Increased swallowing frequency in GORD is likely to be caused by perception of reflux episodes

Prevalence and severity of abdominal bloating in patients with gastroesophageal reflux disease

Abdominal bloating (AB) is a common symptom among patients with gastroesophageal reflux disease (GERD); however, in clinical practice, its prevalence is likely underestimated due to the lack of objective tools to measure its frequency and severity. It is associated with dissatisfaction and worse quality of life, but data on its prevalence before and after mechanical control of GERD (i.e. fundoplication, magnetic sphincter augmentation, and antireflux mucosectomy) are lacking. To assess and determine the pre- and postoperative prevalence and severity of AB among patients with GERD, we conducted a structured literature search using MeSH and free-text terms in MEDLINE (via Pubmed), EMBASE, and Taylor & Francis Online between January 1977 and October 2022. Fifteen articles reporting the prevalence or severity of AB using quality-of-life questionnaires before or after antireflux surgery (ARS) were included. Overall, a high prevalence of AB before ARS was found. A decline in the prevalence and severity of AB was documented postoperatively in most cases independent of the surgical approach. Among surgical approaches, a complete fundoplication had the highest reported postoperative AB. Overall, patients reported less severe and less frequent AB after ARS than before. The traditional belief that postoperative bloating is a sequela of ARS should be reevaluated.

Relevance of Excessive Air Swallowing in GERD Patients With Concomitant Functional Dyspepsia and Poor Response to PPI Therapy

GOALS

The present study was aimed at evaluating the possible role of air swallowing in the association between gastroesophageal reflux disease (GERD) symptoms and concomitant functional dyspepsia (FD) and their role in GERD symptom persistence despite proton pump inhibitor (PPI) therapy.

BACKGROUND

It has been shown that individuals with excessive air swallowing experience FD. It has been also demonstrated that a consistent group of GERD patients not responding to PPI therapy swallow more air during mealtime and also have more mixed refluxes.

MATERIALS AND METHODS

Multichannel intraluminal impedance-pH tracings from consecutive patients were retrospectively evaluated. A validated structured questionnaire was used to evaluate GERD and concomitant FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard-dose PPI therapy.

RESULTS

A total of 35 patients with conclusive GERD, 35 patients with reflux hypersensitivity, and 35 with functional heartburn were studied. A direct relationship was observed between the number of air swallows and of mixed refluxes (R=0.64). At receiver operating characteristic curve analysis, air swallows and mixed refluxes were significantly associated to the presence of FD and PPI refractoriness. An air swallow cutoff of 107 episodes/24 hours was identified to discriminate patients with and without FD (sensitivity: 87%, specificity: 82.8%). A mixed reflux cutoff of 34 episodes/24 hours was identified to discriminate PPI responders from nonresponders (sensitivity: 84.8%, specificity: 69%). At multivariate analysis, an abnormal number of air swallows and of mixed refluxes were significantly associated to FD and PPI refractoriness.

CONCLUSION

Our study highlights the relevant role of excessive air swallowing in eliciting both dyspepsia and refractoriness of typical GERD symptoms to PPI therapy.

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.

Moving Air in the Esophagus During Cryoballoon Ablation

A 56-year-old male patient underwent cryoballoon ablation for symptomatic paroxysmal atrial fibrillation. Massive air movement reminiscent of an air esophagram was detected during cryoballoon application in the right superior pulmonary vein. In this case report, we sought to consider all possible explanations of this finding.

The relationship between reflux symptoms and glycogenic acanthosis lesions of the oesophagus

Introduction

Glycogenic acanthosis (GA) is a benign, polypoid lesion frequently seen in upper endoscopy with little known aetiology. Information about how it occurs and its clinical significance is lacking.

Aim

In this study, the relationship between GA and reflux symptoms was investigated in patients who underwent endoscopy due to reflux symptoms.

Material and methods

Sixty patients undergoing endoscopy for reflux symptoms and 60 controls without reflux symptoms were included in the study. Among the patients with reflux symptoms, two groups were formed: GA group 1 (n = 30) and non-GA group 2 (n = 30).

Results

The mean age of all patients participating in the study was 44.65 ±15.54 years; in group 1 it was 52.56 ±10.90 years and in group 2 it was 39.40 ±13.87 years. The mean age of group 1 patients was statistically significantly higher than that of group 2 patients (p < 0.05). The incidence of GA was higher in group 1 than in the control group (p = 0.001). In the reflux group, group 1 and group 2 were compared in terms of oesophagitis; group 1 had a higher incidence of oesophagitis (p < 0.05). In the reflux group, in those with GA, the risk of oesophagitis was 6.6 times higher than among those without GA (OR = 6.571; 95% CI: 2.109–20.479).

Conclusions

We think that GA is associated with advanced age, reflux disease, and oesophagitis in our study.

[Belching]

Supragastric belching is the most important factor in the etiology of excessive belching complaints. Supragastric belching is a belching disorder with a behavioral origin. The standard diagnosis is made by monitoring the esophageal impedance. Supragastric belching has been shown to be associated with globus, as well as reflux symptoms in proton pump inhibitor non-responders in gastroesophageal reflux disease; however, the pathophysiology of supragastric belching in patients with gastroesophageal reflux disease or functional dyspepsia has not been clarified. Patient education with behavioral therapy is the treatment of choice in isolated supragastric belching. On the other hand, the best management of supragastric belching associated with globus, gastroesophageal reflux disease, and dyspepsia remains to be studied.

Supragastric belch may be related to globus symptom - a prospective clinical study

BACKGROUND

The etiology of globus is poorly understood. It is controversial, whether gastroesophageal reflux disease (GERD) has a role in globus. To investigate the possible esophageal background of this symptom, we performed transnasal esophagoscopy (TNE), high-resolution manometry (HRM), and 24-h multichannel intraluminal impedance (MII) and pH monitoring on globus patients.

METHODS

Thirty consecutive patients were referred to Helsinki University Hospital, Department of Otorhinolaryngology - Head and Neck Surgery for treatment of globus; 24 consecutive patients with difficult reflux symptoms from the Department of Surgery served as controls. We compared the results of the patient groups in endoscopies, HRM, and 24-h MII-pH monitoring.

KEY RESULTS

In MII monitoring, globus patients had supragastric belch (6/20, 30% vs 1/24, 4%; p = 0.038) more often than controls. Total reflux time was higher in controls (p = 0.004), and they had more acid reflux events (p = 0.002) in MII, but between groups, the number of non-acid reflux events was similar. In pH monitoring, DeMeester score and total pH <4 time were higher in controls (P < 0.001). In HRM, the upper esophageal sphincter (UES) mean basal and residual pressures did not differ.

CONCLUSIONS & INFERENCES

Supragastric belch was more common in globus patients, suggesting the possible role of this condition in globus sensation. However, globus patients in this series had no acid or non-acid GERD or elevated UES pressure.

[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.

Management of belching, hiccups, and aerophagia

Although belching and hiccups are regarded as normal behaviors, they can occur at high frequency or become persistent, becoming bothersome and requiring medical care. Patients with excessive belching frequently have supragastric belches. Excessive belching should be treated as a behavioral disorder. Persistent hiccups, however, can be the first presentation of a serious disorder that requires extensive diagnostic testing. When no cause is found, only the symptoms can be treated. Aerophagia is an episodic or chronic disorder in which patients (children and adults) swallow large quantities of air, which accumulate in the gastrointestinal tract to cause abdominal distention and bloating. These patients should not undergo explorative laparotomy because they do not have ileus. New treatment approaches are needed for patients with aerophagia.

Validation and demonstration of an isolated acoustic recording technique to estimate spontaneous swallow frequency

Spontaneous swallowing is considered a reflexive, pharyngeal clearance mechanism. Reductions in spontaneous swallow frequency may be a sensitive index for dysphagia and related morbidities. This study evaluated an acoustic recording technique as a measure to estimate spontaneous swallow frequency. Initially, a multichannel physiologic (surface electromyography, swallow apnea, cervical auscultation) recording technique was validated and subsequently compared to an isolated acoustic (microphone) recording technique on a sample of younger (25 ± 2.8 years) and older (68 ± 5.3 years) healthy adult participants. Sensitivity (94 %), specificity (99 %), and classification accuracy (98 %) were high for swallow identification from the multichannel physiologic recording technique. Interjudge reliability was high (k = 0.94, 95 % CI = 0.92-0.96). No significant differences in spontaneous swallow frequency were observed between the multichannel physiologic recordings and the acoustic recordings (0.85 vs. 0.81 swallows per minute). Furthermore, these two techniques were highly correlated (r = 0.95). Interjudge reliability for swallow identification via acoustic recordings was high (k = 0.96, 95 % CI = 0.94-0.99). Preliminary evaluation of the temporal stability of spontaneous swallow frequency measured from acoustic recordings indicated that time samples as short as 5 min produce viable results. Age differences were identified in spontaneous swallow frequency rates, with older participants swallowing less frequently than younger participants (0.47 vs. 1.02 swallows per minute). Collectively, these results indicate that an isolated acoustic recording technique is a valid approach to estimate spontaneous swallow frequency.

Excessive belching and aerophagia: two different disorders

Belching is physiological venting of excessive gastric air. Excessive and bothersome belching is a common symptom, which is often seen in patients with functional dyspepsia and gastroesophageal reflux disease. Other symptoms are usually predominant. However, a small group of patients complain of isolated excessive belching, with a frequency of several belches per minute. In these patients, the eructated air does not originate from the stomach but is sucked or injected in the esophagus from the pharynx and expelled immediately afterward in oral direction. This behavior is called supragastric belching because the air does not originate from the stomach and does not reach the stomach either. Excessive belching can be treated by speech therapy or behavior therapy. The term aerophagia should be reserved for those patients where there is evidence that they swallow air too frequently and in too large quantities. These patients have excessive amounts of intestinal gas visualized on a plain abdominal radiogram and their primary symptoms are bloating and abdominal distension and they belch only to a lesser degree. Aerophagia and excessive supragastric belching are thus two distinct disorders.

Aerophagia: excessive air swallowing demonstrated by esophageal impedance monitoring

BACKGROUND & AIMS

Patients with aerophagia suffer from the presence of an excessive volume of intestinal gas, which is thought to result from excessive air ingestion. However, this has not been shown thus far. The aim of this study was therefore to assess swallowing and air swallowing frequencies in patients with suspected aerophagia.

METHODS

Ambulatory 24-hour pH-impedance monitoring was performed in patients in whom excessive amounts of intestinal gas were visualized on plain abdominal radiograms. All patients had symptoms of bloating, abdominal distention, flatulence, or excessive belching. Reflux parameters and the number of swallows and air swallows were assessed.

RESULTS

The most common symptoms were bloating, abdominal distention, and constipation. Only 3 patients reported excessive belching and 1 patient reported flatulence as their predominant symptom. During the 24-hour measurement, patients showed high incidences of air swallows (521 +/- 63) and gastric belches (126 +/- 37). Patients had normal swallowing frequency (741 +/- 71).

CONCLUSIONS

This study presents objective parameters that confirm the existence of excessive air swallowing or aerophagia using esophageal impedance monitoring.