Inability to belch syndrome: what the gastroenterologist needs to know.

PURPOSE OF REVIEW: To review recent publications on the inability to belch syndrome. RECENT FINDINGS: Five recent retrospective case series indicate that the inability to belch syndrome usually starts in early childhood and is often accompanied by gurgling noises in the chest, pain in the chest or upper abdomen, bloating, and excessive flatulence. Currently, the vast majority of patients who have been identified with inability to belch have self-diagnosed the syndrome on the basis of information available on the internet. A favorable response to injection of botulinum toxin in the cricopharyngeus muscle is regarded as confirmation of the diagnosis. In a mechanistic study in eight patients, absence of reflexogenic relaxation of the upper esophageal sphincter upon rapid gaseous esophageal distension was confirmed to play a pivotal role in the pathogenesis of the syndrome. SUMMARY: The inability to belch syndrome, caused by failure of the upper esophageal sphincter to relax when the esophageal body is distended, clearly exists and may not be as rare as thought hitherto. However, overdiagnosis is also likely to occur because the diagnosis is usually made on the basis of symptoms only. The efficacy of botulinum toxin injection in the upper sphincter needs to be assessed in double-blind placebo-controlled studies.

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.

[Gastric vs. supragastric belching, singultus, aerophagia, and differential diagnoses : An interdisciplinary perspective for otorhinolaryngologists]. / Gastrisches versus supragastrisches "belching", Singultus, Aerophagie und Differenzialdiagnosen : Eine interdisziplinäre Übersicht für den HNO-Arzt.

Belching is the act of expelling air from the stomach or esophagus into the pharynx. Although the process is regarded as physiological, excessive belching might be associated with a significant burden for affected patients in the sense of a belching disorder. Diagnosis of a belching disorder is often challenging, and its differentiation from other conditions such as rumination syndrome, singultus, or aerophagia can be difficult. Treatment of these disorders also represents a challenge for otorhinolaryngologists. Hence, the aim of this review is to provide an interdisciplinary overview of these clinical syndromes and provide practical guidance for their diagnosis and treatment.

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.

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.

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.

[Atypical complaint in myocardial ischaemia: belching]. / Atípusos panasz myocardialis ischaemiában: böfögés.

While educating non-medical personnel on acute coronary syndrome we often emphasize the importance of early recognition and urgent transfer to acute cardiac center of patients with acute myocardial infarction. Aside from typical symptoms of chest tightness and pain radiating to shoulder, arm and jaw, angina often presents with atypical, non-cardiac complaints. These symptoms, often suggesting gastrointestinal problems, can sometimes mislead even the most experienced physicians. We would like to present the case of an 83-year-old woman with several decades long history of ischaemic heart disease, who recently developed a new anginal symptom: lound, uncontrollable belching. Within the past eight months she was admitted four times with complaints of belching followed by chest pain. Even though initially it was thought as an incidental finding, in all four cases she had proven coronary occlusion requiring cardiac intervention. Orv. Hetil., 2017, 158(5), 183-186.

The overlap of upper functional gastrointestinal disorders with irritable bowel syndrome in Chinese outpatients: A multicenter study.

BACKGROUND AND AIM: Irritable bowel syndrome (IBS) is a common functional bowel disease, and the overlap with upper functional gastrointestinal disorders (FGIDs) is popular. However, the coexistent upper GI symptom profiles, upper FGID spectra, and related risk factors among IBS subjects remain unclear in mainland of China. METHODS: Consecutive patients from the outpatient gastroenterology clinics of three tertiary hospitals in China were enrolled in this multicenter study. All upper GI symptoms occurring at least once a week in the last 3 months were recorded. Diagnostic criteria of functional esophageal, gastroduodenal disorders and IBS were based on Rome III criteria. Risk factors were assessed using a multivariate logistic regression model. RESULTS: Of the 8906 consecutive patients, 751 patients met Rome III criteria for IBS and 735 IBS patients participated in the interview. Postprandial fullness (30.6%), belching (27.1%), and regurgitation (21.8%) were the three most prevalent upper GI symptoms in IBS. Functional dyspepsia (FD, 36.7%), belching disorders (27.1%), and functional heartburn (16.3%) were the three most frequent upper FGID in IBS patients. Female sex, divorced or widowed versus married status, defecation straining, reduced bowel movement, mixed IBS, abdominal distention, mild abdominal pain, moderate discomfort were positively associated with IBS-FD overlap. Female sex, drinking, moderate discomfort, and mild to moderate distension were independent risk factors for IBS-belching disorder overlap. CONCLUSIONS: The study provides detailed overlap spectra of upper FGID with IBS. Mixed IBS is an important risk factor for IBS-FD overlap, which deserved more concern.

Belching during gastroscopy and its association with gastroesophageal reflux disease.

Belching may result from transient lower esophageal sphincter relaxation; therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). This study was conducted to investigate the frequency of belching during esophagogastroduodenoscopy (EGD) and its association with GERD. A retrospective review was performed on prospectively collected clinical and endoscopic data from 404 subjects who underwent EGD without sedation from December 2012 to May 2013 in a training hospital in Korea. All detectable belching events during endoscopy were counted. Frequency and severity of belching events were compared between the group with and without GERD using an ordinal logistic regression model. There were 145 GERD patients (26 erosive reflux disease and 119 nonerosive reflux disease [NERD]). In the multivariable analysis, GERD was significantly associated with a higher frequency of belching events (odds ratio = 6.59, P < 0.001). Central obesity, female, and younger age were also risk factors for frequent belching during EGD. Subgroup analyses were performed in subjects without erosive reflux disease (n = 378) and NERD (n = 293). NERD was also a predictive factor for frequent belching during EGD (odds ratio = 6.61, P < 0.001), and the frequency of belching was significantly correlated with GERD severity according to the Los Angeles classification (P < 0.05). Frequent belching during EGD was associated with GERD, including NERD. Future research should focus on its adjuvant role in the diagnosis of GERD/NERD and the necessity for applying differentiated endoscopy strategies for GERD patients, leading to less discomfort during EGD in patients at risk for intolerability.

The Physiology of Eructation.

Eructation is composed of three independent phases: gas escape, upper barrier elimination, and gas transport phases. The gas escape phase is the gastro-LES inhibitory reflex that causes transient relaxation of the lower esophageal sphincter, which is activated by distension of stretch receptors of the proximal stomach. The upper barrier elimination phase is the transient relaxation of the upper esophageal sphincter along with airway protection. This phase is activated by stimulation of rapidly adapting mechanoreceptors of the esophageal mucosa. The gas transport phase is esophageal reverse peristalsis mediated by elementary reflexes, and it is theorized that this phase is activated by serosal rapidly adapting tension receptors. Alteration of the receptors which activate the upper barrier elimination phase of eructation by gastro-esophageal reflux of acid may in part contribute to the development of supra-esophageal reflux disease.

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.

Gastrointestinal distress is common during a 161-km ultramarathon.

This study examined the incidence, severity, and timing of gastrointestinal (GI) symptoms in finishers and non-finishers of the 161-km Western States Endurance Run. A total of 272 runners (71.0% of starters) completed a post-race questionnaire that assessed the incidence and severity (none = 0, mild = 1, moderate = 2, severe = 3, very severe = 4) of 12 upper (reflux/heartburn, belching, stomach bloating, stomach cramps/pain, nausea, vomiting) and lower (intestinal cramps/pain, flatulence, side ache/stitch, urge to defecate, loose stool/diarrhoea, intestinal bleeding/bloody faeces) GI symptoms experienced during each of four race segments. GI symptoms were experienced by most runners (96.0%). Flatulence (65.9% frequency, mean value 1.0, s = 0.6 severity), belching (61.3% frequency, mean value 1.0, s = 0.6 severity), and nausea (60.3% frequency, mean value 1.0, s = 0.7 severity) were the most common symptoms. Among race finishers, 43.9% reported that GI symptoms affected their race performance, with nausea being the most common symptom (86.0%). Among race non-finishers, 35.6% reported that GI symptoms were a reason for dropping out of the race, with nausea being the most common symptom (90.5%). For both finishers and non-finishers, nausea was greatest during the most challenging and hottest part of the race. GI symptoms are very common during ultramarathon running, and in particular, nausea is the most common complaint for finishers and non-finishers.

The pathophysiology, diagnosis and treatment of excessive belching symptoms.

Excessive belching is a commonly observed complaint in clinical practice that can occur not only as an isolated symptom but also as a concomitant symptom in patients with gastroesophageal reflux disease (GERD) or functional dyspepsia. Impedance monitoring has revealed that there are two mechanisms through which belching can occur: the gastric belch and the supragastric belch. The gastric belch is the result of a vagally mediated reflex leading to relaxation of the lower esophageal sphincter and venting of gastric air. The supragastric belch is a behavioral peculiarity. During this type of belch, pharyngeal air is sucked or injected into the esophagus, after which it is immediately expulsed before it has reached the stomach. Patients who belch excessively invariably exhibit an increased incidence of supragastric, not of gastric belches. Moreover, supragastric belches can elicit regurgitation episodes in patients with the rumination syndrome and sometimes appear to induce reflux episodes as well. Behavioral therapy has been proven to decrease belching complaints in patients with isolated excessive belching, but its effect is unknown in frequently belching patients with GERD, functional dyspepsia or rumination.

Objective manometric criteria for the rumination syndrome.

OBJECTIVES: The rumination syndrome is a behavioral disorder resulting in recurrent regurgitation of undigested food. The diagnosis of this syndrome is currently based on clinical features. We aimed to determine criteria for the rumination syndrome based on physiological measurements. METHODS: We studied patients with clinically confirmed rumination syndrome and gastroesophageal reflux disease (GERD) patients with predominant symptoms of regurgitation. All patients underwent combined high-resolution manometry and pH-impedance measurement after a standardized meal. All reflux events extending to the proximal esophagus were analyzed. Furthermore, ambulatory measurements were performed in the majority of patients. RESULTS: In the rumination group, the amplitude of the abdominal pressure increase during proximal reflux events and the esophageal pressure peaks were significantly higher compared with GERD patients. None of the GERD patients exhibited abdominal pressure peaks >30 mm Hg, whereas in the rumination patients 70% of the pressure peaks had an amplitude >30 mm Hg. Abdominal pressure patterns were also observed during ambulatory pH impedance-pressure monitoring in the rumination patients. pH-impedance monitoring alone could not differentiate between GERD and rumination, however, a higher percentage of reflux events reached the proximal esophagus in the rumination patients. Notably, three different mechanisms of rumination were observed: (i) primary rumination, in which the abdominal pressure increase preceded the retrograde flow, (ii) secondary rumination, consisting of an increase in abdominal pressure following the onset of a reflux event and (iii) supragastric belch-associated rumination, consisting of a supragastric belch immediately followed by a rumination event. CONCLUSIONS: The diagnosis of the rumination syndrome can be made when reflux events extending to the proximal esophagus that are closely associated with an abdominal pressure increase >30 mm Hg and an esophageal pressure increase are observed during combined pressure-impedance monitoring.

Current diagnosis and management of the rumination syndrome.

The rumination syndrome is a behavioral condition characterized by postprandial regurgitation. In contrast to what many think, the disorder does not exclusively occur in mentally disabled patients or children but also in otherwise healthy adults. As symptoms of postprandial regurgitation are often mistaken for gastroesophageal reflux disease or vomiting, the rumination syndrome is an underappreciated condition. Rumination episodes are caused by an intragastric pressure increases which forces the gastric content into the esophagus and mouth and occurs during 3 distinct mechanisms: primary rumination, secondary rumination, and supragastric belch-associated rumination. Combined manometry-impedance can distinguish rumination from gastroesophageal reflux disease. Treatment of the rumination syndrome consists of a thorough explanation of the mechanisms underlying the rumination episodes and behavioral therapy. As behavioral therapy is a time-consuming and often expensive treatment, we propose that a clinical suspicion of the disorder is always confirmed by a manometry-impedance measurement.

Development and validation of a patient-reported outcome instrument in partial responders to proton pump inhibitors.

OBJECTIVE: The Reflux Symptom Questionnaire 7-day recall (RESQ-7) was developed, in line with the US Food and Drug Administration (FDA) guidelines, to address the need for a patient-reported outcome (PRO) instrument assessing symptoms specifically in patients with gastroesophageal reflux disease (GERD) who are only partially responsive to proton pump inhibitor (PPI) therapy. MATERIALS AND METHODS: The RESQ-7 was constructed using patient interviews and expert consensus. The instrument was psychometrically validated in a clinical trial setting in patients with persistent GERD symptoms despite PPI therapy. RESULTS: Evaluation of content validity yielded a 13-item structure for the RESQ-7, incorporating symptoms overlooked by existing GERD questionnaires, such as hoarseness, cough, difficulty swallowing and burping. Principal component analysis suggested a four-domain structure. All domains had a high inter-item correlation (Cronbach's α lower 95% confidence limits: 0.77-0.87 for intensity; 0.72-0.82 for frequency). Test-retest reliability was fair-to-good or excellent (intraclass correlation coefficient lower 95% confidence limits: 0.70-0.78 for intensity; 0.65-0.75 for frequency). Convergent and discriminant validity were confirmed by correlation comparisons with the Gastrointestinal Symptom Rating Scale. DISCUSSION: The RESQ-7 demonstrated good content validity and psychometric properties in patients with GERD and a partial response to PPIs. The weekly recall makes the RESQ-7 appropriate for use in routine clinical care. The authors believe that it is the first instrument to be developed specifically for patients with a partial response to PPI therapy in line with FDA guidelines on PROs (ClinicalTrials.gov identifier: NCT00703534).

Characteristics of belching, swallowing, and gastroesophageal reflux in belching patients based on Rome III criteria.

BACKGROUND AND AIMS: Belching is a common disorder with undetermined pathogenesis. With the combined multichannel intraluminal impedance pH monitoring, two different models of belching have been defined: gastric belching (GB) and supragastric belching (SB). The aim of this study was to assess whether SB was associated with air swallowing as compared with GB or healthy volunteers based on Rome III criteria. METHODS: Consecutive patients who presented with troublesome repetitive belching were recruited. Both upper endoscopy and multichannel intraluminal impedance pH monitoring were performed. Patients were divided into two groups: SB and GB groups according to the percentage of the predominant belching types. Twenty volunteers were enrolled as healthy controls. The number of air swallowing, regular swallowing, and gastroesophageal reflux profile was compared among the three groups. RESULTS: Thirty-seven patients were included in the study: 25 in the SB group and 12 in GB group. SB patients presented more belching events than GB patients (P < 0.05). There were no significant differences among the SB, GB patients, and healthy volunteers concerning the episodes of air swallowing and regular swallowing (P > 0.05). No significant difference was found among the three groups in regard with the reflux parameters (P > 0.05). The number of gas-containing reflux episodes were 33.0 (20.0, 48.0), 39.5 (29.5, 47.5), and 30.5 (27.0, 41.8) among SB, GB, and healthy volunteers (P = 0.383), respectively. CONCLUSIONS: SB patients presented with more belching events compared with GB patients. However, air swallowing and reflux profile were similar among the SB, GB patients, and normal controls.

Gas-related symptoms after antireflux surgery.

BACKGROUND: Gas-related symptoms such as bloating, flatulence, and impaired ability to belch are frequent after antireflux surgery, but it is not known how these symptoms affect patient satisfaction with the procedure or what determines the severity of these complaints. We aimed to assess the impact of gas-related symptoms on patient-perceived success of surgery and to determine whether the severity of gas-related complaints after antireflux surgery is associated with objectively measured abnormalities. METHODS: Fifty-two patients were studied at a median of 27 months after antireflux surgery. The influence of gas-related symptoms on their quality of life and satisfaction with surgical outcome was assessed. The rates of air swallows and gastric and supragastric belches before and after surgery were assessed using impedance measurements. RESULTS: Bloating and flatulence were associated with a decreased quality of life and less satisfaction with surgical outcome. Notably, 9 % of the patients would not opt for surgery again due to gas-related symptoms. Antireflux surgery decreased the total number of gastric belches but did not affect the number of air swallows. The severity of gas-related symptoms was not associated with an increased number of preoperative air swallows and/or belches or a larger postoperative decrease in the number of gastric belches. CONCLUSION: Gas-related symptoms are associated with less satisfaction with surgical outcome. The severity of gas-related symptoms is not determined by the number of preoperative air swallows or a more severe impairment of the ability to belch after surgery. Preoperative predictors of postoperative gas-related symptoms therefore could not be identified.

Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience.

BACKGROUND: Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication. METHODS: All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported. RESULTS: Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication. CONCLUSIONS: Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.