"I've never been able to burp": Preliminary description of retrograde cricopharyngeal dysfunction in children

Inability to belch syndrome: what the gastroenterologist needs to know

PURPOSE OF REVIEW

To review recent publications on the inability to belch syndrome.

RECENT FINDINGS

Five recent retrospective case series indicate that the inability to belch syndrome usually starts in early childhood and is often accompanied by gurgling noises in the chest, pain in the chest or upper abdomen, bloating, and excessive flatulence. Currently, the vast majority of patients who have been identified with inability to belch have self-diagnosed the syndrome on the basis of information available on the internet. A favorable response to injection of botulinum toxin in the cricopharyngeus muscle is regarded as confirmation of the diagnosis. In a mechanistic study in eight patients, absence of reflexogenic relaxation of the upper esophageal sphincter upon rapid gaseous esophageal distension was confirmed to play a pivotal role in the pathogenesis of the syndrome.

SUMMARY

The inability to belch syndrome, caused by failure of the upper esophageal sphincter to relax when the esophageal body is distended, clearly exists and may not be as rare as thought hitherto. However, overdiagnosis is also likely to occur because the diagnosis is usually made on the basis of symptoms only. The efficacy of botulinum toxin injection in the upper sphincter needs to be assessed in double-blind placebo-controlled studies.

Botulinum Toxin Injection for Retrograde Cricopharyngeal Dysfunction: A Prospective Cohort Study

OBJECTIVES

Retrograde Cricopharyngeal Dysfunction (RCPD) is treated by botulinum toxin (BTX) injection into the cricopharyngeus. This prospective study compares the effectiveness and side effects of operating room (OR) and in-office (IO) injections.

METHODS

Patients over 18 years of age with inability to burp, abdominal, thoracic, or cervical gurgling sounds, bloating, and excessive flatulence were diagnosed with RCPD and included in the study. Injections were performed in the OR (80U) or IO (30U) by the senior author. An RCPD questionnaire quantifying major and minor symptoms on a Likert scale, Eating Assessment Tool-10 (EAT-10), and Generalized Anxiety Score-7 (GAD-7), were completed preinjection; at 1, 2, and 3 weeks; and 3 months postoperatively. Linear mixed models were used to analyze effects of BTX injection on RCPD symptoms, the EAT-10, and the GAD-7.

RESULTS

108 (55 M/53F) patients completed the pretreatment survey, 53 (31 OR vs. 22 IO) completed the 3-week follow-up, and 36 (22 OR vs. 14 IO) completed the 3-month questionnaire. Average posttreatment RCPD scores were significantly lower in both groups at 3 weeks and 3 months (p < 0.0001), There was no difference between IO or OR (p = 0.4924). GAD-7 scores were significantly lower in both groups at week 3 (p = 0.0018) and month 3 (p = 0.0012). Postinjection EAT-10 scores were significantly higher in OR compared with IO (p = 0.0379).

CONCLUSION

OR and IO injections are equally effective in the treatment of RCPD. Postinjection dysphagia is more severe after the OR injections which may be related to higher doses of BTX used. General anxiety levels decrease with treatment.

LEVEL OF EVIDENCE

2 Laryngoscope, 2024.

Experiences of Patients Living with Retrograde Cricopharyngeal Dysfunction

OBJECTIVES

Retrograde cricopharyngeal dysfunction (RCPD) is a newly described condition resulting from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension that results in the inability to burp. Patients' perspectives on symptom experiences, barriers to care, and treatment benefits were investigated.

STUDY DESIGN

Qualitative semi-structured interviews were conducted with patients diagnosed with RCPD who had been treated with botulinum toxin injection into the cricopharyngeus muscle. Interview questions centered on their experience living with RCPD. Conventional content analysis was performed on interview transcripts.

RESULTS

Thematic saturation was reached with 13 participants. All participants were diagnosed with RCPD by an otolaryngologist and underwent botulinum toxin injection into the cricopharyngeus muscle with or without dilation of the upper esophageal sphincter in the operating room. Participants described having no memories of ever being able to burp, and all started experiencing RCPD symptoms during adolescence. Patients with RCPD experienced increased social isolation, lost productivity, and worsened mental health. Unanimously, participants first learned about RCPD on social media. All patients were seen by physicians in non-otolaryngology specialties regarding their symptoms prior to learning about their RCPD diagnosis and undergoing treatment by an otolaryngologist. Dilation and chemodenervation resulted in complete resolution of RCPD symptoms for 84.6% of participants. Participants emphasized a desire for more health providers to learn about RCPD and the impact it has on quality-of-life.

CONCLUSION(S)

The lived experience of patients with RCPD significantly impacts quality of life and is often met with diagnostic barriers in the medical community. Although social media plays a significant role in increasing awareness of RCPD, physician education about the impact of RCPD is essential to improve diagnosis and treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2136-2143, 2024.

Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry

OBJECTIVES

The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD.

METHODS

Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features.

RESULTS

We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle.

CONCLUSIONS

Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Retrograde cricopharyngeal dysfunction and treatment with botulinum toxin: a systematic review

PURPOSE

Retrograde cricopharyngeal dysfunction (RCPD) is a disease first described systematically in 2019. The main symptom is inability to belch due to cricopharyngeal muscle dysfunction. Other symptoms include gurgling noises, chest pain, bloating, and excessive flatulence. This paper aims to describe RCPD, the aetiology and diagnosis, treatment options, follow-up, and treatment with botulinum toxin (BT).

METHODS

A systematic review was done according to the PRISMA guidelines, using the databases PubMed, Embase, and Cochrane at 8/3/2024. The search combined BT with different descriptions of RCPD. All papers were screened by two authors.

RESULTS

120 papers were identified in the search. After screening 13 papers describing 472 patients in total were included. Mean age was 29.3 years with 51.1% men. Diagnosis was established in 82.4% of the cases by symptomatology, 2.1% by high-resolution manometry, and 15.3% by oesophagoscopy. The mean amount of BT was 66 units (U). Mean follow-up time was 13 months. After 1-4 weeks 93.7% had an effect post-treatment and 81.0% after 6 months. Common symptoms were inability to belch (99.8%), chest pain and/or bloating (95.4%), gurgling noises (84.9%), and excessive flatulence (75.9%). Common complications were mild and transient dysphagia (59.4%) and reflux (35.4%).

CONCLUSION

The accumulated numbers of patients with RCPD indicates a growing attention to the plausible condition. Injection with BT is a good and safe treatment of RCPD. Most patients only experience mild and transient complications to the treatment. Much is still unknown about RCPD and conditions for setting the diagnosis needs to be evaluated and established internationally.

Retrograde cricopharyngeus dysfunction: How does the inability to burp affect daily life?

BACKGROUND

Retrograde cricopharyngeus dysfunction (R-CPD), a condition first detailed in 1987 and termed in 2019, refers to the cricopharyngeal muscle's inability to relax to allow the retrograde passage of gas. Limited research exists on the fundamental characteristics of this condition, including its impact on one's life. The purpose of this study is to characterize R-CPD and how the inability to burp affects the social lives of people who suffer from it.

METHODS

A Qualtrics survey was distributed on the subreddit "r/noburp," a community of 26,000 individuals sharing information about R-CPD. Adults aged 18-89 experiencing R-CPD symptoms were invited to participate. Participants reported on their experiences with R-CPD and its effects on social life on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Data was analyzed using descriptive statistics.

KEY RESULTS

Among the 199 respondents, the mean age was 30.9, and gender identity was 74%/25% female/male. 99% reported inability to burp, 98% reported abdominal bloating, 93% reported socially awkward gurgling noises, 89% reported excessive flatulence, and 55% reported difficulty vomiting. Only half discussed their symptoms with their primary care provider (PCP), and 90% disagreed with receiving adequate help. Average Likert scores indicated embarrassment (3.4), anxiety/depression (3.1), negative impact on relationships (2.6), and work disruption (2.7) due to R-CPD.

CONCLUSIONS & INFERENCES

R-CPD is unfamiliar to many healthcare providers, leaving patients underserved. It not only affects daily life but also personal and professional relationships. Raising awareness by understanding disease basic features may increase diagnosis and treatment rates, improving quality of life.

Retrograde Cricopharyngeal Dysfunction: A Review

Retrograde cricopharyngeal dysfunction (RCPD), also referred to as retrograde cricopharyngeus dysfunction, is a condition characterized by the inability to burp. The pathophysiology of this condition is thought to result from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension, which leads to patients' bothersome symptoms. RCPD negatively impacts patients' quality of life and is associated with bloating, gurgling, avoidance of carbonation, self-imposed dietary and lifestyle changes designed to minimize discomfort, and flatulence. Complaints often start during adolescence, and many patients search for a diagnosis for years before obtaining treatment. A recent increase in awareness through patient-led social media discussion boards describing the 'no burp' syndrome is leading to an increasing incidence of presentations, often with patients making a self-diagnosis. The increased incidence of RCPD is fueling a larger case series investigating treatment options and outcomes. In this review, we discuss what is known about the pathophysiology of this condition, the otolaryngologic perspective on diagnosis and treatment, the patients' lived experience of this condition, and the influence of social media on RCPD.

The kid who couldn't burp: the management of a pediatric case of retrograde cricopharyngeal dysfunction

Retrograde cricopharyngeal dysfunction is a newly described syndrome characterized by the inability to belch, loud abdominal gurgling, excessive flatulence, and pain or distension of the low neck, chest, or abdomen. Treatment is with botulinum toxin injection into the cricopharyngeus muscle. We present a pediatric case of this syndrome to increase awareness among the medical community and for clinicians to expand their index of suspicion for retrograde cricopharyngeal dysfunction.