Belching (Eructation)

Han Seung Ryu; Suck Chei Choi; Joon Seong Lee

doi:10.4166/kjg.2014.64.1.4

Journal List > Korean J Gastroenterol > v.64(1) > 1007319

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Ryu, Choi, and Lee: Belching (Eructation)

Review Article

Korean J Gastroenterol 2014;64(1):4-9.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.64.1.4

Belching (Eructation)

Han Seung Ryu, Suck Chei Choi, Joon Seong Lee¹

Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, Iksan, Korea

¹Department of Internal Medicine, Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea

Correspondence to: Joon Seong Lee, Institute for Digestive Research, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea. Tel: +82-2-709-9691, Fax: +82-2-709-9696, E-mail: joonlee@schmc.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Belching is a normal physiological function that may occur when ingested air accumulated in the stomach is expelled or when food containing air and gas produced in the gastrointestinal tract is expelled. Excessive belching can cause patients to complain of abdominal discomfort, disturbed daily life activities, decreased quality of life and may be related to various gastrointestinal disorders such as gastroesophageal reflux disease, functional dyspepsia, aerophagia and rumination syndrome. Belching disorders can be classified into aerophagia and unspecified belching disorder according to the Rome III criteria. Since the introduction of multichannel intraluminal impedance monitoring, efforts are being made to elucidate the types and pathogenic mechanisms of belching disorders. Treatment modalities such as behavioral therapy, speech therapy, baclofen, tranquilizers and proton pump inhibitors can be attempted, but further investigations on the effective treatment of belching disorders are warranted.

Keywords: Eructation, Electric impedance, Lower esophageal sphincter

References

1. Klauser AG, Schindlbeck NE, Müller-Lissner SA. Symptoms in gastro-oesophageal reflux disease. Lancet. 1990; 335:205–208.

2. Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol. 2006; 101:1721–1726.

3. Hemmink GJ, Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Supragastric belching in patients with reflux symptoms. Am J Gastroenterol. 2009; 104:1992–1997.

4. Hemmink GJ, Weusten BL, Bredenoord AJ, Timmer R, Smout AJ. Increased swallowing frequency in GORD is likely to be caused by perception of reflux episodes. Neurogastroenterol Motil. 2009; 21:143–148.

5. Kessing BF, Bredenoord AJ, Velosa M, Smout AJ. Supragastric belches are the main determinants of troublesome belching symptoms in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2012; 35:1073–1079.

6. Lin M, Triadafilopoulos G. Belching: dyspepsia or gastroesophageal reflux disease? Am J Gastroenterol. 2003; 98:2139–2145.

7. Tack J, Caenepeel P, Fischler B, Piessevaux H, Janssens J. Symptoms associated with hypersensitivity to gastric distention in functional dyspepsia. Gastroenterology. 2001; 121:526–535.

8. Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout AJ. Air swallowing, belching, acid and nonacid reflux in patients with functional dyspepsia. Aliment Pharmacol Ther. 2007; 25:965–971.

9. Hemmink GJ, Weusten BL, Bredenoord AJ, Timmer R, Smout AJ. Aerophagia: excessive air swallowing demonstrated by esophageal impedance monitoring. Clin Gastroenterol Hepatol. 2009; 7:1127–1129.

10. Rommel N, Tack J, Arts J, Caenepeel P, Bisschops R, Sifrim D. Rumination or belching-regurgitation? Differential diagnosis using oesophageal impedance-manometry. Neurogastroenterol Motil. 2010; 22:e97–e104.

11. Bredenoord AJ, Smout AJ. Impaired health-related quality of life in patients with excessive supragastric belching. Eur J Gastroenterol Hepatol. 2010; 22:1420–1423.

12. Pouderoux P, Ergun GA, Lin S, Kahrilas PJ. Esophageal bolus transit imaged by ultrafast computerized tomography. Gastroenterology. 1996; 110:1422–1428.

13. Penagini R, Carmagnola S, Cantù P, Allocca M, Bianchi PA. Mechanoreceptors of the proximal stomach: Role in triggering transient lower esophageal sphincter relaxation. Gastroenterology. 2004; 126:49–56.

14. Mittal RK, Fisher MJ. Electrical and mechanical inhibition of the crural diaphragm during transient relaxation of the lower esophageal sphincter. Gastroenterology. 1990; 99:1265–1268.

15. Lang IM, Medda BK, Shaker R. Digestive and respiratory tract motor responses associated with eructation. Am J Physiol Gastrointest Liver Physiol. 2013; 304:G1044–G1053.

16. Babaei A, Bhargava V, Korsapati H, Zheng WH, Mittal RK. A unique longitudinal muscle contraction pattern associated with transient lower esophageal sphincter relaxation. Gastroenterology. 2008; 134:1322–1331.

17. Shaker R, Ren J, Kern M, Dodds WJ, Hogan WJ, Li Q. Mechanisms of airway protection and upper esophageal sphincter opening during belching. Am J Physiol. 1992; 262:G621–G628.

18. Bredenoord AJ, Weusten BL, Timmer R, Akkermans LM, Smout AJ. Relationships between air swallowing, intragastric air, belching and gastro-oesophageal reflux. Neurogastroenterol Motil. 2005; 17:341–347.

19. Bredenoord AJ, Weusten BL, Sifrim D, Timmer R, Smout AJ. Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring. Gut. 2004; 53:1561–1565.

20. Sifrim D, Silny J, Holloway RH, Janssens JJ. Patterns of gas and liquid reflux during transient lower oesophageal sphincter relaxation: a study using intraluminal electrical impedance. Gut. 1999; 44:47–54.

21. Bredenoord AJ, Smout AJ. Physiologic and pathologic belching. Clin Gastroenterol Hepatol. 2007; 5:772–775.

22. Kessing BF, Bredenoord AJ, Smout AJ. Mechanisms of gastric and supragastric belching: a study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2012; 24:e573–e579.

23. Han DH, Lee JS, Baek SH, et al. A case of aerophagia presenting with intractable belching. Korean J Neurogastroenterol Motil. 2006; 12:69–72.

24. Bredenoord AJ. Management of belching, hiccups, and aerophagia. Clin Gastroenterol Hepatol. 2013; 11:6–12.

25. Chitkara DK, Bredenoord AJ, Rucker MJ, Talley NJ. Aerophagia in adults: a comparison with functional dyspepsia. Aliment Pharmacol Ther. 2005; 22:855–858.

26. Zella SJ, Geenens DL, Horst JN. Repetitive eructation as a manifestation of obsessive-compulsive disorder. Psychosomatics. 1998; 39:299–301.

27. Jones WR, Morgan JF. Eructophilia in bulimia nervosa: a clinical feature. Int J Eat Disord. 2012; 45:298–301.

28. Karamanolis G, Triantafyllou K, Tsiamoulos Z, et al. Effect of sleep on excessive belching: a 24-hour impedance-pH study. J Clin Gastroenterol. 2010; 44:332–334.

29. Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Psychological factors affect the frequency of belching in patients with aerophagia. Am J Gastroenterol. 2006; 101:2777–2781.

30. Bredenoord AJ. Excessive belching and aerophagia: two different disorders. Dis Esophagus. 2010; 23:347–352.

31. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology. 2006; 130:1466–1479.

32. Chitkara DK, Bredenoord AJ, Talley NJ, Whitehead WE. Aerophagia and rumination: recognition and therapy. Curr Treat Options Gastroenterol. 2006; 9:305–313.

33. Lee TH. A case of rumination documented by using high-resolution impedance manometry. J Neurogastroenterol Motil. 2013; 19:259–260.

34. Tack J, Blondeau K, Boecxstaens V, Rommel N. Review article: the pathophysiology, differential diagnosis and management of rumination syndrome. Aliment Pharmacol Ther. 2011; 33:782–788.

35. Katzka DA. Simple office-based behavioral approach to patients with chronic belching. Dis Esophagus. 2013; 26:570–573.

36. Hemmink GJ, Ten Cate L, Bredenoord AJ, Timmer R, Weusten BL, Smout AJ. Speech therapy in patients with excessive supragastric belching–a pilot study. Neurogastroenterol Motil. 2010; 22:24–28.

37. Blondeau K, Boecxstaens V, Rommel N, et al. Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching. Clin Gastroenterol Hepatol. 2012; 10:379–384.

38. Koek GH, Sifrim D, Lerut T, Janssens J, Tack J. Effect of the GABA(B) agonist baclofen in patients with symptoms and duode-no-gastro-oesophageal reflux refractory to proton pump inhibitors. Gut. 2003; 52:1397–1402.

39. Lehmann A, Bremner-Danielsen M, Brändén L, Kärrberg L. Inhibitory effects of GABA(B) receptor agonists on swallowing in the dog. Eur J Pharmacol. 2002; 448:67–70.

40. Spiegel SB. Uses of hypnosis in the treatment of uncontrollable belching: a case report. Am J Clin Hypn. 1996; 38:263–270.

41. Cigrang JA, Hunter CM, Peterson AL. Behavioral treatment of chronic belching due to aerophagia in a normal adult. Behav Modif. 2006; 30:341–351.

Fig. 1.

Mechanism of belching. The ingested air during swallowing of food and water accumulates in the proximal stomach. Increased volume in proximal stomach induces transient lower esophageal sphincter relaxation (tLESR), followed by rapid moving of gastric air into the esophagus. Abrupt distension of esophagus by refluxed air induces secondary peristalsis or esophago-UES relaxation reflex, which allows venting of gas. LES, lower esophageal sphincter; UES, upper esophageal sphincter.

Fig. 2.

Types and mechanisms of belching. (A) Gastric belching. The ingested air that accumulates in the stomach or gas that is generated from food or gastrointestinal tract is expelled during relaxation of the lower esophageal sphincter. (B) Supragastric belching. The ingested air does not enter the stomach but is expelled immediately. (C) Aerophagia. As patients swallow air continuously, some portion of the air is vented by gastric belching and moves to the intestine, causing abdominal distention. (D) Rumination syndrome. The voluntary contraction of the abdominal wall musculature increases intragastric pressure, thereby causing reflux of gastric contents into the esophagus and venting of air simultaneously.

Table 1.

Clinical Workup and Therapeutic Modalities of Belching

History	Frequency of belching, occurrence of belching after meal, during sleep or other activities, scent or taste of belching, audible (loud or not), effect of stress, reflux symptoms, dyspepsia, signs of psychiatric comorbidity, perceived symptom severity, impact of psychosocial aspect and quality of life
Physical examination	Exclude other causes, thorough examination of neck and abdomen, inspection of air swallowing
Abdominal radiograph	No abnormalities in supragastric belching
Esophageal impedance monitoring (and combined manometry)	Supragastric or gastric belches, differential diagnosis of aerophagia and rumination syndrome
Upper endoscopy on indication Therapy
	Behavior therapy
	Speech therapy
	Baclofen
	Proton pump inhibitor

Data from the articles of Bredenoord (Clin Gastroenterol Hepatol 2013;11:6–12/Dis Esophagus 2010;23:347–352).^24,30

TOOLS

Similar articles