A Patient with Uncontrollable Belching: What to Do?

Aim. In this paper, we discuss the clinical significance of belching and present a clinical case with the description of the belching differential diagnosis.
Main findings. Belching may be either a physiological or a pathological phenomenon. Pathological belching requires an adequate diagnostic approach in order to clarify the nature of its occurrence. Gastric belching occurs reflexively at the moment of stomach stretching by excess air trapped during swallowing, which initiates the transient relaxation of the lower esophageal sphincter. As a consequence, the swallowed air escapes from the stomach first into the esophagus and then into the throat. Supragastric belching is a phenomenon, in which the air entering the esophagus does not reach the stomach, but rapidly returns to the throat. In this case, unlike aerophagia, the air entering the esophagus is not accompanied by the act of swallowing. Supragastric belching is not a reflex process; rather, it is considered to be a manifestation of behavioural disorders. 24-hour pH-impedancemetry and high-resolution esophageal manometry are highly informative methods for detecting various types of belching (gastric and supragastric), as well as their mechanisms. We present a clinical observation of a 47-year-old patient suffering from supragastric belching and treated by speech therapy under the supervision of a speech therapist.
Conclusion. 24-hour pH-impedancemetry and high-resolution esophageal manometry (also in combination with impedancemetry) provide a complete differential diagnosis of belching and allow the most effective patient management strategy to be selected.

1. Bredenoord A.J., Weusten B.L., Timmer R. et al. Relationships between air swallowing, intragastric air, belching and gastro-oesophageal reflux. Neurogastroenterol Motil. 2005;17:341–7.

2. Ivashkin V.T., Maev I.V., Trukhmanov A.S., Storonova O.A. et al. High resolution manometry and the new classification of esophageal motility disorders. Therapeutic Archive. 2018;05:93–100 (In Rus.).

3. Ten Cate L., Herregots T.V.K., Dejonckere P.H., Hemmink G.J.M. et al. Speech therapy as treatment for supragastric belching. Dysphagia. 2018;33(5):707–15.

4. Kessing B.F., Bredenoord A.J., Smout A.J. Mechanisms of gastric and supragastric belching: a study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2012;24(12):573–9.

5. Chitkara D.K., Bredenoord A.J., Rucher M.J. et al. Aerophagia in adults: a comparison with functional dyspepsia. Aliment Pharmacol Ther. 2005;22:855–8.

6. Karamanolis G., Triantafyiiou K., Tsiamoulos Z. et al. Effect of sleep on excessive belching: a 24-hour impedancepH study. J Clin Gastroenterol. 2010;44:332–4.

7. Bredenoord A.J. Management of belching, hiccups, and aerophagia. Clin Gastroenterol Hepatol. 2013;11:6–12.

8. Bredenoord A.J., Smout A. Physiologic and pathologic belching. Clin Gastroenterol Hepatol. 2007;5:772–5.

9. Roman S., Gyawali C.P., Savarino E. et al. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil. 2017;29:1–15.

10. Maev I.V., Barkalova E.V., Ovsepyan M.A., Kucheryavyy Yu.A. et al. Esophageal pHimpedance monitoring and high-resolution manometry in patients with various forms of gastroesophageal reflux disease. Therapeutic Archive. 2017;89(2):76–83 (In Rus.).

11. Kessing B.F., Bredenoord A.J., Smout A.J. The pathophysiology, diagnosis and treatmet of excessive belching symptoms. The Am J Gastroenterol. 2014;109(8):1196–203.

12. Barkalova E.V., Kucheryavyy Yu.A., Mayev I.V. High resolution manometry in the diagnosis of esophageal motility disorders. Medical Council. 2018;(5):104–10 (In Rus.).

13. Gyawali C.P. High resolution manometry: the Ray Clouse legacy. Neurogastroenterol Motil. 2012;24(Suppl 1):2–4.

14. Rohof W.O.A., Bredenoord A.J. Chicago Classification of Esophageal Motility Disorders: Lessons Learned. Curr Gastroenterol Rep. 2017;19(8):37.

15. Savarino E., de Bortoli N., Bellini M., Galeazzi F. et al. Practice guidelines on the use of esophageal manometry — A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis. 2016;48(10):1124–35.

16. Maev I.V., Barkalova E.V., Ovsepyan M.A., Kucheryavyi Yu.A. et al. High resolution esophageal manometry in clinical practice. Clinical Medicine (Russian Journal). 2017;95(12):1127–37 (In Rus.).

17. Kahrilas P., Bredenoord A., Fox M., Gyawali C. et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol. Motil. 2015;27:160–74.

18. Glasinovic E., Wynter E., Arguero J., Ooi J. et al. Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux. Am J Gastroenterol. 2018;113(4):539–47.