Supragastric belches are the main determinants of troublesome belching symptoms in patients with gastro-oesophageal reflux disease

Pathophysiology of gastro-oesophageal reflux disease: implications for diagnosis and management

Gastro-oesophageal reflux disease (GERD) is a common gastrointestinal disorder in which retrograde flow of gastric content into the oesophagus causes uncomfortable symptoms and/or complications. It has a multifactorial and partially understood pathophysiology. GERD starts in the stomach, where the refluxate material is produced. Following the trajectory of reflux, the failure of the antireflux barrier, primarily the lower oesophageal sphincter and the crural diaphragm, enables the refluxate to reach the oesophageal lumen, triggering oesophageal or extra-oesophageal symptoms. Reflux clearance mechanisms such as primary and secondary peristalsis and the arrival of bicarbonate-rich saliva are critical to prevent mucosal damage. Alterations of the oesophageal mucosal integrity, such as macroscopic oesophagitis or microscopic changes, determine the perception of symptoms. The intensity of the symptoms is affected by peripheral and central neural and psychological mechanisms. In this Review, we describe an updated understanding of the complex and multifactorial pathophysiology of GERD. It is now recognized that different GERD phenotypes have different degrees of reflux, severity of mucosal integrity damage and type, and severity of symptoms. These variations are probably due to the occurrence of a predominant pathophysiological mechanism in each patient. We also describe the main pathophysiological mechanisms of GERD and their implications for personalized diagnosis and management.

Belching Disorders and Rumination Syndrome: A Literature Review

BACKGROUND

Belching disorders and rumination syndrome (RS) are disorders of gut-brain interaction (DGBIs) in Rome IV. Belching disorders are composed of excessive gastric belching (GB) and supragastric belching (SGB). Excessive GB is related to physiological phenomenon whereas excessive SGB and RS are behavioral disorders.

SUMMARY

A recent large internet survey found that prevalence of belching disorders and RS were 1% and 2.8%, respectively. It has been recognized that not a few patients with two behavioral disorders, excessive SGB and RS, could be misdiagnosed as proton pump inhibitors (PPI)-refractory gastroesophageal reflux disease (GERD). In patients with reflux symptoms, distinguishing these conditions is essential because they need psychological treatment (i.e., cognitive behavioral therapy (CBT) rather than acid suppressants. Clinicians should take a medical history meticulously first to identify possible excessive SGB and/or RS. High-resolution impedance manometry and/or 24-h impedance-pH monitoring can offer an objective diagnosis of the disorders. Several therapeutic options are available for excessive SGB and RS. The first-line therapy should be CBT using diaphragmatic breathing that can stop the behaviors involving complex muscle contraction (e.g., abdominal straining) to generate SGB or rumination. Overlap with eating disorders and/or other DGBIs such as functional dyspepsia can make management of the behavioral disorders challenging since such coexisting conditions often require additional treatments.

KEY MESSAGES

Excessive SGB and RS are not unusual conditions. It is important to raise awareness of the behavioral disorders for appropriate management.

Management of supragastric belching

Increased SGB is currently more often recognized not only in patients with belching as a main symptom, but also in patients with reflux like symptoms that are refractory to PPI treatment or patients with reflux hypersensitivity. Detection of increased SGB during analysis of impedance-pHmetry can help to better understand the pathophysiology of symptoms in individual patients and to provide more focused and specific treatment. At the moment, the most efficient treatments for increased SGB are CBT and Speech therapies, pharmacological treatment being less effective and prone to mild secondary effects. In this issue of Neurogastroenterology and Motility, Punkinnen et al demonstrate, in controlled clinical trial, that behavioral therapy was superior to follow-up without intervention in patients with SGB. We present a critical review of the different treatment modalities currently available for patients with pathological SGB.

Behavioral therapy is superior to follow-up without intervention in patients with supragastric belching-A randomized study

BACKGROUND

Behavioral therapy (BT) has been proven effective in the treatment of supragastric belching (SGB) in open studies. The aim was to compare BT to follow-up without intervention in patients with SGB in a randomized study.

METHODS

Forty-two patients were randomized to receive 5 sessions of BT, comprising diaphragmatic breathing exercises, or to follow-up without intervention. Patients were evaluated at 6 months, at which point the control group was also offered BT and evaluated after another 6 months. The frequency and intensity of belching and mental well-being were evaluated with a visual analog scale (VAS). Depression, anxiety, and health-related quality of life (HRQoL) were evaluated with four questionnaires: BDI, BAI, 15D, and RAND-36.

KEY RESULTS

The frequency and intensity of SGB were significantly lower in the therapy group (n = 19) than in the control group (n = 18) at the 6-month control (p < 0.001). When all patients (n = 36) were evaluated 6 months after BT, in addition to relief in the frequency and intensity of belching (p < 0.001), mental well-being had also improved (p < 0.05). Of all 36 patients, 27(75%) responded to BT. Depression scores were lower after therapy (p < 0.05). Only minor changes occurred in anxiety and HRQoL.

CONCLUSIONS AND INFERENCES

Behavioral therapy is superior to follow-up without intervention in patients with SGB in reducing belching and depression; it also improves mental well-being but has only a modest effect on anxiety and HRQoL.

Belching in children: Prevalence and association with gastroesophageal reflux disease

BACKGROUND

Excessive belching is frequently reported in adult patients with gastro-oesophageal reflux disease (GORD) and dyspepsia. Although postprandial gastric belching (GB) is considered a physiological mechanism for gastric venting, supra-gastric belching (SGB) is considered a distinct behavioural disorder. We aimed to define the prevalence of different types of belching and its association with reflux disease in paediatric patients.

METHODS

We retrospectively analysed reflux monitoring studies from 287 patients (median age: 7.0 years; interquartile range 3.0-11.3 years) with a suspicion of GORD. Based on oesophageal acid exposure time (AET) patients were divided in 3 groups: (a) physiological AET, (b) borderline AET and (c) pathological AET. MII-pH studies were manually edited and reflux disease parameters were measured together with quantification of GB and SGB.

KEY RESULTS

Two hundred one children (70.0%) had physiological AET (median: 0.8; interquartile range 0.3-1.6), 52 (18.1%) had borderline AET (median: 4.2; interquartile range 3.4-5.3) and 34 (11.9%) had pathologic AET (median: 10.7; interquartile range 9.1-14.2). Gastric belching was observed in all studies. Gastric belching related reflux was more frequently observed in patients with borderline and pathological AET (p < 0.001). This was more common in older children. SGB were observed in only 7 (2.4%) children (age range: 8-17years) in our population and all patients had Physiological AET. Only 3 (1%) patients had pathological number of SGB (>13/24 h).

CONCLUSIONS AND INFERENCES

Gastric belching related reflux is observed in children with increased AET. SGB is very rare in the paediatric population.

Characteristics of symptomatic belching in patients with belching disorder and patients who exhibit gastroesophageal reflux disease with belching

Background/Aims

Belching disorder (BD) is clinically distinct from gastroesophageal reflux disease (GERD) with belching. Supragastric belching (SGB) is closely associated with reflux episodes. This study investigates belch characteristics in association with reflux, compared between patients with BD and those who had GERD with belching.

Methods

Impedance pH monitoring data from 10 patients with BD and 10 patients with GERD who exhibited belching were retrospectively analyzed. Belches were considered "isolated" or "reflux-related" and acidic/non-acidic. Belch characteristics were compared between patients with BD and those with GERD.

Results

Symptomatic belches were more frequent in patients with BD than in patients with GERD (median, 160.5 vs 56.0, P < 0.05). SGB was the most common type in both groups; common subtypes comprised "isolated" in patients with BD and "isolated during the reflux period" in patients with GERD. Reflux-related SGB was more common in patients with GERD than in BD (78.3% vs 45.2%, P < 0.005). Both "preceding belching" including the reflux period and acidic SGB were more common in patients with GERD than in BD (31.8% vs 8.6% and 38.1% vs 8.9%, both P < 0.05). Supragastric belch number positively correlated with all reflux episodes in patients with GERD (adjusted R² = 0.572, P = 0.007).

Conclusions

BD is characterized by more belching, compared to GERD. SGB is more frequently associated with reflux in GERD than in BD; acidity may be related to GERD. In BD, SGB is typically non-acidic and unrelated to reflux. Distinct SGB characteristics may reflect different pathogenic mechanisms of reflux and associated symptoms.

The prevalence of intestinal dysbiosis in patients referred for antireflux surgery

Background

Prior to antireflux surgery, most patients with symptoms of gastroesophageal reflux disease (GERD) have been taking long-term proton pump inhibitors (PPIs). PPIs have been shown to cause changes to the intestinal microbiota, such as small intestinal bacterial overgrowth (SIBO), which is characterised by symptoms of gas bloating. Patients undergoing antireflux surgery are not routinely screened for SIBO, yet many patients experience gas-related symptoms postoperatively.

Methods

Data from consecutive patients (n = 104) referred to a speciality reflux centre were retrospectively assessed. Patients underwent a routine diagnostic workup for GERD including history, endoscopy, oesophageal manometry and 24-h pH-impedance monitoring off PPIs. Intestinal dysbiosis was determined by hydrogen and methane breath testing with a hydrogen-positive result indicative of SIBO and a methane-positive result indicative of intestinal methanogen overgrowth (IMO).

Results

60.6% of patients had intestinal dysbiosis (39.4% had SIBO and 35.6% had IMO). Patients with dysbiosis were more likely to report bloating (74.6% vs 48.8%; P = 0.01) and belching (60.3% vs 34.1%; P = 0.01). The oesophageal acid exposure time and number of reflux episodes were similar between dysbiosis and non-dysbiosis groups, but patients with dysbiosis were more likely to have a positive reflux-symptom association (76.2% vs 31.7%; P < 0.001), especially for regurgitation in those with SIBO (P = 0.01). Hydrogen gas production was significantly greater in patients with a positive reflux-symptom association for regurgitation (228.8 ppm vs 129.1 ppm, P = 0.004) and belching (mean AUC 214.8 ppm vs 135.9 ppm, P = 0.02).

Conclusions

The prevalence of intestinal dysbiosis is high in patients with GERD, and these patients are more likely to report gas-related symptoms prior to antireflux surgery. Independently, SIBO may be a contributory factor to refractory reflux symptoms and gas bloating in antireflux surgery candidates.

Belching in Gastroesophageal Reflux Disease: Literature Review

Belching is a common phenomenon. However, it becomes bothersome if excessive. Impedance–pH monitoring can classify the belching into two types: gastric belching and supragastric belching (SGB). The former is a physiological mechanism to vent swallowed air from the stomach, whereas the latter is a behavioral disorder. Gastroesophageal reflux disease (GERD) is the most relevant condition in both types of belching. Recent findings have raised awareness that excessive SGB possibly sheds light on the pathogenesis of a part of proton pump inhibitor (PPI) refractoriness in GERD. SGB could cause typical reflux symptoms such as heartburn, regurgitation or chest pain in two ways: SGB-induced gastroesophageal reflux or SGB-induced esophageal distension. In PPI-refractory GERD, it is important to detect hidden SGB as a cause of reflux symptoms since SGB requires psychological treatment instead of high dose PPIs or pain modulators. In the case of PPI-refractory GERD with excessive SGB, recent studies imply that the combination of a psychological approach and conventional treatment can improve treatment outcome.

Personalized Approach in the Work-up and Management of Gastroesophageal Reflux Disease

Patients with gastroesophageal reflux disease (GERD) present with heterogeneous symptoms, response to treatment, and physiologic profiles, requiring distinct and personalized management. This article provides a stepwise framework to phenotype GERD beginning with (1) characterization of symptom profile and response to acid suppression; (2) endoscopic evaluation of mucosal and anatomic integrity; (3) ambulatory reflux monitoring to characterize reflux burden and sensitivity; and (4) esophageal physiologic testing to assess gastroesophageal reflux mechanism and effectors of reflux clearance, and evaluate for alternate causes.

Belching in Irritable Bowel Syndrome: An Impedance Study

Background/Aims

There are limited data about the relation between belching and irritable bowel syndrome (IBS). We aim to evaluate belching in patients with IBS.

Methods

Twenty-five patients with IBS and 12 healthy volunteers were enrolled in the study. IBS was diagnosed in accordance with the Rome III criteria. All patients were questioned about the presence of symptoms for belching, gastroesophageal reflux disease, and dyspepsia. Esophageal manometry and 24-hour pH-impedance were performed in all patients and healthy volunteers. Each of the patients with IBS underwent gastroscopy and colonoscopy.

Results

Demographic features were similar in both groups (P > 0.05). The belching rate was 32% in patients with IBS. The mean DeMeester score was significantly higher in IBS patients (13.80 ± 14.40 vs 6.04 ± 5.60, P = 0.027) and 24% of patients had pathologic acid reflux (DeMeester score > 14). Gastroscopy was normal in all patients. Symptom association probability positivity was detected in 24% of patients in the impedance study. The rate of weak acid reflux was also significantly higher in patients with IBS (97.00 ± 56.20 vs 58.20 ± 29.30, P = 0.025). The number of supine gas reflux (7.50 ± 6.40 vs 2.42 ± 2.80, P = 0.001) and supragastric belches was significantly higher in patients with IBS (51.20 ± 41.20 vs 25.08 ± 15.20, P = 0.035). Although the number of gastric belching was higher in controls, the difference did not reach statistical significance (12.10 ± 17.60 vs 4.90 ± 3.80, P = 0.575). We did not find any correlation between belching and any symptoms of IBS.

Conclusions

Belching is frequent in patients with IBS. Non-erosive reflux disease is frequent in IBS, which may be related to supragastric belching.

Increased Belching After Sleeve Gastrectomy

Introduction

Laparoscopic sleeve gastrectomy (LSG) is considered to be an effective procedure for patients with morbid obesity. Belching is frequently reported after this procedure, but it has not been well studied in the bariatric population. This study aims to assess the changes in belching before and after sleeve gastrectomy, as measured with impedance monitoring.

Methods

In a prospective study, patients underwent 24-h pH-impedance monitoring before and 3 months after LSG. Using this technique, belches can be identified. Preoperative and postoperative upper gastrointestinal symptoms were assessed using the Reflux Disease Questionnaire (RDQ).

Results

Fifteen patients (1 M/14 F, mean age 42.2 ± 11.0 years, mean weight 134.5 ± 21.1 kg, mean BMI 46.4 ± 6.0 kg/m²) participated in this study. Belching occurred significantly more often after LSG, with an increase in symptom score from 2.9 ± 2.6 before to 5.3 ± 3.5 3 months after LSG (p = 0.04). The total number of gastric belches increased from 29.7 ± 11.7 before to 59.5 ± 38.3/24 h 3 months after LSG (p = 0.03). The total number of supragastric belches did not change after LSG. The number of swallows decreased from 746.9 ± 302.4 before to 555.7 ± 172.5 3 months after the procedure (p = 0.03). The number of air swallows tended to decrease (p = 0.08).

Esophageal acid exposure increased significantly, from 3.7 ± 2.9 % before to 12.6 ± 10.5 % after LSG (p = 0.01).

Conclusion

Subjectively (as reported by patients) and objectively (as measured by impedance monitoring), an increase in gastric belches is seen after LSG, while the number of (air) swallows tends to decrease after the procedure and the incidence of supragastric belches remains constant. The altered anatomy as well as increased gastroesophageal reflux after LSG may play a role in the increase of belching.

Gender differences in symptoms in partial responders to proton pump inhibitors for gastro-oesophageal reflux disease

BACKGROUND

Gender differences may exist in the symptom experience of patients with gastro-oesophageal reflux disease (GERD) who have a partial response to proton pump inhibitors (PPIs).

OBJECTIVE

The purpose of this study was to analyse gender differences in partial responders to PPIs.

METHODS

Patients with GERD who responded partially to PPIs (n = 580; NCT00703534) completed the Reflux Symptom Questionnaire 7-day recall (RESQ-7) and the Gastrointestinal Symptom Rating Scale (GSRS). Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale.

RESULTS

Women had significantly higher RESQ-7 domain scores than men for Heartburn (frequency: 4.3 vs 3.9; intensity: 3.1 vs 2.8), Burping (frequency: 4.9 vs 4.4; intensity: 3.1 vs 2.8) and Hoarseness, cough and difficulty swallowing (frequency: 2.6 vs 2.2; intensity: 1.8 vs 1.5), and had higher GSRS domain discomfort scores than men for Abdominal pain (3.51 vs 3.23), Indigestion (3.80 vs 3.45) and Constipation (2.69 vs 2.17) (all p < 0.05). Anxiety and depression were significantly more prevalent in women than in men.

CONCLUSION

In this population of partial responders, women had more frequent/intense heartburn and extra-oesophageal symptoms and more discomfort from abdominal pain, indigestion and constipation than men. Comorbid anxiety and depression may contribute to the increased symptom burden in women.

Managing a patient with excessive belching

A 50-year-old man with end-stage renal failure was referred by his general practitioner with dyspeptic symptoms. On further questioning the patient complained of a 10-year history of frequent belching. This was noticeably worse after meals and during times of stress. He did not have nocturnal belching and episodes of belching were less frequent when the patient was talking or distracted. There was no history of gastro-oesophageal reflux, vomiting, dysphagia, loss of appetite or weight loss. He was diagnosed with excessive, probably supragastric, belching. Further investigation was not deemed necessary. His symptoms have since settled with simple reassurance and explanation of their origin provided during the clinic visit.

Management of belching, hiccups, and aerophagia

Although belching and hiccups are regarded as normal behaviors, they can occur at high frequency or become persistent, becoming bothersome and requiring medical care. Patients with excessive belching frequently have supragastric belches. Excessive belching should be treated as a behavioral disorder. Persistent hiccups, however, can be the first presentation of a serious disorder that requires extensive diagnostic testing. When no cause is found, only the symptoms can be treated. Aerophagia is an episodic or chronic disorder in which patients (children and adults) swallow large quantities of air, which accumulate in the gastrointestinal tract to cause abdominal distention and bloating. These patients should not undergo explorative laparotomy because they do not have ileus. New treatment approaches are needed for patients with aerophagia.