophagus rapidly from proximal and was expulsed almost immediately in oral direction. Air swallows were characterized by an increase of at least 50% of basal impedance and saliva swallow by a decrease of at least 50% of basal impedance, that progress from proximal to distal esophagus.

RESULTS

In base period, air swallowing was more frequent in patients than in controls and saliva swallowing was more frequent in controls than in patients. There was no difference between the medians of controls and patients in the number of gastric belches and supragastric belches. In six patients, supragastric belches were seen at least once during the 20-minute base period. None of the controls had supragastric belches. In the control group, the ingestion of yogurt caused no significant alteration in the number of air swallows, saliva swallows, gastric belches and supragastric belches. In the patient group, there was an increase in the number of air swallows. If the subjects were chewing gum during this 20-minute period, there was an increase in the number of saliva swallows in both groups, without alterations of the number of air swallow, gastric belches and supragastric belches. There was no alteration in the number of the saliva swallows, air swallows, gastric belches and supragastric belches in both groups for subjects who did not chew gum in the 20-40 minute period after yogurt ingestion. When the subjects were chewing the gum, there was an increase in saliva swallows in the control and patients groups and in air swallows in the patients group.

CONCLUSION

Gum chewing causes an increase in saliva swallowing in both patients with excessive belching and in controls, and an increase in air swallowing in patients with excessive belching 20 minutes after yogurt ingestion. Gum chewing did not increase or decrease the frequency of gastric or supragastric belches.

Supragastric Belching: Prevalence and Association With Gastroesophageal Reflux Disease and Esophageal Hypomotility

Background/Aims

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.

Methods

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 recorded by a standardized questionnaire evaluating for reflux, dysphagia, and dyspepsia symptoms. We reviewed the predominant symptoms, 24-hour pH-impedance and high-resolution esophageal manometry results.

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 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 (118.3 ± 106.1 vs 80.6 ± 75.7, P = 0.020).

Conclusions

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.

[Belching (eructation)]

Belching is a normal physiological function that may occur when ingested air accumulated in the stomach is expelled or when food containing air and gas produced in the gastrointestinal tract is expelled. Excessive belching can cause patients to complain of abdominal discomfort, disturbed daily life activities, decreased quality of life and may be related to various gastrointestinal disorders such as gastroesophageal reflux disease, functional dyspepsia, aerophagia and rumination syndrome. Belching disorders can be classified into aerophagia and unspecified belching disorder according to the Rome III criteria. Since the introduction of multichannel intraluminal impedance monitoring, efforts are being made to elucidate the types and pathogenic mechanisms of belching disorders. Treatment modalities such as behavioral therapy, speech therapy, baclofen, tranquilizers and proton pump inhibitors can be attempted, but further investigations on the effective treatment of belching disorders are warranted.

Managing a patient with excessive belching

A 50-year-old man with end-stage renal failure was referred by his general practitioner with dyspeptic symptoms. On further questioning the patient complained of a 10-year history of frequent belching. This was noticeably worse after meals and during times of stress. He did not have nocturnal belching and episodes of belching were less frequent when the patient was talking or distracted. There was no history of gastro-oesophageal reflux, vomiting, dysphagia, loss of appetite or weight loss. He was diagnosed with excessive, probably supragastric, belching. Further investigation was not deemed necessary. His symptoms have since settled with simple reassurance and explanation of their origin provided during the clinic visit.