Series: "Disorders that upset us in gastroenterology"
We chose this title to define a particular set of conditions that are difficult to manage. According to the Dictionary of the Royal Academy, a disorder is defined as a “mild alteration in health” and the verb to upset means “to disturb or remove tranquility or peace.” Doctors are often disturbed by these conditions that, although not serious, greatly upset the patient and represent a frequent reason for consultation. In many cases we lack an effective treatment and the literature is insufficient to help us. The purpose of this guide is to know how far we have come in the study and treatment of these disorders, what experts think and what evidence-based medicine contributes.
Series index
- oral thrush
- burning mouth
- anal itching
- Prolonged hiccups
- Functional anorectal pain
- Belching
- balloon
- Halitosis
In each of them we will make an introduction where we will summarize the basics of current medical knowledge.
Excessive belching: the clinical problem
Excessive belching is a disorder frequently observed in clinical practice. It may occur as an isolated disorder or associated with dyspepsia or gastroesophageal reflux. Impedanciometry has shown that there are two types of belching:
- supragastric belch
- gastric belch
In the supragastric belch , air is swallowed and immediately eliminated before it reaches the stomach, often a second later. Generally, the patient is convinced that it is his stomach that is producing excess air that he must eliminate to get better and, indeed, when he burps he experiences improvement.
This leads him to swallow air again to increase the improvement. In these cases, the belching is usually repeated, frequent and often audible or excessively loud, altering the quality of life and leading to medical consultation.
Gastric belching is a consequence of a vagal reflex that allows the relaxation of the lower esophageal sphincter, releasing gastric air and is not usually a reason for consultation. It may be a temporary event associated with acute gastritis secondary to infectious agents or food intolerances.
Etiopathogenesis
Supragastric belching is a behavioral disorder
Impedanciometry has clearly demonstrated that supragastric belching is a behavioral disorder . It has become possible to monitor the passage of air through the esophagus in a prograde and retrograde direction.
In fact, it does not occur during sleep, although the patient usually reports that the belching appears as soon as he wakes up, according to his interpretation to eliminate what accumulated while sleeping. Furthermore, supragastric belching is reduced when the patient is distracted.
Another common clinical finding is that the patient does not belch while speaking . He burps when the doctor questions him, but not when he answers the questions asked by the professional.
In addition to the supragastric belch where air is swallowed and eliminated without reaching the stomach, there is the possibility that swallowed air reaches the stomach and is then eventually belched.
It has been proven that patients with Gastroesophageal Reflux (GERD) swallow air more frequently and belch more frequently than healthy individuals.
In studies with impedanciometry it was shown that there are two patterns, one in which the belching is secondary to aerophagia, causes and precedes the GER episode, and another in which the GER precedes the belch and would be the cause of it. Based on the latter, a therapeutic trial with PPI could be justified.
Physiological gastric belching is a protective mechanism that prevents excessive gastric distention. It occurs in almost all people at a rate of 30 belches in 24 hours. The intake of carbonated drinks obviously produces an increase in gastric air.
The inability to belch, as sometimes seen in fundoplication, causes discomfort of varying magnitude and may require the use of maneuvers to dilate the fundoplication.
Treatment
Sometimes the frequency of supragastric belching can be reduced by making the patient aware that the belching is self-induced . If the patient does not swallow, the belch disappears and to swallow air he has to keep his mouth closed at that moment. You can keep your mouth open by biting down on a pencil or making it difficult to swallow with your head in forced hyperextension or by holding a small cork in your mouth. This may be helpful for the patient to become aware that the belching is self-induced by aerophagia, but even accepting the origin of the belching, he may state that he cannot avoid doing so.
Perhaps in the future a biofeedback treatment could be used , but it is not something developed for now. However, taking into account that it is usually a behavioral disorder, positive results have been reported with cognitive behavioral therapy and also with hypnosis.
There is a report that reports a positive effect of baclofen, to reduce the number of belching, but the drug has central side effects that limit prolonged use. Since some patients may have belching secondary to GER, it would not seem inappropriate to try a trial treatment with PPIs.
Recommended readings
1) Keesing BF, Bredenoord AJ, Smout AJ The Pathophysiology, Diagnosis and Treatment of Excessive Belching Symptoms. Am J Gastroenterol 2014 Aug: 109 (8) 1196 - 203.
2) Supragastric Belching: Prevalence and Association With Gastroesophageal Reflux Disease. Koukias N, Woodland P, Etsuro Y, Sifrim D. J Neurogastroenterol Motil: 2015, Jul, 21(3). Published online 2015, Jul 3. doi: 10.5056jnm 1 15002.
3) Nikolaos Koukias, Philip Woodland, Etsuro Yazaki, Daniel Sifrim
J Neurogastroenterol Motil. 2015 Jul; 21(3): 398–403. Published online 2015 Jul 3. doi: .5056/jnm15002
