the pathophysiology, diagnosis and treatment of · pdf filetric belch is the so-called...

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The American Journal of GASTROENTEROLOGY VOLUME 109 | AUGUST 2014 www.amjgastro.com

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INTRODUCTION Belching (eructation) can be defi ned as the oral expulsion of a

gas bolus from the upper gastrointestinal tract that can be audi-

ble or in some cases the eructation occurs silently. In most indi-

viduals, belching occurs as a physiological event and the belching

is not perceived as a symptom. However, some patients seek

medical attention because of excessive belching complaints or

complaints by those surrounding the patients. Although exces-

sive belching may appear as a rather harmless complaint at

fi rst, in these patients the belching is responsible for a decreased

quality of life ( 1 ).

Although excessive belching complaints in the general popu-

lation have not yet been systematically assessed, belching com-

plaints are reported by 50 % of the general population with

dyspeptic symptoms ( 2 ). Moreover, in this specifi c group, over

20 % of these patients experiences moderate-to-severe interfer-

ence with daily activities due to these belching complaints ( 2 ).

During the last decade, developments with regards to the tech-

nical capabilities of our research equipment, such as imped-

ance monitoring and high-resolution manometry, have greatly

enhanced our understanding of belching ( 3 ). Th is review aims

to describe our current understanding of patients with excessive

belching complaints.

PHYSIOLOGY OF BELCHING With each swallow, a variable volume of air is ingested and

transported to the stomach. Furthermore, the consumption of

carbonated beverages also results in an increase of gastric air.

During a belch, the accumulated intragastric air is vented into the

esophagus aft er which it can be orally expelled ( 4 ). Th is so-called

gastric belching occurs in almost every individual at an average

rate of 30 times / 24 h (ref. ( 5 )). Belching is therefore a physiologi-

cal mechanism that prevents the accumulation of excess gas in the

stomach or duodenum.

Manometric studies carried out in the 1980s have demon strated

that gastric belches occur mainly during spontaneous (not-swal-

low induced) transient relaxations of the lower esophageal sphinc-

ter (TLESR) ( 4,6,7 ) ( Figure 1 ). TLESRs are triggered by distention

of the stomach, such as caused by intragastric air, and allow

this air to be vented from the stomach into the esophagus ( 8 ).

Th ereaft er, the air in the esophagus quickly distends to the

proximal esophagus and triggers a second refl ex that causes

relaxation of the upper esophageal sphincter (UES), and the air in

the esophagus can be orally expulsed during which it is perceived

as a belch ( 9 ) ( Figure 2 ).

Several neurotransmitters that infl uence the rate of TLESRs

have been identifi ed of which gamma-aminobutyric acid is most

The Pathophysiology, Diagnosis and Treatment of Excessive Belching Symptoms Boudewijn F. Kessing , MD 1 , Albert J. Bredenoord , MD, PhD 1 and Andr é J.P.M. Smout , MD, PhD 1

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 refl ux 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 refl ex 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 refl ux 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. Am J Gastroenterol 2014; 109:1196–1203; doi: 10.1038/ajg.2014.165; published online 8 July 2014

1 Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam , Amsterdam , The Netherlands . Correspondence: Boudewijn F. Kessing, MD , Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam , Meibergdreef 9 , 1105 AZ Amsterdam , The Netherlands . E-mail: [email protected] Received 18 July 2013; accepted 18 April 2014

CME

© 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

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Excessive Belching Symptoms

TransientLES relaxation

UESrelaxation

Pressureincrease

Airoutflow

Stomach

Intragastricair

Airoutflow Closed

UES

Figure 2 . Mechanism of gastric belching. ( a ) Intragastric air triggers a transient lower esophageal sphincter relaxation (TLESR). ( b ) Gastric air fl ows into the esophagus. ( c ) Increased pressure in the proximal esophagus distends the proximal esophagus. ( d ) Relaxation of the upper esophageal sphincter (UES) results in air outfl ow from the esophagus into the oral cavity.

extensively investigated ( 10 ). Other relevant neurotransmitters

and receptors involved are metabotropic glutamate receptors, can-

nabinoid receptor 1, nitric oxide and cholecystokinin (11 – 13) .

PATHOPHYSIOLOGY Isolated excessive belching Since the early 1990s, the presence of air in the esophagus can

be detected using esophageal electrical impedance monitoring.

Intraluminal esophageal impedance monitoring is based on the

concept of measuring the resistance / impedance encountered by

an alternating electric current that is generated between pairs of

electrodes mounted on a non-conductive catheter. Th e technique

was primarily developed not only for the detection of esophageal

transit of fl uid boluses and gastroesophageal refl ux but also for

studying belching. Th e conductivity of air is almost infi nitely low,

and the presence of air between the electrodes therefore results in

a high impedance level. Placement of a series of electrodes along

the catheter also enables one to evaluate the direction of airfl ow

through the esophagus. Th erefore, gastric belching can be recog-

nized with impedance monitoring as an increase in impedance

level starting in the distal channel and progressing to the most

proximal channel ( Figure 3 ).

With the use of esophageal impedance monitoring, a diff erent

type of belch was identifi ed in patients with isolated excessive

belching (14) ( Figure 4 ). During this second type of belch, air is

rapidly brought into the esophagus and immediately followed by

a rapid expulsion. As, with this second type of belch, the air nei-

ther originates from the stomach nor does it reach the stomach, it

has been referred to as supragastric belching. A recent study from

our center that incorporated the use of combined high-resolution

manometry and impedance monitoring has further elucidated two

200

180

160

140

120

100

80

60

40

200

(mm Hg)

UES

LES

2 s

Figure 1 . An example of a gastric belch during a transient lower esopha-geal sphincter (LES) relaxation as measured by combined high-resolution manometry and impedance measurement. The continuous high-pressure zone of the LES is temporarily interrupted during relaxation to allow venting of gas from the stomach into the esophagus. The dotted arrow indicates the direction of airfl ow. The continuous high-pressure zone of the upper esophageal sphincter (UES) is temporarily interrupted after the infl ux of air in the esophagus. The white line represent impedance channels, and the gastric belch is characterized by an increase in impedance level starting in the distal channel and progressing to the most proximal channel.


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( 16 ). Patients with severe and frequent belching oft en describe

that their belches initially started with bloating or a bothersome

sensation in the stomach. Th erefore, their belching behavior

might have started as a deliberate attempt to reduce symptoms.

In a later stage, the patient is no longer aware of the fact that

mechanisms by which a supragastric belch can be induced ( 15 ).

Th e fi rst and most common mechanism resulting in a supragas-

tric belch is the so-called air-suction method that is characterized

by a movement of the diaphragm in aboral direction ( Figures 5

and 6 ). Th e latter results in a negative intra-thoracic pressure as

would occur during deep inspiration ( 14 ). However, during a

supragastric belch, UES relaxation occurs during which the glot-

tis is closed and air therefore fl ows from the atmospheric pressure

in the pharynx to the subatmospheric pressure in the esophagus.

Th ereaft er, the esophageal air is immediately expulsed orally as

a result of straining that is perceived by the patient as a belch.

Notably, UES relaxation during supragastric belching occurs

before the infl ux of air in the esophagus in contrast to gastric

belching during which UES relaxation is a late event in response

to the infl ux of air. Moreover, as the driving force behind the

air infl ow during supragastric belching is a pressure gradient,

the air fl ows into the esophagus much faster than would occur

during air swallowing in which the driving force is esophageal

peristalsis ( Figure 7 ).

Some individuals with supragastric belching do not use the

air-suction method to bring air into the esophagus but use what

has been labeled the air-injection method, characterized by a

simultaneous pressure increase in the pharynx initiating the infl ux

of air into the esophagus ( 14 ). In this mechanism, the driving

force behind the infl ux of air is the pressure gradient between the

elevated pharyngeal pressure and unchanged intra-esophageal

pressure. As the increase in pharyngeal pressure occurs simultane-

ously at all pharyngeal levels, it is most likely caused by a contrac-

tion of the base of the tongue and not a peristaltic contraction of

the pharynx. Also, this contraction is not followed by a peristaltic

wave in the esophageal body, in contrast to peristaltic contractions

of the pharynx that usually are followed by esophageal peristalsis.

It has been suggested that supragastric belching may start as

a voluntary response to an unpleasant gastrointestinal sensation

15,000 Ω

0.5 s

Proximal

Gas

Distal

Figure 3 . Gastric belching as measured by impedance monitoring is characterized by an increase in impedance level starting in the distal chan-nel and progressing to the most proximal channel. Thereafter, the air is cleared from the esophagus in oral direction that is seen in the impedance signals as a return to the baseline level, starting in the most distal channel and progressing to the proximal channel. Arrows indicate the direction of airfl ow.

15,000 Ω

0.5 s

Proximal

Gas

Distal

Figure 4 . Supragastric belching as measured by impedance monitoring is characterized by an increase in impedance level starting in the proximal impedance channel and progressing to the most distal impedance chan-nel. Thereafter, the air is cleared from the esophagus in oral direction that is seen in the impedance signals as a return to the baseline level, starting in the most distal channel and progressing to the proximal channel. Arrows indicate the direction of airfl ow.

UES190

165

140

115

90

65

40

15

–10

(mm Hg)LES 2 s

Figure 5 . Example of a supragastric belch as measured by combined high-resolution manometry and impedance monitoring. The continu-ous high-pressure zone at the position of the lower esophageal sphincter (LES) moves in aboral direction due to a contraction of the diaphragm. Simultaneously, a subatmospheric pressure in the esophagus is observed and the continuous high-pressure zone of the upper esophageal sphincter (UES) is interrupted that allows the infl ux of air from the pharynx into the esophagus. The dotted arrows indicate the direction of airfl ow. The white lines represent impedance signals. The supragastric belch is characterized by an increase in impedance, starting in the proximal impedance channel, and progressing to the most distal impedance channel and followed by a return to baseline, starting in the most distal channel and progressing to the proximal channel.


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supragastric belches in patients with GERD respond to any form of

behavioral therapy. Th e majority of studies that assessed the eff ect

of proton pump inhibitor therapy on belching in patients with

GERD have shown a decrease in belching complaints (24 – 27) . How-

ever, in clinical practice, patients with GERD who are not already

15,000 Ω

1 s

Proximal

Gas

Distal

Figure 7 . Air swallowing as identifi ed by impedance monitoring is charac-terized by an increase in impedance starting in the proximal impedance channel and progressing to the most distal impedance channel. Thereaf-ter, the air is cleared from the esophagus and enters the stomach as char-acterized by a return to baseline impedance level, starting in the proximal channel and progressing to the most distal channel. As the driving forces determining the airfl ow in the esophagus during swallowing is esophageal peristalsis, air fl ows slower than would occur during a supragastric belch.

the belches are under his or her voluntary control. Karamanolis

et al. ( 17 ) demonstrated that supragastric belches do not occur

during sleep, corroborating the notion that supragastric belch-

ing is a voluntary behavior. Moreover, it has been shown that

the frequency of supragastric belches decreases while a patient

is distracted, which suggests that psychological factors such

as stress could have a role in the pathophysiology of excessive

belching ( 18 ). Furthermore, a deliberate belch is oft en observed

in healthy individuals, further suggesting that belching can be a

learned behavior.

Notably, excessive belching is oft en reported during pregnancy

( 19 ). Although belching during pregnancy is oft en considered to

be a symptom of gastroesophageal refl ux disease (GERD) ( 20 ),

a recent report demonstrated that isolated belching complaints

that develop during pregnancy can also be due to supragastric

belching rather than due to GERD ( 21 ). Th e latter further con-

fi rms the theory that supragastric belching can start as a response

to fi nd relief in a sensation of fullness.

Belching in patients with GERD In patients with GERD, belching is common with the symptom

being reported by 40 – 49 % of these patients (22) . Hemmink

et al. ( 16 ) demonstrated that most of the belches that occur in a

large subgroup of patients with GERD are supragastric in nature.

Moreover, it was shown that the burden of belching complaints

in patients with GERD is caused by supragastric belches but not

by gastric belches (23) . Th us far, no study has assessed whether

Stomach

ClosedLES

Diaphragmcontraction

UESrelaxation

Closedglottis

Atmosphericpressure

Negativepressure

Air outflow

Pressureincrease

Air inflow

Negativepressure

Figure 6 . Mechanism of supragastric belching. ( a ) Contraction of the diaphragm results in a negative pressure in the esophagus. ( b ) During relaxation of the upper esophageal sphincter (UES) air fl ows from the atmospheric pressure in the pharynx to the negative pressure in the esophagus. ( c ) The esopha-gus is fi lled with air but the air does not enter the stomach. ( d ) Pressure in the esophagus and abdomen increases and air is forced out of the esophagus into the oral cavity. LES, lower esophageal sphincter.


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Kessing et al.

and can cause symptoms of regurgitation (33,34) . Th ese fi ndings

suggest that supragastric belching underlies rumination episodes

in a subgroup of patients. Th erefore, in patients with symptoms of

belching and regurgitation, supragastric belch-induced rumina-

tion should be considered.

Belching in the pediatric population Excessive belching can also occur in children (35,36) . However,

no studies have been performed to assess the relationship between

complaints and objectively identifi ed abnormalities such as supra-

gastric belching or increased air swallowing. Moreover, there are

currently no proven therapeutic options for belching disorders in

children. Th erefore, more research is warranted to determine eti-

ology and treatment of belching complaints in children.

Aerophagia Clinicians oft en confuse supragastric belching with aerophagia.

Aerophagia is a disorder characterized by increased swallowing

of air that results in increased volumes of intragastric and intrain-

testinal gas, which can be observed during an abdominal X-ray.

Patients with aerophagia seldom complain of excessive belching,

instead their main complaint is abdominal bloating and abdomi-

nal distension (37) .

DIAGNOSIS Studies from our center have demonstrated that patients present-

ing with excessive belching have a similar frequency of gastric

on a stable dose of proton pump inhibitor are rare, and the clinical

relevance of proton pump inhibitor treatment in GERD patients

with belching complaints appears to be modest.

Recently, a novel type of refl ux mechanism that is characterized

by a supragastric belch immediately preceding a refl ux episode has

been identifi ed ( Figure 8 ) (16,23) . Th e observations suggest that in

a subgroup of patients with GERD, supragastric belches can induce

refl ux episodes. However, more research is needed to study this

phenomenon in detail and to determine whether or not supragas-

tric belch-associated GERD deserves recognition as a subtype of

GERD. Th eoretically, patients with this subtype of GERD can be

treated with behavioral therapy.

Belching in patients with functional dyspepsia Belching is also common in patients presenting with other func-

tional upper gastrointestinal complaints (28) . However, only one

study has been performed that specifi cally assessed gas fl ow events

in patients with functional dyspepsia using impedance monitor-

ing. Conchillo et al. (29) observed that gas refl ux episodes occur

more frequently in patients with functional dyspepsia. Unfortu-

nately, the number of patients in this study was limited and the

authors did not search for supragastric belching in these patients.

Moreover, it was not reported whether these patients with func-

tional dyspepsia experienced troublesome belching.

Belching and the rumination syndrome Th e rumination syndrome is a functional gastroduodenal disor-

der that is characterized by persistent or recurrent regurgitation

of recently ingested food into the mouth 30 . Rumination episodes

are induced by a rise in intra-gastric pressure that is generated by

a voluntary, but oft en not intentional, contraction of the abdomi-

nal wall musculature (31,32) . Recently, a subgroup of patients

with the rumination syndrome has been identifi ed who exhibit a

typical behavior that is characterized by a supragastric belch that

is immediately followed by a quick rise in intragastric pressure

( Figure 9 ). Th e latter forces gastric content into the esophagus

15,000 Ω

ProximalGas

Drop in pH

2 s

Distal

pH 7

pH 4

Reflux

pH <4

Figure 8 . Example of a refl ux episode that is immediately preceded by a supragastric belch as measured by combined pH-impedance monitoring. The impedance level after the supragastric belch is > 50 % lower than before the supragastric belch, indicating that the supragastric belch coin-cided with the onset of the refl ux episode. Arrows indicate the direction of airfl ow or the refl uxate.

190

Reflux150

110

70

30

–10

(mm Hg)

Figure 9 . Example of a supragastric belch-induced rumination episode as measured by combined high-resolution manometry and impedance monitoring. The supragastric belch is followed by a forceful expulsion of the esophageal air during which the pressure in the stomach overcomes the pressure of the lower esophageal sphincter, and gastric content fl ows from the stomach into the esophagus. The impedance level during the forceful expulsion of air is > 50 % lower than before the supragastric belch, indicating that gastric content has simultaneously entered the esophagus.


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belches but an increased number of supragastric belches. Th ere

seems to be no exception to the rule that patients with complaints

of excessive belching have their complaints due to supragastric

belches.

Supragastric belching can oft en be diagnosed without invasive

investigations if a patient exhibits excessive, repetitive belching

during a consultation. Other classical clinical features of supra-

gastric belching involve the absence of belches during speaking.

Typically, a patient belches while the physician is asking ques-

tions, whereas a patient does not belch while responding to these

questions.

Repetitive belching is a phenomenon that is oft en observed in

patients with supragastric belching. Studies during which air was

insufl ated into the stomach have demonstrated that even large

amounts of air can be vented during a single gastric belch, thereby

rendering rapid repetitive gastric belching unlikely to occur (29) .

Th e last typical feature of supragastric belching is that the fre-

quency of supragastric belches decreases when a patient is actively

distracted ( 18 ).

Although a thorough history and clinical observation can oft en

identify patients with supragastric belching, the gold standard

for the diagnosis is impedance monitoring (38) . Th is technique

allows a diff erentiation between gastric belching and supragastric

belching, thus enabling identifi cation of the cause of the belching

complaints. Moreover, during ambulatory monitoring , patients

can report symptomatic belches, thereby allowing the clinician to

pinpoint specifi c belch events and determine the type of belch that

causes the belching complaints of a patient. Notably, impedance

monitoring during a 90-min period also identifi es supragastric

belches in the majority of patients with excessive belching (15) .

Th erefore, one could suggest that impedance monitoring during a

short period of time can also identify the cause of the complaints.

However, no study has yet assessed the optimal period of imped-

ance monitoring in the diagnostic work-up of excessive belching,

and 24-h ambulatory impedance monitoring therefore remains

the diagnostic modality of choice, also because it allows diff eren-

tiation with GERD.

Impedance monitoring has also been used in patients with

aerophagia and an increased frequency of air swallowing was

observed in these patients but no supragastric belches (37) . Th ere-

fore, it has been suggested that impedance monitoring can also aid

in the diagnostic work-up of patients with suspected aerophagia.

TREATMENT Th e cornerstone of treatment in patients with bothersome

supragastric belching is a thorough explanation of the underly-

ing mechanism. In our experience, patients oft en expect that an

organic cause for their disease can be found, and may be reluc-

tant to accept that their complaints are due to abnormal behavior.

Impedance monitoring, therefore, not only aids in the diagnosis

but also provides an indisputable confi rmation of the underlying

behavioral disorder.

As supragastric belching is a behavioral disorder, behavioral ther-

apy is the therapy of choice. Hemmink et al. (39) demonstrated

that behavioral therapy in the form of speech therapy reduces

symptoms in patients with excessive belching (39) . Until today, we

still use the same protocol in our center to treat patients with

supragastric belching. Th e fi rst step of our treatment protocol con-

sists of a description of the behavior that underlies the sucking or

injection of air into the esophagus. Th ereaft er, the patient is trained

to refrain from this behavior and to acquire a fl uent breathing pat-

tern. Th e latter is practiced by conventional breathing and vocal

exercises that can vary between diff erent speech therapists, but

as the diaphragm is the cause of supragastric belches in the major-

ity of patients, the applied behavioral therapy should rely heavily

on abdominal breathing exercises. If no speech therapist is avail-

able to perform breathing exercises, one can also learn abdomi-

nal breathing exercises to the patient by placing a hand on the

abdomen during respiration and explaining that the hand on the

abdomen should move with breathing. As early as possible, during

the behavioral therapy, attention on belching is moved to atten-

tion on the behavior underlying their belching and this cognitive

process is considered as an important aspect of the therapy. In our

experience, 10 sessions of behavioral therapy is oft en suffi cient to

provide a signifi cant decrease in belching complaints, although in

some patients 20 sessions was needed to provide optimal decrease

in complaints. Even though behavioral therapy can greatly ben-

efi t patients, speech therapists need to be well informed about the

mechanism underlying supragastric belching in order to provide

optimal treatment. Until today, the eff ect of behavioral therapy

has not yet been assessed objectively by means of impedance

monitoring. Th erapy has also not been standardized: a variety

of behavioral therapies are being used. Th erefore, further studies

that assess the objective outcomes of diff erent types of behavioral

therapy have to be awaited before the optimal treatment strategy

for supragastric belching can be decided upon.

A recent study by Blondeau et al. (40) assessed the eff ect of baclofen

on the frequency of supragastric belches. Th e authors observed a

signifi cant decrease in the number of so-called fl ow events, defi ned

as the total of all rumination events, refl ux events, air swallows, and

supragastric belches. It should be noted that only two of the patients

presented with belching as the predominant symptom. Obviously,

more extensive research on the eff ect of baclofen in patients with

supragastric belching is needed, as well as the long-term eff ects of

the application of baclofen in patients with belching symptoms.

Furthermore, baclofen has many central side eff ects that limit the

long-term use in patients with excessive belching.

Th ere are currently no studies in which treatment modalities in

patients with belching induced rumination are evaluated. How-

ever, as supragastric belching and the rumination syndrome both

respond favorably to behavioral therapy, it is the current treatment

of choice for these patients ( 39,41 ).

DISCUSSION Belching is a common symptom in adults and children. It can

occur as an isolated symptom or as part of the spectrum of com-

plaints in patients with GERD or functional dyspepsia. During

the last decade, the use of esophageal impedance monitoring in


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8 . Martin CJ , Patrikios J , Dent J . Abolition of gas refl ux and transient lower esophageal sphincter relaxation by vagal blockade in the dog . Gastroenterology 1986 ; 91 : 890 – 6 .

9 . Lang IM , Medda BK , Jadcherla SR et al. Th e role of the superior laryn-geal nerve in esophageal refl exes . Am J Physiol Gastrointest Liver Physiol 302 : G1445 – 57 .

10 . Lidums I , Lehmann A , Checklin H et al. Control of transient lower esophageal sphincter relaxations and refl ux by the GABA(B) agonist baclofen in normal subjects . Gastroenterology 2000 ; 118 : 7 – 13 .

11 . Frisby CL , Mattsson JP , Jensen JM et al. Inhibition of transient lower esophageal sphincter relaxation and gastroesophageal refl ux by metabotropic glutamate receptor ligands . Gastroenterology 2005 ; 129 : 995 – 1004 .

12 . Partosoedarso ER , Abrahams TP , Scullion RT et al. Cannabinoid1 receptor in the dorsal vagal complex modulates lower oesophageal sphincter relaxation in ferrets . J Physiol 2003 ; 550 : 149 – 58 .

13 . Hirsch DP , Holloway RH , Tytgat GN et al. Involvement of nitric oxide in human transient lower esophageal sphincter relaxations and esophageal primary peristalsis . Gastroenterology 1998 ; 115 : 1374 – 80 .

14 . Bredenoord AJ , Weusten BLAM , Sifrim D et al. Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring . Gut 2004 ; 53 : 1561 – 5 .

15 . Kessing BF , Bredenoord AJ , Smout AJPM . Mechanisms of gastric and supragastric belching: a study using concurrent high-resolution manometry and impedance monitoring . Neurogastroenterol Motil 2012 ; 24 : e573 – 579 .

16 . Hemmink GJM , Bredenoord AJ , Weusten BLAM et al. Supragastric belching in patients with refl ux symptoms . Am J Gastroenterol 2009 ; 104 : 1992 – 7 .

17 . Karamanolis G , Triantafyllou K , Tsiamoulos Z et al. Eff ect of sleep on excessive belching: a 24-hour impedance-pH study . J Clin Gastroenterol 2010 ; 44 : 332 – 4 .

18 . Bredenoord AJ , Weusten BLAM , Timmer R et al. Psychological factors aff ect the frequency of belching in patients with aerophagia . Am J Gastroenterol 2006 ; 101 : 2777 – 81 .

19 . Keller J , Frederking D , Layer P . Th e spectrum and treatment of gastroin-testinal disorders during pregnancy . Nat Clin Pract Gastroenterol Hepatol 2008 ; 5 : 430 – 43 .

20 . Rey E , Rodr í guez-Artalejo F , Herraiz MA et al. Atypical symptoms of gastro-esophageal refl ux during pregnancy . Rev Esp Enferm Dig 2011 ; 103 : 129 – 32 .

21 . Kessing BF , Bredenoord AJ , Smout AJPM . A pregnant patient with excessive belching . Dis Esophagus , advance online publication, 16 April 2013; doi:10.1111/dote.12076 (e-pub ahead of print) .

22 . Klauser AG , Schindlbeck NE , M ü ller-Lissner SA . Symptoms in gastro-oesophageal refl ux disease . Th e Lancet 1990 ; 335 : 205 – 8 .

23 . Kessing BF , Bredenoord AJ , Velosa M et al. Supragastric belches are the main determinants of troublesome belching symptoms in patients with gastro-oesophageal refl ux disease . Aliment Pharmacol Th er 2012 ; 35 : 1073 – 9 .

24 . Kahrilas P , Miner P , Johanson J et al. Effi cacy of Rabeprazole in the treatment of symptomatic gastroesophageal refl ux disease . Dig Dis Sci 2005 ; 50 : 2009 – 18 .

25 . Miner P . Rabeprazole in nonerosive gastroesophageal refl ux disease: a randomized placebo-controlled trial . Am J Gastroenterol 2002 ; 97 : 1332 – 9 .

26 . Gerson LB , Kahrilas PJ , Fass R . Insights into gastroesophageal refl ux disease – associated dyspeptic symptoms . Clin Gastroenterol Hepatol 2011 ; 9 : 824 – 33 .

27 . Kriengkirakul C , Patcharatrakul T , Gonlachanvit S . Th e therapeutic and diagnostic value of 2-week high dose proton pump inhibitor treatment in overlapping non-erosive gastroesophageal refl ux disease and functional dyspepsia patients . J Neurogastroenterol Motil 2012 ; 18 : 174 – 80 .

28 . Lin M , Triadafi lopoulos G . Belching: dyspepsia or gastroesophageal refl ux disease? Am J Gastroenterol 2003 ; 98 : 2139 – 45 .

29 . Conchillo JM , Selimah M , Bredenoord AJ et al. Air swallowing, belching, acid and non-acid refl ux in patients with functional dyspepsia . Aliment Pharmacol Th er 2007 ; 25 : 965 – 71 .

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patients complaining of excessive belching has resulted in many

new insights in the etiology and pathophysiology.

Currently, only two studies have assessed the eff ect of treat-

ment in patients with supragastric belching, and these studies only

included small numbers of patients or lacked objective outcomes.

Furthermore, there are no data yet on the eff ect of treatment of

supragastric belching in patients with GERD, rumination, or func-

tional dyspepsia. Moreover, research on the etiology and treatment

of complaints of belching in children is lacking. However, the clini-

cal presentation of belching complaints in children appears to be

similar to adults, and one could therefore hypothesize an impor-

tant role for supragastric belching as well.

In conclusion, supragastric belching appears to be the most

important factor in the etiology of excessive belching complaints,

and the available information indicates that this disorder can be

treated with behavioral therapy. Additional studies, such as those

assessing the eff ect of behavioral therapy in patients with GERD,

rumination, or functional dyspepsia and determining the patho-

physiology of excessive belching in children, are needed.

ACKNOWLEDGMENTS We would like to thank Inge Kos-Oosterling, medical illustrator

AMC, for her help with creating the artwork of this paper.

CONFLICT OF INTEREST Guarantor of the article: Andr é J.P.M. Smout, MD, PhD.

Specifi c author contributions: Draft ing of the manuscript and

approval of fi nal submitted draft : B.F. Kessing; and critical revision

of the manuscript for important intellectual content and approval of

fi nal submitted draft : A.J. Bredenoord and A.J.P.M. Smout.

Financial support: A.J. Bredenoord is supported by Th e Nether-

lands Organization for Scientifi c Research (NWO).

Potential competing interests: A.J. Bredenoord has been a consult-

ant and honoraria recipient for AstraZeneca, has received grant

funding from Shire, and payment for development of educational

presentations from MMS International. Th e remaining authors

declare no confl ict of interest.

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2 . Piessevaux H , De Winter B , Louis E et al. Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings . Neurogastroenterol Motil 2009 ; 21 : 378 – 88 .

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4 . Wyman JB , Dent J , Heddle R et al. Control of belching by the lower oesophageal sphincter . Gut 1990 ; 31 : 639 – 46 .

5 . Bredenoord AJ , Weusten BL , Timmer R et al. Air swallowing, belching, and refl ux in patients with gastroesophageal refl ux disease . Am J Gastroenterol 2006 ; 101 : 1721 – 6 .

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7 . Kessing BF , Conchillo JM , Bredenoord AJ et al. Review article: the clinical relevance of transient lower oesophageal sphincter relaxations in gastro-oesophageal refl ux disease . Aliment Pharmacol Th er 2011 ; 33 : 650 – 61 .


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32 . Rommel N , Tack J , Arts J et al. Rumination or belching-regurgitation? Diff erential diagnosis using oesophageal impedance-manometry . Neuro-gastroenterol Motil 2010 ; 22 : e97 – 104 .

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GASTROENTEROLOGY ARTICLE OF THE WEEK January 29, 2015

Kessing B, Bredenoord AJ, Smout AJ. The pathophysiology, diagnosis and treatment of excessive belching symptoms. Am J Gastroenterol 2014;109:1196-1203 1. Characteristic of supragastric belching include

a. Often takes place during the office visit, while the physician speaks, never when the patient is speaking

b. Does not occur when the patient is sleeping or distracted c. Cannot be diagnosed with impedance testing d. When triggered by GERD, usually resolves with PPI therapy True or False 2. Supragastric belching is caused by aerophagia 3. Belching typically occurs during episodes of spontaneous transient lower esophageal sphincter relaxation (TLESRs) 4. Belching or air in the esophagus is recognized on impedance testing as increased impedance 5. Supragastric belching is triggered by swallowing air and is an acquired condition 6. Belching is common in GERD, most belches are not supragastric 7. Excessive belching during the clinic visit (by the patient, not the physician), is diagnostic of supragastric belching 8. Impedance testing in supragastric belching will show a rise in impedance progressing from UES to the distal esophagus, followed by reverse movement of the high impedance wave towards the UES

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