The first step in the clinical evaluation of the patient with excessive belching is a comprehensive history and physical examination. This helps to ensure that red flags for organic disorders, such as weight loss and dysphagia, do not exist and also to better understand the clinical pattern including the frequency and timing of belching [ 30 ].
Impedance monitoring is the gold standard in the diagnosis of belching and aerophagia and helps to identify the underlying cause of belching and to differentiate supragastric belching from gastric belching [ 29 , 31 ].
Impedance allows the presence and movement patterns of air in the esophagus. It helps to study belching by providing objective evidence of supragastric belching events. Intraluminal esophageal impedance monitoring is also helpful in the detection of esophageal transit of fluid boluses and gastroesophageal reflux. Gastric belching is characterized by an increase in impedance level starting in the distal channel and progressing to the most proximal channel Fig. Up to 13 events of supragastric belching in 24 h have been demonstrated to be physiologic in asymptomatic patients which considered as an upper limit of normal; we therefore assume this can go unnoticed in healthy subjects as well.
Patients with symptomatic supragastric belching have average of events in 24 h ranging from 7 to which is much higher even when compared to the patients with gastric belching [ 5 ]. In another study, on min impedance monitoring, the median number of belching events captured for patients with gastric belching was 1, compared with 36 for those with supragastric belching [ 9 ].
Gastric belching during liquid reflux episode. In this figure, impedance monitoring shows a decrease in impedance starting distally and moving in proximal direction blue arrow and an increase in impedance level starts during the liquid reflux episode spreading in proximal direction.
Supragastric belching. In this figure, the impedance monitoring shows an increase of impedance level form the proximal channel to the most distal impedance channel. High-resolution manometry HRM is not commonly recommended in diagnosis of supragastric belching, but if combined with impedance, monitoring helps to differentiate between supragastric belching, gastric belching, and rumination syndrome.
It also allows to distinguish the underlying manometric technique, air suction, or pharyngeal air pushing, although it is not clear if this helps treatment [ 30 ].
The keystone for treating patients with supragastric belching and gastric belching is a comprehensive clarification of the etiology of these symptoms which makes the patient aware that this is a behavioral disorder. It is often challenging for the patient to accept that there is no pathological explanation for their disease [ 1 ].
The most described effective treatment for supragastric belching is behavioral modification known as psychoeducation [ 32 ]. Speech therapy is the most described treatment in supragastric belching. A report by Ten Cate et al. In this method, an experienced speech pathologist provided care in ten sessions with average of 60 min for the first three sessions followed by 30 min of training for the remaining sessions.
The treatment gives the patients insight into the underlying behavioral problem related to excessive swallowing of air and strategies to tackle it. Abdominal breathing was also beneficial in the reduction of belching symptoms. In severe cases, patients were encouraged to retrain their breathing, while they put their finger between their mouth and breath by open mouth [ 33 ].
This technique should be practiced on a daily basis until the patients picks up the new habits. The previous study by Hemmink et al. Speech therapy has been tried differently in different studies. Riehl et al. Cognitive behavioral therapy CBT was also effective in the treatment of supragastric belching as shown in the study by Glasinovic et al.
In this interventional study, the severity of symptoms was assessed pre- and posttreatment. The intervention involved five CBT sessions which have three components: a cognitive part, a behavioral component, and an assessment of treatment and outcome.
In the first session, patients were separately assessed by gastroenterologist and psychologist, and the contributing psychosocial factors were identified. In the following sessions, the treatment was initiated with a focus on assisting the patient how to recognize the etiology of the disease, triggering factors and explanation of how treatment could improve their symptoms.
The critical component of CBT was to recognize the warning signs which most patients described as abnormal tension or uncomfortable pressure-like feeling in the retrosternal area just before the supragastric belching starts. Following this warning sign, they were encouraged to practice awareness training technique to stop belching with diaphragmatic breathing, mouth opening, and tongue positioning. The patients were assessed based on MII-pH pre- and posttreatment at 8 weeks. It was also effective in decreasing the esophageal acid exposure time in the patients with elevated acid exposure time at baseline and declining of mean VAS score from to CBT also decreased the frequency of supragastric belching and associated esophageal acid reflux, but it was not effective in reducing the frequency of gastric belching [ 36 ].
A randomized double-blinded placebo-controlled study was performed by Pauwels et al. Regurgitation was the main symptom in 16 patients; belching was predominant in 5. The patients were commenced on mg baclofen, three times a day for 2 weeks, and were then assessed by high-resolution manometry.
This study showed that baclofen significantly decreases the number of rumination episodes and the ratio of rumination to straining. However, it was not effective in the treatment of supragastric belching. In patients treated with baclofen, the pressure of postprandial lower esophageal sphincter was considerably higher than the placebo group which resulted in the reduction of the number of rumination symptoms.
Another study on a small number of patients revealed improvement in symptoms and reduction in postprandial flow events in patients with rumination and SBG who treated with baclofen [ 43 ]. In a study by Oor et al. This study showed that Toupet fundoplication and anterior fundoplication controlled reflux symptoms equally and resulted in a similar reduction in the number of belching and supragastric belching [ 44 ].
Belching is a common physiological symptom in general population which can happen isolated or associated with other gastrointestinal complains such as GERD, rumination syndrome, or functional dyspepsia. Impedance monitoring helped to better understand the pathophysiology of belching and to divide belching to gastric or supragastric belching based on its mechanism. Psychoeducation is considered as the most effective strategy for treatment of supragastric belching and consists of speech pathology and cognitive behavioral therapy.
Baclofen effectiveness in symptoms management varied in different studies, and it is recommended to use baclofen only if other treatment options failed. The pathophysiology, diagnosis and treatment of excessive belching symptoms. Am J Gastroenterol. PubMed Google Scholar.
Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease. Impaired health-related quality of life in patients with excessive supragastric belching. Eur J Gastroenterol Hepatol. Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings. Neurogastroenterol Motil. Supragastric belching: prevalence and association with Gastroesophageal reflux disease and esophageal Hypomotility.
J Neurogastroenterol Motil. Effect of sleep on excessive belching: a hour impedance-pH study. J Clin Gastroenterol. You can say belch instead of saying burp and vice versa. Both belch and burp are the process of passing out gas loudly from the stomach through the mouth.
One would normally belch or burp because they have eaten a lot of food or taken in a lot of beverage. While there no difference between the two, some say that technically there can be a slight difference between the two.
According to this school of thought, although both belch and burp involve the passing out of gas from the stomach through the mouth, there is a slight difference. Belching will only relieve discomfort associated with swallowing air, however. Aerophagia is the voluntary or involuntary swallowing of air. Swallowing excessive amounts of air can happen when eating or drinking too quickly. It can also occur when:.
Some foods and drinks can also cause more frequent belching. These include carbonated drinks, alcohol, and foods high in starch, sugar, or fiber that cause gas. Common culprits include:. A number of different medications may lead to belching or to disorders that cause belching.
These may include:. Some medical conditions may also include belching as a symptom. However, as belching is a natural response to abdominal discomfort, there must be other symptoms present to make a diagnosis. However, if belching becomes excessive, you should contact a medical professional to explore possible conditions that may be causing the problem. Adopting a knees-to-chest position can also be helpful. Hold the position until the gas passes. They may also ask you to keep a food diary for a few days.
This will help your doctor build a full picture of the problem, which will help them find the most likely solution. Your doctor may examine you physically and could order further tests such as abdominal X-rays or gastric emptying studies. Other tests include:. These will give your doctor a clear view of your digestive system, which will help them make a diagnosis.
You may also begin to experience other symptoms until the problem is diagnosed and treated.
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