Belching Disorders and Rumination Syndrome: A Literature Review

BACKGROUND

Belching disorders and rumination syndrome (RS) are disorders of gut-brain interaction (DGBIs) in Rome IV. Belching disorders are composed of excessive gastric belching (GB) and supragastric belching (SGB). Excessive GB is related to physiological phenomenon whereas excessive SGB and RS are behavioral disorders.

SUMMARY

A recent large internet survey found that prevalence of belching disorders and RS were 1% and 2.8%, respectively. It has been recognized that not a few patients with two behavioral disorders, excessive SGB and RS, could be misdiagnosed as proton pump inhibitors (PPI)-refractory gastroesophageal reflux disease (GERD). In patients with reflux symptoms, distinguishing these conditions is essential because they need psychological treatment (i.e., cognitive behavioral therapy (CBT) rather than acid suppressants. Clinicians should take a medical history meticulously first to identify possible excessive SGB and/or RS. High-resolution impedance manometry and/or 24-h impedance-pH monitoring can offer an objective diagnosis of the disorders. Several therapeutic options are available for excessive SGB and RS. The first-line therapy should be CBT using diaphragmatic breathing that can stop the behaviors involving complex muscle contraction (e.g., abdominal straining) to generate SGB or rumination. Overlap with eating disorders and/or other DGBIs such as functional dyspepsia can make management of the behavioral disorders challenging since such coexisting conditions often require additional treatments.

KEY MESSAGES

Excessive SGB and RS are not unusual conditions. It is important to raise awareness of the behavioral disorders for appropriate management.

The time to peak blood bicarbonate (HCO3-), pH, and the strong ion difference (SID) following sodium bicarbonate (NaHCO3) ingestion in highly trained adolescent swimmers

The timing of sodium bicarbonate (NaHCO₃) supplementation has been suggested to be most optimal when coincided with a personal time that bicarbonate (HCO₃^–) or pH peaks in the blood following ingestion. However, the ergogenic mechanisms supporting this ingestion strategy are strongly contested. It is therefore plausible that NaHCO₃ may be ergogenic by causing beneficial shifts in the strong ion difference (SID), though the time course of this blood acid base balance variable is yet to be investigated. Twelve highly trained, adolescent swimmers (age: 15.9 ± 1.0 years, body mass: 65.3 ± 9.6 kg) consumed their typical pre-competition nutrition 1–3 hours before ingesting 0.3 g∙kg BM^-1 NaHCO₃ in gelatine capsules. Capillary blood samples were then taken during seated rest on nine occasions (0, 60, 75, 90, 105, 120, 135, 150, 165 min post-ingestion) to identify the time course changes in HCO₃^–, pH, and the SID. No significant differences were found in the time to peak of each blood measure (HCO₃^–: 130 ± 35 min, pH: 120 ± 38 min, SID: 98 ± 37 min; p = 0.08); however, a large effect size was calculated between time to peak HCO₃^– and the SID (g = 0.88). Considering that a difference between time to peak blood HCO₃^– and the SID was identified in adolescents, future research should compare the ergogenic effects of these two individualized NaHCO₃ ingestion strategies compared to a traditional, standardized approach.

Supragastric belching in Japan: lower prevalence and relevance for management of gastroesophageal reflux disease compared to United Kingdom

BACKGROUND

Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK.

METHODS

We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries.

RESULTS

Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P < 0.001). Japanese patients had significantly lower prevalence of excessive SGB (18.5%) than the UK (36.1%) irrespective of reflux phenotype (P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09-7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0-4.9)] compared to the UK [35% (0-54.1)] (P = 0.071).

CONCLUSIONS

The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized.

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

Gas, bloating, and belching are associated with a variety of conditions but are most commonly caused by functional gastrointestinal disorders. These disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress. An organized approach to the evaluation of symptoms fosters trusting therapeutic relationships. Patients can be reliably diagnosed without exhaustive testing and can be classified as having gastric bloating, small bowel bloating, bloating with constipation, or belching disorders. Functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation are the most common causes of these disorders. For presumed functional dyspepsia, noninvasive testing for Helicobacter pylori and eradication of confirmed infection (i.e., test and treat) are more cost-effective than endoscopy. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease. Patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation. Empiric therapy is a reasonable initial approach to functional gastrointestinal disorders, including acid suppression with proton pump inhibitors for functional dyspepsia, antispasmodics for irritable bowel syndrome, and osmotic laxatives and increased fiber for chronic idiopathic constipation. Nonceliac sensitivities to gluten and other food components are increasingly recognized, but highly restrictive exclusion diets have insufficient evidence to support their routine use except in confirmed celiac disease.

Primary gastric inflammatory myofibroblastic tumor: A case report

RATIONALE

Primary gastric inflammatory myofibroblastic tumor is extremely rare. Only a few cases were reported in the domestic and foreign medical literature with corresponding imaging findings of this disease even more rarely reported.

PATIENT CONCERNS

We present one case of a 52-year-old female patient with upper abdominal pain, acid reflux, and belching for 2 months.

DIAGNOSES AND INTERVENTIONS

Electron ultrasound gastroscopy (EUS) revealed elevation of gastric antrum mucosa. A whole abdominal and pelvic multi-slice spiral computed tomography (CT) detected a round nodule in the gastric antrum with considerably delayed enhancement, with initial suspicion of gastrointestinal stromal tumors (GISTS). Then a laparoscopic assisted distal gastrectomy was performed. Finally, the postoperative pathology confirmed the diagnosis of primary gastric IMT.

OUTCOMES

After 6 months of follow-up, the patient was still alive without any evidence of metastasis or recurrence.

LESSONS

Familiarizing with the CT features of this rare tumor may raise radiologists' awareness of the disease and potentially could avoid misdiagnosis.

Small hepatocellular carcinoma suppressed by chemotherapy for synchronous gastric carcinoma after laparoscopy-assisted radical distal gastrectomy: A case report and literature review

RATIONALE

Synchronous gastric carcinoma and hepatocellular carcinoma (HCC) is rare. It is hard to distinguish synchronous HCC from metastatic liver cancer in this condition. The treatment and prognosis is quite different for synchronous HCC of gastric carcinoma and liver metastasis of gastric carcinoma.

PATIENT CONCERNS

A 68-year-old man with a chief complaint of epigastric pain for 1 year, accompanied by reflux and belching. The patient was diagnosed with gastric carcinoma (cT4NxM0) and laparoscopy-assisted radical distal gastrectomy was performed. This was followed by chemotherapy of FOLFOX regimen. However, a liver nodule growth was observed after postoperative systemic treatment.

DIAGNOSIS

The initial diagnosis was liver metastasis of gastric carcinoma. However after hepatectomy of segment VI and VII as well as thrombectomy of right hepatic vein, histology revealed intermediate to poor differentiated HCC. Hence this case was diagnosed as synchronous gastric carcinoma and HCC.

INTERVENTIONS

A preventive transcatheter arterial chemoembolization (TACE) was conducted at 4 weeks after hepatectomy. Another FOLFOX regimen was suggested, but was refused by the patient.

OUTCOMES

The patient survived without tumor recurrence for 9 months after the second surgery.

LESSONS

Synchronous HCC should be routinely distinguished from gastric carcinoma liver metastasis, especially for patients with hepatitis B virus (HBV) infection. The FOLFOX4 regimen for treating gastric carcinoma liver metastasis may have inhibited the progression of primary HCC in this case. This patient with HCC benefited from liver resection, inspite of hepatic vein tumor thrombosis.

Postprandial High-Resolution Impedance Manometry Identifies Mechanisms of Nonresponse to Proton Pump Inhibitors

BACKGROUND & AIMS

Recognition of rumination and supragastric belching is often delayed as symptoms may be mistakenly attributed to gastroesophageal reflux disease. However, distinct from gastroesophageal reflux disease, rumination and supragastric belching are more responsive to behavioral interventions than to acid-suppressive and antireflux therapies. Postprandial high-resolution impedance manometry (PP-HRIM) is an efficient method to identify rumination and belches. We investigated the distribution of postprandial profiles determined by PP-HRIM, and identified patient features associated with postprandial profiles among patients with nonresponse to proton pump inhibitors (PPIs).

METHODS

We performed a retrospective analysis of PP-HRIM studies performed on 94 adults (mean age, 50.6 y; 62% female) evaluated for PPI nonresponsiveness at an esophageal referral center, from January 2010 through May 2016. Following a standard esophageal manometry protocol, patients ingested a solid refluxogenic test meal (identified by patients as one that induces symptoms) with postprandial monitoring up to 90 minutes (median, 50 min). Patients were assigned to 1 of 4 postprandial profiles: normal; reflux only (>6 transient lower esophageal sphincter relaxations (TLESRs)/h); supragastric belch (>2 supragastric belches/h), with or without TLESR; or rumination (≥1 rumination episode/h) with or without TLESR and supragastric belching. The primary outcome was postprandial profile.

RESULTS

Of the study participants, 24% had a normal postprandial profile, 14% had a reflux-only profile, 42% had a supragastric belch profile, and 20% had a rumination profile. In multinomial regression analysis, the rumination group most frequently presented with regurgitation, the supragastric belch and rumination groups were younger in age, and the reflux-only group had a lower esophagogastric junction contractile integral. The number of weakly acidic reflux events measured by impedance-pH monitoring in patients receiving PPI therapy was significantly associated with frequency of rumination episodes and supragastric belches.

CONCLUSIONS

In a retrospective analysis of 94 nonresponders to PPI therapy evaluated by PP-HRIM, we detected an abnormal postprandial pattern in 76% of cases: 42% of these were characterized as supragastric belching, 20% as rumination, and 14% as reflux only. Age, esophagogastric junction contractility, impedance-pH profiles, and symptom presentation differed significantly among groups. PP-HRIM can be used in the clinic to evaluate mechanisms of PPI nonresponse.

Gas and Bloating-Controlling Emissions: A Case-Based Review for the Primary Care Provider

The evaluation of the patient with gas and bloating can be complex and the treatment extremely challenging. In this article, a simplified approach to the history and relevant physical examination is presented and applied in a case-oriented manner, suitable for application in the primary care setting.

Help from habit reversal for supragastric belching

Supragastric belching differs from common gastric belching. It can be detected by 24-hour intra-esophageal impedance monitoring. Belching is seldom the only symptom: reflux symptom is present in 95% and dysphagia in 65% of the patients. In supragastric belching, the air does not come from the stomach but instead from the esophagus. Belching is caused by the patient him/herself swallowing air into the esophagus. This voluntary but unconscious symptom is treated by therapy in which explaining the mechanism of belching for the patient and learning of correct diaphragmatic breathing technique play a central role. Habit reversal is utilized for teaching the patient to react correctly to preemptive symptoms.

Belching, regurgitation, chest tightness and dyspnea: Not gastroesophageal reflux disease but asthma

Belching is a common symptom of gastroesophageal reflux disease. If the symptoms are not relieved after anti-reflux treatment, another etiology should be considered. Here, we report a case of a 43-year-old man who presented with belching, regurgitation, chest tightness and dyspnea for 18 mo, which became gradually more severe. Gastroscopic examination suggested superficial gastritis. Twenty-four-hour esophageal pH monitoring showed that the Demeester score was 11.4, in the normal range. High-resolution manometry showed that integrated relaxation pressure and intrabolus pressure were higher than normal (20 mmHg and 22.4 mmHg, respectively), indicating gastroesophageal junction outflow tract obstruction. Pulmonary function test showed severe obstructive ventilation dysfunction [forced expiratory volume in 1 second (FEV1)/forced vital capacity 32%, FEV1 was 1.21 L, occupying 35% predicted value after salbuterol inhalation], and positive bronchial dilation test (∆FEV1 260 mL, ∆FEV1% 27%). Skin prick test showed Dermatophagoides farinae (++), house dust mite (++++), and shrimp protein (++). Fractional exhaled nitric oxide measurement was 76 ppb. All the symptoms were alleviated completely and pulmonary function increased after combination therapy with corticosteroids and long-acting β2-agonist. Bronchial asthma was eventually diagnosed by laboratory tests and the effect of anti-asthmatic treatment, therefore, physicians, especially the Gastrointestinal physicians, should pay attention to the belching symptoms of asthma.

Wind -- problems with intestinal gas

BACKGROUND

Problems with intestinal gas and its transit through the gut are common, although the mechanisms causing the most common problems of belching (eructation), bloating, and passing flatus from the anus are reasonably complex.

OBJECTIVE

This article outlines the role of intestinal gas in the genesis of the common symptoms of wind, the importance of gas transit, and considers new information about our understanding of small bowel motility.

DISCUSSION

Healthcare providers often underestimate the severity of a patient's symptoms relating to the oesophagus, stomach, small bowel, and colon, especially the loose relationship between bloating and abdominal distension. Medications and diet modification play a key role in management, particularly in terms of fibre, resistant starch and fat intake.

Vesiculopustular dermatosis: an uncommon side-effect of liraglutide?

Liraglutide is a GLP-1 receptor agonist, a novel medication for type 2 diabetes. We describe a case of pustules in a patient recently started on liraglutide. Common side effects of liraglutide are gastrointestinal disorders. Skin and tissue reactions are less well-known side effects. Liraglutide could be the cause of skin eruptions in this patient, possibly by immunogenicity.

[Gastrointestinal syndromes (3): flatulence (1)]

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

Physiologic and pathologic belching

Accumulation of air in the stomach increases gastric volume, which activates receptors in the gastric wall. A reflex is initiated, leading to relaxation of the lower esophageal sphincter, upward movement of the air through the esophagus, and finally passage through the upper esophageal sphincter, during which an audible belch can sometimes be heard. Excessive belching is often reported in patients with gastroesophageal reflux disease and functional dyspepsia. Often other symptoms are predominant, and these should be treated first. Sometimes patients present with excessive belching as an isolated symptom. These patients belch in very high frequencies, up to 20 times per minute, and often during consultation. This condition is referred to as aerophagia. In these patients air is sucked into the esophagus or injected by pharyngeal contraction, after which it is expelled immediately. Aerophagia is a behavioral disorder, and behavioral therapy and/or speech therapy seems to be the therapy of choice.

[Fat, spices and gastro-oesophageal reflux]

In spite of poor evidence, many patients with gastro-oesophageal reflux are advised to avoid fat and spices. We therefore measured gastro-oesophageal reflux after fatty and spicy meals. During three 24-h pH monitoring sessions, eight volunteers ate two identical, low fat and mild beef stews, or a hot and fatty Indian curry for lunch. Meals for dinner were the beef stew, the hot Indian curry or a mild curry. Day-time acid exposure was significantly longer after the hot curry (7.5 % [1.4 - 27.1]) than after the beef stews (2.3 % [0.4 - 9.8] and 2.5 % [0.7 - 15.7]). Night-time acid exposure was also significantly shorter after the beef stew (1.3 % [0 - 9]) than after the mild curry (2.9 % [0 - 19.1]) or the hot curry (4.6 % [0.2 - 22.5]). Within two hours postprandially, reflux was not different between the meals. The number of episodes, however, that occurred more than two hours after lunch was significantly lower after the beef stews (4 [2 - 14] and 4.5 [2 - 10]) than after the hot curry (9 [5 - 16]). The same phenomenon was observed after beef stew (0.5 [0 - 2]), mild curry (2 [0 - 4]) and hot curry (2 [1 - 9]) for dinner. We conclude that meals high in fat can provoke reflux, possibly through delayed gastric emptying. Additional spices, however, do not further increase reflux.

Air swallowing, belching, acid and non-acid reflux in patients with functional dyspepsia

BACKGROUND

Frequent belching is a common symptom in patients with functional dyspepsia with a reported incidence up to 80%. We hypothesized that patients with functional dyspepsia possibly have a higher frequency of belching than healthy subjects secondary to frequent air swallowing.

AIM

To assess air swallowing, belching, acid and non-acid reflux patterns of patients with functional dyspepsia.

METHODS

Combined 24-h oesophageal impedance and pH monitoring was performed in 10 functional dyspepsia patients and 10 controls. Analysis of the impedance-pH signals included incidence of air swallows, belching, acid and non-acid reflux.

RESULTS

The incidence of air swallows in functional dyspepsia patients were significantly higher compared with controls (153 +/- 15 vs. 79 +/- 10, P < 0.001), while the incidence of liquid-only swallows were not significantly increased. The proportions of gas-containing reflux episodes (belches) and non-acid reflux episodes in functional dyspepsia patients were significantly higher when compared with controls (66.4 vs. 44.4%, P = 0.04 and 70.1 vs. 45.9%, P = 0.009, respectively).

CONCLUSION

Patients with functional dyspepsia swallow air more frequently than controls and this is associated with an increased incidence of non-acid gaseous gastro-oesophageal reflux.

Effect of antisecretory therapy on atypical symptoms in gastroesophageal reflux disease

The effect of proton pump inhibitor (PPI) therapy on extraesophageal or atypical manifestations of gastroesophageal reflux disease (GERD) remains unclear. This study aimed to evaluate the prevalence of atypical manifestations in patients with acid reflux disease and the effect of PPI treatment. Patients with symptoms and signs suggestive of reflux were enrolled. Erosive esophagitis was stratified using the Los Angeles classification. Demographic data and symptoms were assessed using a questionnaire and included typical symptoms (heartburn, regurgitation, dysphagia, odynophagia), and atypical symptoms (e.g., chest pain, sialorrhea, hoarseness, globus sensation, chronic coughing, episodic bronchospasm, hiccup, eructations, laryngitis, and pharyngitis). Symptoms were reassessed after a 3-month course of b.i.d. PPI therapy. A total of 266 patients with a first diagnosis of GERD (erosive, 166; non-erosive, 100) were entered in the study. Presentation with atypical symptoms was approximately equal in those with erosive GERD and with non-erosive GERD, 72% vs 79% (P = 0.18). None of the study variables showed a significant association with the body mass index. PPI therapy resulted in complete symptom resolution in 69% (162/237) of the participants, 12% (28) had improved symptoms, and 20% (47) had minimal or no improvement. We conclude that atypical symptoms are frequent in patients with GERD. A trial of PPI therapy should be considered prior to referring these patients to specialists.

Impedance signature of pharyngeal gaseous reflux

BACKGROUND

Pharyngeal impedance changes induced by various pharyngeal reflux events have not been characterized.

OBJECTIVES

To characterize pharyngeal impedance changes induced by participant-perceived belching events.

METHODS

We systematically evaluated pharyngeal impedance and pH changes related to 453 belch events in 11 gastroesophageal reflux disease, 10 reflux attributed-laryngitis patients and 16 controls.

RESULTS

Of 453 belch events, 362 were analyzable. Of these, 72% occurred within 10 s, 93% within 20 s, 99% within 30 s and 100% within 40 s of the time that participants marked a belch event. In 15% impedance changes in the pharynx preceded, in 12% they were simultaneous and in 73% they occurred after the start of the impedance change in the proximal esophagus. Time interval between the two events ranged between 0.4+/-0.03 and 0.7+/-0.1 s. In all, there were three types of belch-induced impedance changes: (a) impedance increase, (b) impedance decrease and (c) multiphasic. Twenty percent of impedance events associated with belching had less than 50% change from baseline, whereas in 51% changes exceeded or were equal to 50%. Among events with a drop in pharyngeal impedance, only two satisfied the criteria for the liquid reflux event.

CONCLUSIONS

Pharyngeal ventilation of gastric gaseous content seems to have a unique impedance signature. During pharyngeal gas reflux events, impedance changes may start before or after proximal esophageal changes. Belching may induce negative pharyngeal changes that do not meet the criteria for liquid reflux. These findings need to be taken into consideration in the analysis of pharyngeal reflux events.

[Belching (ructus)]

Accumulation of air in the stomach increases the gastric volume, which activates receptors in the gastric wall. This results in a reflex that relaxes the lower oesophageal sphincter, whereby the intragastric air can escape through the oesophagus. Ventilation of the stomach via the oesophagus is known as belching (ructus). Belching often occurs in combination with reflux symptoms and dyspepsia. In these cases, other symptoms are often more predominant, and it is advisable to treat these first. In patients with aerophagia, belching is the most common reason for medical consultation. These patients belch frequently, up to 20 times per minute, and often during consultation. Aerophagia results from air being sucked into the oesophagus or injected by pharyngeal contraction, after which it is expelled immediately. In contrast to the described gastric belching, aerophagia is therefore a form of supragastric belching. Aerophagia is a behavioural disorder, and behavioural therapy or logopedics appears to be most common therapeutic approach.

Dietary influence on electro-gastrography and association of alterations in gastric myoelectrical activity with symptoms in patients with functional dyspepsia

BACKGROUND AND AIM

It is unclear which type of meal is adequate in measuring electro-gastrography and which parameter of electro-gastrography is of clinical relevance. The aims of the present study were to compare the influence of water and a nutrient drink on electro-gastrography in patients with functional dyspepsia (FD) and in healthy volunteers, and to investigate the association of alterations of electro-gastrography with symptoms.

METHOD

In 30 patients with FD and 12 healthy volunteers, the recording of electro-gastrography with symptom assessments was performed pre-prandially and postprandially. Subjects ingested the same volume of water and a nutrient drink at a fixed rate, which was performed in a randomized cross-over design.

RESULTS

Unlike water, the power ratio after/before a nutrient drink was significantly lower in patients compared to controls. Patients had more severe bloating and epigastric pain after nutrient ingestion than after water intake. Absent postprandial increase of power was observed in seven of the 30 patients after nutrient intake, and in three of the 30 patients after water intake. The former patients had significantly more severe fullness and bloating. Irrespective of a test meal, the percentage rates of normogastria significantly decreased postprandially in the patient group, but not in the control group. No differences in symptom severity were observed between patients with and without abnormally low percentage rates of normogastria.

CONCLUSIONS

Decreased postprandial rates of normogastria and absent postprandial increase of power are electro-gastrographic abnormalities found in a subset of patients with FD. A nutrient drink is more adequate for the detection of such alterations than water. The lack of a postprandial increase of power is associated with the severity of some dyspeptic symptoms, but decreased postprandial rates of normogastria are not.

Clinical features of pathologic childhood aerophagia: early recognition and essential diagnostic criteria

OBJECTIVE

This study investigated the early recognition and diagnosis of pathologic childhood aerophagia to avoid unnecessary diagnostic approaches and serious complications.

METHODS

Between 1995 and 2003, data from 42 consecutive patients with pathologic childhood aerophagia, aged 2 to 16 years, were reviewed. An esophageal air sign was defined as an abnormal air shadow on the proximal esophagus adjacent to the trachea on a full-inflated chest radiograph.

RESULTS

Of the 42 patients, the chief complaints were abdominal distention (52.4%), recurrent abdominal pain syndrome (21.4%), chronic diarrhea (11.9%), acute abdominal pain (7.1%) and others (7.2%). Mean symptom duration before diagnosis was 10.6 months (range, 1 to 60 months), and it exceeded 12 months for 16 (38.1%) patients. The clinical features common to all patients were abdominal distention that increased progressively during the day, increased flatus on sleep, increased bowel sound on auscultation and an air-distended stomach with increased gas in the small and large bowel by radiography. Visible or audible air swallowing (26.2%) and repetitive belching (9.5%) were also noted. Esophageal air sign was observed in 76.2% of the patients and in 9.7% of the controls (P=0.0001). The subgroups of pathologic childhood aerophagia divided by underlying associations were pathologic childhood aerophagia without severe mental retardation (76.2%), which consisted of psychological stresses and uncertain condition, and pathologic childhood aerophagia with severe mental retardation (23.8%).

CONCLUSIONS

The common manifestations of pathologic childhood aerophagia may be its essential diagnostic criteria, and esophageal air sign may be useful for the early recognition of pathologic childhood aerophagia. Our observations show that the diagnostic clinical profiles suggested by Rome II criteria should be detailed and made clearer if they are to serve as diagnostic criteria for pathologic childhood aerophagia.

Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring

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. In the first type air flowed from the stomach through the oesophagus in oral direction ("gastric belch"). In the second type air entered the oesophagus rapidly from proximal and was expulsed almost immediately in oral direction ("supragastric belch"). 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.

Hiccups, eructation, and other uncommon prodromal manifestations of herpes zoster

Although the most frequent presentation of herpes zoster involves sensory neurons, motor and autonomic symptomatology is also known to occur in this disease. An unusual symptom of hiccups is described here. Other infrequent manifestations of this common illness, including the Ramsay Hunt syndrome, herpes zoster ophthalmicus, urinary and fecal retention, sexual dysfunction, and zoster sine herpete, are reviewed. Greater awareness of unusual presentations of herpes zoster is necessary for proper diagnosis and timely management of complications that may otherwise lead to disability and serious long-term sequelae.

[Diagnostic image (161). A woman suffering from abdominal pain, sickness and belching. Thoracic herniation of the stomach]

A 20-year-old woman presented with abdominal pain, sickness and belching due to thoracic herniation of the stomach.

Belching: dyspepsia or gastroesophageal reflux disease?

OBJECTIVES

Eructation (belching) is a common symptom seen in clinical practice. Because either belching or heartburn may result from transient lower esophageal sphincter relaxations, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). In this retrospective study we evaluated the prevalence of belching in dyspepsia and GERD and the relation of belching to acid reflux events documented by pH monitoring.

METHODS

We examined the prevalence, frequency, and severity of belching and other GERD symptoms by use of standardized questionnaires in 180 GERD patients (group A) and 78 dyspeptic controls (group B) referred for evaluation at our institution. GERD was defined as either endoscopic esophagitis (or Barrett's esophagus) or positive DeMeester score (>14.2) on pH monitoring or both. Dyspeptic patients had normal endoscopy and pH studies. We also analyzed the relationship of belching to acid reflux events during the 24-h period of pH studies.

RESULTS

Of 180 GERD patients, 132 (70%) reported belching during pH monitoring, versus 63 of 78 dyspeptic patients (80%) (p = ns). Similarly, 163 of 180 GERD patients (90%) reported heartburn versus 64 of 78 of dyspeptic patients (82%) (p = ns). Review of symptom questionnaires revealed no significant difference in belching severity between groups. However, heartburn and acid regurgitation were significantly more severe among GERD patients. There was a significantly higher correlation of both heartburn and belching with acid events in patients with GERD compared with patients with dyspepsia. In addition, although both belching and heartburn were significantly improved in patients with GERD, belching scores remained unchanged after proton pump inhibitor (PPI) therapy in patients with dyspepsia.

CONCLUSIONS

Belching is as common and as severe in patients with dyspepsia as it is in patients with GERD. Belching and heartburn in GERD patients are more likely correlated with episodes of pathological acid reflux. Because belching cannot be clinically used as a discriminatory symptom, ambulatory pH monitoring should be considered to elucidate the relationship of belching to acid reflux in patients with dyspepsia or GERD.

Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia

OBJECTIVE

The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern.

METHODS

In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored.

RESULTS

Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30).

CONCLUSIONS

A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.

Masticatory performance is not associated with diet quality in Class II orthognathic surgery patients

This study evaluated the association between masticatory function, diet, and digestive system problems in 59 Class II patients 5 years after bilateral sagittal split osteotomy. Dietary intake data were recorded in 4-day diet diaries and analyzed for overall diet quality (Healthy Eating Index) and selected dietary components. Masticatory function was assessed through measurements of masticatory performance, maximum bilateral bite force, and chewing time and number of chewing strokes until the subject felt that the bolus was ready to swallow. Self-reported frequency of digestive system problems was recorded with a 7-point Likert scale questionnaire. Masticatory function was not associated with diet quality or gastrointestinal problems. There was a weak association between intake of foods that require chewing (eg, fiber, protein, meat, and vegetables) and masticatory variables. Fourteen subjects (24%) had a poor diet and 45 subjects (76%) had a diet that needed improvement according to the Healthy Eating Index. Self-reported constipation was the only digestive system problem that was significantly associated with masticatory performance.

Globus sensation caused by gastroesophageal reflux disease

OBJECTIVES

This study was designed to examine whether or not gastro esophageal reflux disease (GERD) is implicated in globus sensation.

METHODS

The subjects were 25 patients (16 men/9 women; mean age: 51, range 25-69 years) complaining of globus sensation with one or more of four laryngeal findings suspected of having GERD, such as pooling of saliva, erythema of posterior one-third of larynx, inter-arytenoids edema, and granuloma. All 25 patients were administrated a proton pump inhibitor (PPI) for a period of 8 weeks. All were given esophageal endoscopies, laryngoscopes, and questionnaire before and after PPI dosing. The questionnaire survey was conducted to investigate changes in globus sensation and three symptoms specific to GERD including heartburn, regurgitation, and belching. Subjective symptoms were totalled by the over all scores of the three subjective symptoms which served as an index of severity of GERD.

RESULTS

Fifty-two percent (13/25) of patients had reflux esophagitis. The esophagitis were improved after PPI administration except one case. The incidences of GERD symptoms were high (heart burn 68% (17/25), belching 49% (10/25) and regurgitation 76% (19/25)), and most of these symptoms ameliorated by PPI administration. The laryngeal findings were improved in all patients. Subjective symptoms were improved in 68% (17/25) of globus patients. The improvement rate of total score (before PPI dosing/after PPI dosing) was compared between the two groups: one with improved globus sensation (17 patients) and the other without (8 patients). The improvement rate was significantly higher in the group with improved globus sensation (P<0.05). This means that globus sensation improved because of the improvement in GERD.

CONCLUSION

GERD is therefore concluded to be an inducing factor of globus sensation.

The effect of ad libitum ingestion of a caffeinated carbohydrate-electrolyte solution on urinary caffeine concentration after 4 hours of endurance exercise

The purpose of the present study was to examine the effect of ad libitum ingestion of a carbohydrate-electrolyte solution (CES) with 150 mg x L (-1) caffeine (CAF) on urinary CAF concentration after 4 h of endurance exercise. Fifty-eight healthy and well-trained male subjects ingested ad libitum a 7 % CES with 150 mg x L (-1) CAF during 4 h cycling at 50 % of maximal work capacity. Total fluid consumption (mean +/- SE) was 2799 +/- 72 mL and CAF intake was 420 +/- 11 mg (5.7 +/- 0.2 mg x kg (-1) body weight). The post-exercise urinary CAF concentration (4.53 +/- 0.25 microg x mL (-1)) was below the doping level of the International Olympic Committee (12 microg x mL (-1)) in all subjects (range 1.20 - 10.84 microg x mL (-1)). A highly positive correlation was observed between CAF intake and post-exercise urinary CAF concentration (r = 0.68, p < 0.001). It is concluded that ad libitum ingestion of a CES with 150 mg x L (-1) CAF during 4 h cycling resulted in post-exercise urinary concentration below the doping level in all subjects.

Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up

OBJECTIVE

To determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients.

SUMMARY BACKGROUND DATA

Dividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery.

METHODS

Between May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator.

RESULTS

There were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels.

CONCLUSIONS

Division of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of "wind-related" problems.

Functional dyspepsia symptoms, gastric emptying and satiety provocative test: analysis of relationships

BACKGROUND

The correlation between symptoms and observed impaired function in functional dyspepsia is still inconsistent. The aims of the study were to obtain a measure of satiety by a meal test; to verify whether this compares with severity of symptoms assessed using a reproducible questionnaire; and to correlate the parameters of satiety test and gastric emptying with all the dyspeptic symptoms.

METHODS

Fifty-two functional dyspepsia patients reported their symptoms on a standardized questionnaire that considered belching, bloating, early satiety, epigastric pain and burning, nausea, postprandial fullness and vomiting. They were monitored for gastric emptying of a solid caloric meal using a radionuclide technique and underwent a test to quantify meal-induced satiety by a liquid caloric meal.

RESULTS

The number of kilocalories ingested during the satiety test until the occurrence of maximum satiety in healthy subjects was 110% higher than in the dyspeptic group (mean +/- s(mean): 1110 +/- 23 versus 532 +/- 56; P < 0.01). We found a significant positive correlation between gastric emptying rate and kcal of the satiety test (P < 0.01; r = 0.428). Logistic regression showed a significant inverse association between severity of early satiety-coded as absent, mild, moderate or severe, kcal of meal test (P = 0.01), and gastric emptying lag phase (P = 0.03). Bloating was associated directly with t(1/2) of gastric emptying (P = 0.03) and inversely with lag phase (P = 0.02).

CONCLUSIONS

The satiety test gives a fine numerical measure of satiety and confirms the results of a symptoms questionnaire. Our study showed an indirect correlation between severity of early satiety--as measured by the satiety test, and gastric emptying rate, as well as an association between bloating and delayed gastric emptying.

An understanding of excessive intestinal gas

Complaints of "excessive gas" from patients are very common but are difficult, if not impossible, for the physician to document. This review addresses the pathophysiology and management of such complaints, looking at the sources and routes of elimination, excessive eructation, bloating, and distention. In addition, common flatulence problems are summarized, including excessive flatus volume and noxious flatus.

Gastrointestinal mucosal integrity after prolonged exercise with fluid supplementation

PURPOSE

Studies on the effect of exercise on gastrointestinal (GI) mucosal integrity have been limited to occult-blood tests, which were often nonspecific for human blood. The aim of our study was to investigate more aspects of this integrity.

METHODS

We examined the effect of prolonged exercise and carbohydrate (CHO) supplementation on mucosal integrity in 22 male triathletes by measuring fecal lysozyme, alpha1-antitrypsin, and occult-blood loss, which was examined by two tests specific for human blood (Colon-Albumin and Monohaem test). Exercise consisted of two 150-min tests (alternately running, cycling, and running at 70-75% VO2max), either with a 7.0% CHO drink or water (W). Furthermore, GI symptoms during exercise were registered by questionnaire.

RESULTS

Three subjects showed human albumin only in the first stool after exercise: twice with W and once with CHO. However, human hemoglobin (Hb) could not be detected in these samples. Four other subjects showed an elevated lysozyme concentration after exercise with CHO but not with W. Elevated alpha1-antitrypsin values were found in three of seven specimens in which either positive albumin tests and/or an elevated lysozyme concentration were demonstrated. Twenty-one subjects (95%) reported one or more GI symptoms during exercise. Incidence rates of different GI symptoms varied from 5 to 68%. Most symptoms were more frequent and lasted longer during running than during cycling but did not differ significantly between supplements and were not related to any mucosal integrity parameter.

CONCLUSIONS

GI blood loss during exercise is of no clinical importance, at least in our study design with a group of well-trained male subjects who consumed a relatively high amount of fluid (up to 2.3 L). Nevertheless, an increased alpha1-antitrypsin and lysozyme concentration may indicate a transient local mucosal damage with an inflammatory response.

Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication

BACKGROUND

This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

METHODS

Some 101 patients were operated consecutively with posterior partial (270 degrees ) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6-14 years.

RESULTS

All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

CONCLUSION

Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.