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.

Supragastric belching and rumination syndrome: diagnosis and management.

PURPOSE OF REVIEW: This review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases. RECENT FINDINGS: Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback. SUMMARY: A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.

The influence of supragastric belching severity on esophageal acid exposure and motility.

BACKGROUND: Supragastric belching (SGB) is a phenomenon where air is rapidly sucked from the pharynx into the esophagus and immediately expelled through abdominal straining. It is considered a behavior disorder and is increasingly recognized not only in patients with excessive belching, but also in those with reflux-like symptoms. Increased prevalence of esophageal hypomotility and increased acid exposure were previously reported in small cohorts of SGB patients. We aimed to clarify the impact of SGB on motility, reflux, and acid exposure in a large cohort of SGB patients. METHODS: In a single-center database study, we searched for patients with pathological SGB. MII-pH and Manometry tracings were manually re-evaluated in all patients. Demographic, clinical, motility, reflux, and SGB-related data were gathered. KEY RESULTS: Three hundred and forty-eight patients were included. Heartburn, belching, and regurgitation were the most common symptoms. Ineffective esophageal motility (IEM) was found in 27% of patients. SGB related to 47% of all reflux and to 53.6% of acid reflux events, and accounted for 27.3% of acid exposure time (AET). In those with severe SGB, 62% of acid reflux events and 46% of AET were SGB-related. CONCLUSIONS & INFERENCES: Supragastric belching is common, associated with higher incidence of IEM and is responsible for almost a third of esophageal acid burden. The impact of SGB is proportional to its severity. Diagnosis of SGB should be sought in patients with excessive belching and in patients with refractory reflux symptoms. Recognizing SGB and treating patients with behavioral therapy may alleviate acid exposure and improve quality of life.

Eructo, un síntoma que debemos tomar en serio / Belching, a symptom to be taken seriously

El eructo es un síntoma frecuente en Pediatría que socialmente está mal considerado y puede tener consecuencias negativas en la calidad de vida del paciente. No obstante, no son muchas las publicaciones pediátricas al respecto. Según su origen, se pueden clasificar como eructos supragástricos o gástricos, con una fisiología distinta y que pueden ser síntomas de patologías subyacentes tanto físicas como psicológicas. Se revisa la fisiología del eructo y el diagnóstico diferencial a propósito de dos casos diagnosticados de eructos supragástricos.Caso clínico 1: varón de 14 años con cuadro de 15 días de eructos hasta 20-30 por minuto, sensación de imputación esofágica y dolor abdominal. El dolor mejora con omeprazol, pero los eructos persisten; se realiza endoscopia y tránsito esofágico superior que resultan normales. Mejora tras logopedia e inicio de técnicas de relajación.Caso clínico 2: varón de 10 años con cuadro de 19 días de eructos de más de 15 por minuto, sin otros síntomas digestivos, pero con sintomatología ansiosa. Mejoría tras tratamiento psicológico.Ambos tipos de eructo presentan una fisiología distinta, de manera que en el eructo supragástrico el aire no proviene del estómago. El esfínter esofágico inferior permanece cerrado. Los dos tipos son distinguibles mediante pH-impedanciometría. Conclusión: una cuidadosa anamnesis puede establecer el diagnóstico de sospecha del origen del eructo antes de recurrir a pruebas complementarias y permite orientar el tratamiento más adecuado para cada paciente. (AU)

Belching is a frequent symptom in paediatrics that is negatively perceived in our society and can have a negative impact on the quality of life of patients. However, there is a dearth of data on the subject for the paediatric population. Depending on the origin, belching can be classified as supragastric or gastric, has a different physiology and may be a manifestation of underlying physical or psychological disorders. We review the physiology of belching and the differential diagnosis of 2 cases of supragastric belching.Clinical case 1: male patient aged 14 years presenting with belching of 15 days’ duration at a rate of 20 to 30 burps per minute, sensation of oesophageal impaction and abdominal pain. The pain improved with omeprazole but the belching persisted, the findings of endoscopy and upper oesophageal transit were normal. The patient improved with speech therapy and initiation of relaxation techniques.Clinical case 2: male patient aged 10 years-old male presenting with belching of 19 days’ duration at a rate of more than 15 burps per minute, with no other digestive symptoms but with anxiety symptoms. The patient improved with psychological treatment.The underlying physiology of belching was different in each patient, as in supragastric belching the air does not come from the stomach and the lower oesophageal sphincter remains closed. These 2 types can be differentiated by pH-impedance. Conclusion: A careful anamnesis can establish the suspected diagnosis of the origin of the belching before resorting to diagnostic tests, and can guide the most appropriate treatment for each patient. (AU)

Supragastric belching: Pathogenesis, diagnostic issues and treatment.

Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It becomes pathologic if it is excessive and becomes bothersome. According to Rome IV diagnostic criteria, there is a belching disorder when one experiences bothersome belching (severe enough to impact on usual activities) more than 3 days a week. Esophageal impedance can differentiate between gastric and supragastric belching. The aim of this review was to provide data on pathogenesis and diagnosis of supragastric belching and study its relationship with gastroesophageal reflux disease and psychological factors. Treatment options for supragastric belching are also presented.

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.

Diagnostic yield and reliability of post-prandial high-resolution manometry and impedance-ph for detecting rumination and supragastric belching in PPI non-responders.

BACKGROUND: Supragastric belching (SGB) and rumination are behavioral disorders associated with proton pump inhibitor (PPI) non-response and can be diagnosed using multichannel intraluminal impedance-pH (MII-pH) and post-prandial high-resolution impedance manometry (PPHRIM). This pilot study compared diagnostic yield and inter-rater agreement for SGB and rumination using MII-pH and PPHRIM. METHODS: Three esophageal physiologists performed blinded interpretations of MII-pH and PPHRIM in 22 PPI non-responders. Raters selected from 4 diagnostic impressions (normal, GERD, behavioral disorders, GERD+behavioral disorders) without clinical context. Primary outcomes were diagnostic impressions compared against clinical gold standard impression, between raters, and between test modalities. Following a 28-month wash-out period, raters re-interpreted MII-pH with clinical context and under consensus definition of diagnostic criteria. KEY RESULTS: Compared to gold standard, rater accuracy for presence of behavioral disorders ranged from 45 to 77% on MII-pH and 45-59% on PPHRIM. On MII-pH, inter-rater agreement was fair for diagnosis (ĸ0.32, p < 0.01) and suboptimal for presence of behavioral disorders (ĸ0.13, p = 0.14). On PPHRIM, inter-rater agreement was suboptimal for both diagnosis (ĸ0.03, p = 0.34) and presence of a behavioral disorder (ĸ-0.22, p = 0.96). Inter-rater agreement improved in post hoc MII-pH interpretations. Rumination was more frequently identified on PPHRIM (23, 35%) compared to MII-pH (7, 11%). CONCLUSIONS AND INFERENCES: Diagnostic accuracy and inter-rater agreement are higher for MII-pH than PPHRIM, and behavioral disorders are more frequently identified on PPHRIM. Identifying behavioral disorders on MII-pH and PPHRIM has implications for clinical evaluation of PPI non-response; clinical context is essential for accurate study interpretation. Further work is needed to standardize definitions and interpretations.

ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease.

Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.

Novel Use of Impedance Technology Shows That Esophageal Air Events Can Be Temporally Associated With Gastroesophageal Reflux Disease-like Symptoms.

A few studies have shown that esophageal air events (EAEs), such as air-swallows, may be associated with symptoms that have historically been associated with gastroesophageal reflux disease (GERD). To objectively test a hypothesis that all EAE types (air-swallows, supragastric belches and gastric belches) can be associated with GERD-like symptoms, we removed the impedance "tags" from the GER episodes (placed during autoscan) and instead tagged either air-swallows, supragastric belches or gastric belches in each of 3 copies of the 24-hour impedance tracing for 2 infant patients who presented with symptoms suggestive of GER as an etiology. Impedance system software (MMS) analyses revealed that, in both infants, all EAE types were significantly associated (SAP >95%) with 1 or more of the GERD-like symptom types (cough, pain/crying, back-arching, and gagging). These data underscore the importance of considering other diagnoses when developing management strategies for treating GERD-like symptoms in infants.

Prevalence and clinical characteristics of refractoriness to optimal proton pump inhibitor therapy in non-erosive reflux disease.

BACKGROUND: The real size of the gastro-oesophageal reflux disease (GERD) population not responding to proton pump inhibitor (PPI) therapy has still not been fully elucidated. Causes of PPI refractoriness include incorrect diagnosis and lack of adherence to therapy, in terms of incorrect dosage and timing. AIMS: To evaluate the prevalence of refractoriness to optimal PPI therapy and the contribution of non-erosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn, to PPI refractoriness. The association of functional GI symptoms in non-responders was evaluated. METHODS: Frequency and severity of GERD symptoms (heartburn, regurgitation, chest pain), dysphagia, belching, epigastric pain, postprandial distress, irritable bowel syndrome (IBS), globus, and ear nose and throat (ENT) symptoms were evaluated in patients previously classified as non-responders. Patients with at least one of the oesophageal symptoms with a frequency ≥3 /week were treated with esomeprazole 40 mg once daily for 8 weeks and then re-evaluated. Non-responders (patients with oesophageal symptoms ≥3 times per week) underwent 24 hour multichannel intraluminal impedance-pH monitoring. RESULTS: Of 573 consecutive patients, 92 with oesophageal symptoms and classified as PPI-refractory underwent the esomeprazole trial; 60 did not respond. IBS, epigastric pain, and post-prandial distress episodes were associated with a poor response on multivariate analysis. NERD, reflux hypersensitivity, and functional heartburn patients constituted 32%, 42%, and 26%, respectively of the PPI-refractory group. CONCLUSIONS: True refractoriness in patients with GERD symptoms attending a secondary care setting is lower than previously reported. Following a careful history and optimal PPI dosing, the rate of refractoriness was 20%. True NERD constitutes only a third of the PPI-refractory group.

[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.

Randomised clinical trial: rifaximin versus placebo for the treatment of functional dyspepsia.

BACKGROUND: Gut dysbiosis may contribute to pain and bloating in patients with functional gastrointestinal disease. AIMS: To determine if treatment with rifaximin would improve the symptoms of functional dyspepsia in Chinese patients in a double-blinded, randomised, placebo-controlled trial. METHODS: Consecutive subjects with a diagnosis of functional dyspepsia as per the Rome III criteria were randomised to receive rifaximin 400 mg or placebo, all taken three times daily for 2 weeks. The investigators and study subjects were blinded to the treatment allocation. Subjects were followed up for 8 weeks. The primary end point was adequate relief of global dyspeptic symptoms (GDS). Secondary endpoints were relief of individual dyspeptic symptoms. RESULTS: Eighty-six subjects were recruited. At week 8, there were significantly more subjects in the rifaximin than in the placebo group who experienced adequate relief of GDS (78% vs. 52%, P = 0.02). A trend favouring rifaximin group was also noted in the preceding 4 weeks. Rifaximin was also superior to placebo in providing adequate relief of belching and post-prandial fullness/bloating (PPF) in subjects at week 4. Subgroup analysis revealed that female subjects had more significant response to rifaximin treatment (adequate relief of GDS at week 4: 76% vs. 42%, P = 0.006; week 8: 79% vs. 47%, P = 0.008), as well as improvements in their belching and PPF at week 4. The incidences of adverse effects were similar in both groups. CONCLUSIONS: Treatment with 2 weeks of rifaximin led to adequate relief of global dyspeptic symptoms, belching and post-prandial fullness/bloating in subjects with functional dyspepsia. The difference was more marked in females. (clinicaltrials.org NCT01643083).

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.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls.

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

Impact of laparoscopic antireflux surgery on belching in pediatric GERD patients.

BACKGROUND: Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pomp inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD). Besides preventing reflux of gastric fluid and solid content, LARS may also impair the ability of the stomach to vent intragastric air (i.e. gastric belching) and induce gas-related complications, such as bloating and/or hyperflatulence. Furthermore, it was previously hypothesized that LARS induces a behavioral type of belching, not originating from the stomach, called supragastric belching. The aim of this study was to objectively evaluate the impact of LARS on gastric (GB) and supragastric belching (SGB) in children with GERD. METHODS: We performed a prospective, Dutch multicenter cohort study including 25 patients (12 males, median age 6 (range 2-18) years) with PPI-resistant GERD who were scheduled for LARS. Twenty-four-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after fundoplication. Impedance pH tracings were analyzed for reflux episodes and GBs and SGBs. KEY RESULTS: LARS reduced acid exposure time from 8.5% (6.0-16.2%) to 0.8% (0.2-2.8%), p < 0.001. The number of GBs also significantly decreased after LARS (59 [43-77] VS 5 [2-12], p < 0.001). The number of air swallows remained unchanged after LARS. SGBs were infrequent before LARS with no change in the number of SGB observed after the procedure. Postoperative belching symptoms were associated with GBs, not with SGBs. CONCLUSION & INFERENCES: LARS significantly reduces the number of GBs in children with GERD, whereas the number of air swallows remains unchanged. Postoperative symptomatic belching is associated with GBs, but not with SGBs. These findings suggest that LARS does not induce the occurrence of SGBs in children, but longer follow-up is required.

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 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.

A pregnant patient with excessive belching.

We present a patient that developed severe belching during pregnancy. Esophageal pH-impedance monitoring revealed frequent supragastric belching, but not gastroesophageal reflux disease (GERD). Thus, severe belching during pregnancy can be due to a behavioral disorder in the absence of GERD. Belching complaints during pregnancy should therefore not always be treated as GERD.