Excessive belching and aerophagia: two different disorders (2024)

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Volume 23 Issue 4 1 May 2010

Article Contents

  • Summary

  • Introduction

  • Physiology of Belching

  • Belching and Gastroesophageal Reflux

  • Belching and Functional Dyspepsia

  • Isolated Excessive Belching

  • Aerophagia

  • Conclusions

  • References

  • < Previous

Journal Article

Albert J. Bredenoord

1Department of Gastroenterology, Sint Antonius Hospital, Nieuwegein, and Department of Gastroenterology, University Medical Center Utrecht, Utrecht, the Netherlands

*Dr Albert J. Bredenoord, MD, Department of Gastroenterology, St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, the Netherlands. Email: a.bredenoord@antonius.net

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Oxford Academic

Diseases of the Esophagus, Volume 23, Issue 4, 1 May 2010, Pages 347–352, https://doi.org/10.1111/j.1442-2050.2009.01038.x

Published:

01 May 2010

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Summary

Belching is physiological venting of excessive gastric air. Excessive and bothersome belching is a common symptom, which is often seen in patients with functional dyspepsia and gastroesophageal reflux disease. Other symptoms are usually predominant. However, a small group of patients complain of isolated excessive belching, with a frequency of several belches per minute. In these patients, the eructated air does not originate from the stomach but is sucked or injected in the esophagus from the pharynx and expelled immediately afterward in oral direction. This behavior is called supragastric belching because the air does not originate from the stomach and does not reach the stomach either. Excessive belching can be treated by speech therapy or behavior therapy. The term aerophagia should be reserved for those patients where there is evidence that they swallow air too frequently and in too large quantities. These patients have excessive amounts of intestinal gas visualized on a plain abdominal radiogram and their primary symptoms are bloating and abdominal distension and they belch only to a lesser degree. Aerophagia and excessive supragastric belching are thus two distinct disorders.

Introduction

Gas is a normal constituent of the gastrointestinal tract. Air enters the esophagus and is transported to the stomach with each swallow. Gas can also be released intragastrically from ingested foods and drinks, such as carbon dioxide containing beverages. In the small intestine and colon, gas is usually the result of bacterial fermentation of luminal contents. Gas escapes the gastrointestinal tract proximally in the form of belches and distally as flatus.

Although the presence of some degree of gastrointestinal air is normal, the presence of an excessive volume of gastrointestinal air may lead to symptoms of bloating and abdominal distention. When this is thought to be the result of excessive air swallowing, this disorder is sometimes referred to as aerophagia. Aerophagia can be accompanied by excessive belching, but excessive belching can also occur as an isolated symptom or in combination with gastroesophageal reflux disease (GERD) and functional dyspepsia. In this paper, we review the physiology of belching, the occurrence of excessive belching, and its relationship to GERD, functional dyspepsia, and aerophagia

Physiology of Belching

Belching is the result of release of intragastric air. With each swallow, a certain volume of air is ingested.1 Esophageal peristalsis pushes the air and swallowed saliva and food towards the stomach which is reached after lower esophageal sphincter (LES) relaxation.2 The ingested air accumulates in the proximal stomach. After the ingestion of bicarbonate or CO2-containing beverages, gas is released in the stomach and accumulates in the proximal stomach as well. The dilation of the proximal stomach that is induced by accumulation of gas will activate stretch sensors in the gastric wall and a vago-vagal reflex is initiated.3–5 Activation of the dorsal motor nucleus of the vagal nerve activates efferent nerves that follow the vagal and phrenic nerves and results in relaxation of the LES and crural part of the diaphragm.6 This reflex is called a transient LES relaxation (TLESR) as it is not initiated by a swallow, in contrast to swallow-induced LES relaxation. The intragastric air can now escape the stomach and will reach the esophagus. Rapid dilation of the esophageal body, such as occurs with gaseous reflux will be followed by reflexogenic relaxation of the upper esophageal sphincter in order to let the gas escape.7,8 This is important as a slower dilation of the esophageal body, such as is caused by liquid reflux, will trigger secondary peristalsis, which will push the refluxate back to the stomach.9

This escape of air out of the esophagus is sometimes audible. Belching can thus be regarded as gaseous gastroesophagopharyngeal reflux. In upright position, the gastric venting reflex ensures that only a small amount of swallowed air reaches the intestines. In supine position, the TLESR reflex is depressed, and belching occurs much less frequently.10

The importance of the belch reflex is illustrated by the consequences that follow the inability to belch that sometimes occurs after antireflux surgery. During a fundoplication, the gastric fundus is wrapped around the distal esophagus. As the proximal stomach cannot any longer be distended with air, the TLESR frequency will be decreased and belching has sometimes become completely impossible.11–13 This results in a significant reduction of reflux episodes but also in a reduction of the capacity of the stomach to vent excessive intragastric air resulting in bloating, abdominal distention, and increased flatulence.

Belching and Gastroesophageal Reflux

Besides heartburn and regurgitation, patients with GERD often report an increased frequency of belching.14

As mentioned, TLESRs are the most important mechanism through which gastroesophageal reflux of liquids and gas occurs.15 Belching and reflux thus occur through the same mechanism. It has been suggested that liquid reflux is secondary to reflux of gas during a TLESR. In this view, venting of gastric gas would facilitate acid reflux. With impedance monitoring, transport of gas and liquid in the esophagus can be monitored, and with this technique, it has been shown that most reflux episodes indeed consist of both a liquid and gaseous component.16 However, liquid follows gas reflux just as frequently as gas follows liquid reflux, which leads to the conclusion that reflux is not the result of leakage of liquid gastric contents during belching.

We recently studied the relationships between the frequency of air swallowing, the size of the intragastric air bubble, belching and acid reflux in patients with GERD and healthy volunteers.17,18 With impedance monitoring, an accurate estimation can be made of whether a swallow contains much air (air swallow) or not. Both the size of the intragastric air bubble and the number of belches were found to be related to the frequency of air swallowing. However, no relationship was found between the occurrence of acid reflux and air swallowing, the size of the intragastric air bubble, and the number of belches. This supports the hypothesis that belching and reflux of liquids are not causally related.

A consistent finding, however, is that GERD patients swallow air more often and belch more frequently than healthy subjects.17,19,20 Treatment with a proton pump inhibitor (PPI) reduces the number of swallows in patients with GERD but not in other subjects, which suggests that the unpleasant sensation of heartburn stimulates patients to swallow more and take larger gulps with swallowing.19

Besides the fact that patients with reflux symptoms belch more due to an increased frequency of air swallows, gas reflux as occurs during belching can also result in reflux symptoms. As mentioned, gastroesophageal reflux of gas will distent the esophageal body and this distention can trigger heartburn and chest pain.21,22 Indeed, some patients with GERD reported the sensation of heartburn during reflux episodes of pure gas.23

An evidence-based therapy for symptoms of belching in patients with GERD is lacking. Advice can be given to eat slower and reduce the intake of carbon dioxide-containing beverages. Since air swallowing and belching can be reactions to heartburn, it seems a logical step to initiate a test treatment with a PPI or increase the dose in case a patient already uses one. Antireflux surgery will reduce the frequency of belching but will induce symptoms of bloating and abdominal distention because of the inability to belch and is certainly not indicated. A similar effect is likely to result from pharmacological inhibition of TLESRs such as the GABA-B receptor inhibitors baclofen and lesogaberan.24,25

Belching and Functional Dyspepsia

Frequent belching is a common symptom in patients with functional dyspepsia with a reported incidence up to 80%.26,27 Patients with functional dyspepsia swallow air more frequently than healthy subjects and have more belches, as was shown by 24 h impedance monitoring.28 The cause for the high frequency of air swallowing in these patients has not been investigated, but it seems likely that, similar to patients with GERD, excessive air swallowing is a reaction to unpleasant gastrointestinal sensations. It has been reported that frequent belching occasionally occurs in patients with organic disorders, such as cholecystolithiasis and peptic ulcer disease, but almost without exception, other symptoms are predominant.

Isolated Excessive Belching

Some patients complain of excessive belching in the absence of other gastrointestinal symptoms (Table 1). Patients with isolated excessive belching can belch to up to 20 times a minute and belch often during consultation. Belching occurs loud and, understandably, this is experienced as embarrassing and can lead to social isolation. Anxiety disorders seem to be more prevalent in these patients and it is often reported that the frequency of belching is increased under stressful circ*mstances (eructatio nervosa).29

Table 1

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Excessive belching: clinical workup

HistoryFrequency of belching
Effect of stress, work/school
Absence of GERD, dyspepsia, dysphagia
Physical examNo abnormalities
Abdominal radiographNo abnormalities
Impedance monitoringSupragastric belches
Normal air swallowing
TherapySpeech therapy
Behavior therapy
HistoryFrequency of belching
Effect of stress, work/school
Absence of GERD, dyspepsia, dysphagia
Physical examNo abnormalities
Abdominal radiographNo abnormalities
Impedance monitoringSupragastric belches
Normal air swallowing
TherapySpeech therapy
Behavior therapy

GERD, gastroesophageal reflux disease.

Table 1

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Excessive belching: clinical workup

HistoryFrequency of belching
Effect of stress, work/school
Absence of GERD, dyspepsia, dysphagia
Physical examNo abnormalities
Abdominal radiographNo abnormalities
Impedance monitoringSupragastric belches
Normal air swallowing
TherapySpeech therapy
Behavior therapy
HistoryFrequency of belching
Effect of stress, work/school
Absence of GERD, dyspepsia, dysphagia
Physical examNo abnormalities
Abdominal radiographNo abnormalities
Impedance monitoringSupragastric belches
Normal air swallowing
TherapySpeech therapy
Behavior therapy

GERD, gastroesophageal reflux disease.

Physicians generally believed that excessive swallowing of air leads to the observed high frequency of belching; therefore, this condition was called aerophagia, Greek for air eating. Patients were subsequently referred to a speech therapist to learn to ‘swallow normally.’

With the introduction of impedance monitoring, it recently became possible to monitor the movement of air and fluids in the esophagus. With this technique, air swallows and belches can thus be studied. Using impedance monitoring, we have recently shown that these patients with aerophagia did not swallow air more frequently than healthy subjects.30 They also did not have gaseous gastroesophageal reflux more frequently or have abnormal volumes of intragastric air. Instead, these subjects showed a distinct belch pattern, in which air moved rapidly in the esophagus where it was expelled less than a second later in oral direction, followed by an audible belch (Fig. 1). We called this type of belches ‘supragastric’ belches, as the air did not originate from the stomach and did not even reach the stomach but stayed in the esophagus. Simultaneous esophageal manometry revealed that the patients used two distinct mechanisms through which they moved the air into the esophagus. Some patients pushed the air into the esophagus through contraction of the pharyngeal muscles and others sucked the air into the esophagus by creating a negative intrathoracical pressure, most likely by inspiration with a closed glottis, after which, the upper esophageal sphincter is relaxed. In all subjects, air was expelled by abdominal straining. A supragastric belch is thus not similar to an air swallow as it is not initiated or followed by a peristaltic wave. Aerophagia (air eating) is thus not a correct term for this disorder as the patients suck air or inject air into their esophagus. Two different types of belches can thus be distinguished, gastric and supragastric belches.

Excessive belching and aerophagia: two different disorders (3)

Figure 1

(A) Example of a gastric belch. The increase in impedance starts in the distal esophagus and moves in proximal direction indicating air moving upward. (B) Example of a supragastric belch. The increase in impedance starts in the proximal esophagus and moves rapidly toward the distal esophagus. Less than a second later, the impedance returns to baseline again, starting from the distal esophagus. Air is thus rapidly moving inward the esophagus from the pharynx and expelled in oral direction again. Note that the time scale is different as (A).

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The suspicion that excessive belching is most likely a behavioral disorder is supported by a recent study in which the effect of distraction and stimulation on the frequency of belching was investigated.31 When the patients were kept unaware of being monitored, the frequency of belching was significantly lower than during the period after which they were informed of being measured. During distraction, the frequency of belching decreased again. This study thus supports the hypothesis that suction and injection of air into the esophagus during supragastric belching is a behavior disorder.

Therapy for excessive (supragastric) belching is difficult and little evidence exists to support the various treatment strategies reported in the literature. The first step is reassurance by explaining the cause of belching. Excessive belching is suggested to be a behavior disorder, and therefore, cognitive behavior therapy seems to hold some promise. During behavior therapy, it is explained to patients that excessive belching is self-induced learned behavior, and that it is therefore possible to unlearn this.32,33 Some physicians demonstrate to patients that they can belch intentionally themselves, in order to show the patients that supragastric belching can be controlled.34

Speech therapy may be an alternative. After a laryngectomy, it becomes impossible to speak as the vocal cords are resected. These patients are taught to speak by means of belching which is called esophageal speech. In order to learn to belch intentionally, speech therapists teach these patients the above-described suction and injection methods.35 As it is possible to use speech therapy to teach laryngectomized patients to perform supragastric belches, it would perhaps also be possible to unlearn this behavior to patients with excessive belching. We have recently referred 11 patients to a speech therapist, who is familiar with the concept of supragastric belching.36 A visual analogue scale filled in before and after 10 sessions of therapy showed that patients significantly benefitted from this therapy. Six patients reported a large decrease in symptoms and four patients reported a modest decrease in symptoms.

The use of gas-reducing drugs such as simethicone and dimethicone seems not useful for the treatment of excessive belching since an abnormal amount of gastrointestinal gas is not present. Neither is a diet without gas-containing beverages very helpful. In a few case reports, it has been described that hypnosis and biofeedback therapy can be useful.37,38 Sometimes, excessive belching is secondary to a psychiatric disorder, which should then be treated first.39

Aerophagia

The term aerophagia is thus not correct for patients with excessive supragastric belching, but does true aerophagia not exist at all? Intestinal gas can cause symptoms of distention and bloating. In 90% of the patients with irritable bowel syndrome, bloating and abdominal distention are reported. It has been suggested that at least part of this problem is caused by intestinal air. An increased volume of air, hypersensitivity to intestinal distention, and a different distribution of intestinal air are found. The underlying mechanisms are heterogeneous, and differences in intestinal transit, sensitivity, food intolerance, bacterial overgrowth, and sugar malabsorption are suggested to play a role.40,41 Air swallowing is not suspected to play a role of importance in the irritable bowel syndrome.

Some patients, however, present with abdominal distention, bloating, belching, flatulence, abdominal discomfort or pain, and excessive amounts of intestinal gas visualized on plain abdominal radiograms.42 The plain abdominal radiograph in these patients usually reveals distended small intestinal loops filled with large volumes of gas while air/fluid levels in the intestines are not observed (Fig. 2). Ambulatory 24-h impedance monitoring in these patients showed excessive air swallowing and a high frequency of gastric belching but no supragastric belching in these patients.43 This study thus presented the first objective parameters that confirm the presence of excessive air swallowing and provide evidence for the existence of a disorder called aerophagia.

Excessive belching and aerophagia: two different disorders (4)

Figure 2

Abdominal radiograph of a patient with aerophagia showing a large volume of intestinal air but no air–fluid levels.

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The most common symptoms in the patients with true aerophagia are bloating, abdominal distension, and constipation, while only a minority complains of excessive belching (Table 2).

Table 2

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Aerophagia: clinical workup

HistoryBloating
Belching
Flatulence
Constipation
Physical examIncreased tympany over the abdomen
Normal bowel sounds
Abdominal radiographExcessive volume of intestinal air, no air–fluid levels
Impedance monitoringGastric belches, no supragastric belches
Excessive air swallowing
TherapySpeech therapy
Restriction of gas-containing beverages
Dimethicone potentially may be helpful
HistoryBloating
Belching
Flatulence
Constipation
Physical examIncreased tympany over the abdomen
Normal bowel sounds
Abdominal radiographExcessive volume of intestinal air, no air–fluid levels
Impedance monitoringGastric belches, no supragastric belches
Excessive air swallowing
TherapySpeech therapy
Restriction of gas-containing beverages
Dimethicone potentially may be helpful

Table 2

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Aerophagia: clinical workup

HistoryBloating
Belching
Flatulence
Constipation
Physical examIncreased tympany over the abdomen
Normal bowel sounds
Abdominal radiographExcessive volume of intestinal air, no air–fluid levels
Impedance monitoringGastric belches, no supragastric belches
Excessive air swallowing
TherapySpeech therapy
Restriction of gas-containing beverages
Dimethicone potentially may be helpful
HistoryBloating
Belching
Flatulence
Constipation
Physical examIncreased tympany over the abdomen
Normal bowel sounds
Abdominal radiographExcessive volume of intestinal air, no air–fluid levels
Impedance monitoringGastric belches, no supragastric belches
Excessive air swallowing
TherapySpeech therapy
Restriction of gas-containing beverages
Dimethicone potentially may be helpful

A logical treatment for these patients would be speech therapy, with a different approach compared to the patients with excessive supragastric belching. Therapy for aerophagia needs to be directed at the frequency of air swallowing, in contract to the intended reduction of supragastric belches in the patients with excessive belching. Although the intake of a diet without gas-containing beverages will not solve the underlying disorder, it may help to reduce the volume of intra-intestinal gas and alleviate symptoms. Drugs such as simethicone and dimethicone reduce the surface tension, and therefore reduce gas formation in the intestines. These drugs can thus theoretically be helpful in patients with true aerophagia, although this has never been tested.

Conclusions

Belching is a physiological phenomenon and is defined as gastroesophagopharyngeal reflux of gas. Belching is thus only pathological when it becomes bothersome. Excessive belching is a common symptom, which is often seen in patients with functional dyspepsia and GERD. In these disorders, other symptoms are mostly predominant. However, a small group of patients complain of isolated excessive and repetitive belching. In these patients, the belched air does not originate from the stomach but is sucked or injected in the esophagus from the pharynx and expelled immediately afterwards. This behavior is called supragastric belching and can be treated by a well-informed speech pathologist.

The term aerophagia should be reserved for those patients that swallow air too frequently and in too large quantities. These patients have excessive amounts of intestinal gas visualized on a plain abdominal radiogram, and their primary symptoms are bloating and abdominal distension. Aerophagia and excessive supragastric belching are thus two distinct disorders (Table 3). In the current Rome III criteria, both excessive belching and aerophagia are categorized as gastroduodenal disorders, but given that the causes of these disorders are, respectively, supragastric belching and air swallowing, it would be better to classify these as esophageal disorders.

Table 3

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Difference between excessive belching and aerophagia

Excessive belchingAerophagia
MechanismAir sucking or pushingAir swallowing
Type of belchSupragastric belchGastric belch
Main symptomBelchingBloating
Localization of airEsophagusIntestines
Excessive belchingAerophagia
MechanismAir sucking or pushingAir swallowing
Type of belchSupragastric belchGastric belch
Main symptomBelchingBloating
Localization of airEsophagusIntestines

Table 3

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Difference between excessive belching and aerophagia

Excessive belchingAerophagia
MechanismAir sucking or pushingAir swallowing
Type of belchSupragastric belchGastric belch
Main symptomBelchingBloating
Localization of airEsophagusIntestines
Excessive belchingAerophagia
MechanismAir sucking or pushingAir swallowing
Type of belchSupragastric belchGastric belch
Main symptomBelchingBloating
Localization of airEsophagusIntestines

As the technical developments that enabled recognition of these disorders only recently took place, many questions still remain unanswered. The prevalence, natural course, and effect on quality of life of excessive belching and aerophagia are unknown and more studies with a focus on treatment are warranted.

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