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Keywords:

  • aerophagia;
  • high-resolution manometry;
  • impedance monitoring;
  • speech therapy;
  • supragastric belching

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

Abstract  In patients whose main symptom is excessive belching, supragastric belching appears to be the predominant mechanism. This belch pattern is characterized by a rapid influx of air into the oesophagus, immediately followed by rapid air expulsion. The rate at which supragastric belching occurs is influenced by attention and distraction, suggesting a behavioural disorder and speech therapy may be of benefit to these patients. In 17 consecutive patients with excessive belching, concurrent impedance monitoring and high-resolution manometry were performed to ascertain the mechanism of belching. Patients with supragastric belches were referred to a speech therapist, who was familiar with the concept of supragastric belching. Before and after treatment by the speech therapist, patients filled out a VAS scale regarding the severity of their symptoms. In all patients, supragastric belches were identified with impedance monitoring. Eleven patients were referred to a speech therapist, six patients were not able or willing to undergo repetitive treatments. Eleven patients completed treatment by the speech therapist consisting of 10 (8–10) sessions. Overall, the VAS scales showed a significant improvement of the severity of symptoms (P < 0.05). Six of the 11 patients reported a large decrease (>30%) in their symptoms and four patients reported a modest decrease (<30%). In one patient, the VAS scores indicated an increase in symptoms. Speech therapy performed by a well-informed speech pathologist leads to a significant symptom reduction in patients with excessive supragastric belching. This is the first study indicating benefit of a treatment for excessive belching.


Abbreviations: 
GORD

gastro-oesophageal reflux disease

LOS

lower oesophageal sphincter

SLP

speech language pathologist

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

Belching is a physiological mechanism through which air or gas can be vented from the stomach. This occurs through a relaxation of the lower oesophageal sphincter (LOS), triggered by a vago-vagal reflex induced by distension of the proximal stomach. This relaxation is known as a transient lower oesophageal sphincter relaxation (TLOSR) and acts as a protective mechanism to prevent the stomach from excessive dilatation.1–3

Patients who present with excessive belching as their predominant symptom are often diagnosed with ‘aerophagia’ because they are believed to swallow air too frequently or in too large quantities.4 It has been shown however that these patients do not swallow air too frequently and do not have large amounts of intragastric air, or an increased incidence of TLOSRs.5 Instead, a typical pattern is observed in the impedance tracings. This pattern is known as supragastric belching and is characterized by a rapid influx of air, followed by a rapid air expulsion, often within one second. Recent research has elucidated two manometrically distinct mechanisms through which the air can flow into the oesophagus. Firstly, air can be pushed into the oesophagus by a pharyngeal contraction, marked by a rise in pharyngeal pressure. The second observed pattern is characterized by a negative intrathoracic pressure (air-sucking).

In addition, it has been shown that the frequency of this supragastric belching can be influenced by attention and distraction, indicating that this type of belching can be considered a behavioural disorder.6 Because of the self-induced nature of supragastric belching, behavioural therapy or speech therapy may be of benefit to patients with excessive supragastric belching.

The aim of our study was to assess the effect of speech therapy in patients with excessive supragastric belching.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

Patients and study protocol

Included in this study were consecutive patients with excessive belching as dominant symptom presenting between August 2006 and August 2008 at the out-patients clinics of the participating hospitals.

Patients filled in a standard questionnaire regarding gastrointestinal symptoms based on the Rome III criteria for functional dyspepsia and irritable bowel syndrome and on the Montreal classification for gastro-oesophageal reflux disease (GORD).4,7,8

All patients underwent stationary combined impedance monitoring and high-resolution manometry to assess the number of supragastric belches and the mechanism that resulted in the influx of air.

After an overnight fast, a manometry catheter was introduced transnasally. After correct positioning of the manometry catheter, an impedance catheter was introduced and placed based on the manometrical findings. The stationary measurement consisted of a 10-min adaptation period, followed by a 30-min preprandial and a 1-h postprandial period. A standardized solid meal (505 kCal) was consumed within 30 min (McDonald’s Quarter Pounder). During the measurement, patients remained in upright position. Pre- and postprandial recordings were performed as patients may experience more symptoms in the postprandial period.

In the patients, who presented after August 2007, ambulatory 24-h pH-impedance monitoring was performed immediately after the stationary measurement. Before the study, acid secretion inhibitory drugs were discontinued for 7 days.

When supragastric belches were identified, patients were referred to a well-informed speech language pathologist for treatment.

Stationary combined impedance monitoring and high-resolution manometry

A 17-channel water-perfused manometry catheter was used for manometric recording. In addition to sideholes at 5-cm intervals, additional sideholes were located at 1-cm intervals straddling the LOS and upper oesophageal sphincter (Fig. 1).

image

Figure 1.  Schematic representation and localization of the impedance (left) and manometry (right) catheter used in the stationary measurement. The impedance (left) catheter was placed with the most distal recording segment (Imp 10) at 0–2 cm above the upper border of the lower oesophageal sphincter (LOS). The manometry catheter has additional sideholes at 1-cm intervals straddling the LOS and upper oesophageal sphincter (UOS). Imp, impedance recording segment.

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All sideholes were perfused at 0.08 mL min−1 using a pneumohydraulic perfusion system (Dentsleeve Pty ltd, Wayville, South Australia). Pressures were measured with external pressure transducers (Abbott, Sligo, Ireland) and stored in two digital dataloggers (Medical Measurements Systems, Enschede, The Netherlands), using a sample frequency of 20 Hz.

After localization of the LOS, an impedance catheter (Aachen University of Technology, FEMU, Aachen, Germany) with 10 recording segments was introduced with the most distal recording segment located 0–2 cm above the upper border of the LOS. The other recording segments were located as shown in Fig. 1. Impedance signals were stored in a digital system (Solar; Medical Measurements Systems) recorded with a sample frequency of 50 Hz.

Ambulatory 24-h pH-impedance monitoring

After the stationary measurement, ambulatory 24-h pH-impedance monitoring was performed in a subset of patients. For this measurement, a combined pH-impedance catheter (Versaflex; Alpine Biomed, Fountain Valley, CA, USA) with six impedance recording segments (located at 2–4 cm, 4–6 cm, 6–8 cm, 8–10 cm, 14–16 cm and 16–18 cm above the upper border of the LOS) and an antimony pH-electrode (located at 5 cm above the upper border of the LOS) was used. The impedance and pH signals were stored in a digital datalogger (Ohmega; Medical Measurements Systems) using a sample frequency of 50 and 1 Hz respectively.

Patients were instructed to consume three meals and four beverages at fixed times, and to note the period spent in recumbent position, and reflux symptoms experienced during the measurement.

To obtain objective parameters after speech therapy, all patients were asked to undergo a second 24-h pH-impedance measurement after completion of the speech therapy sessions.

Speech therapy

Patients who exhibited supragastric belches during the stationary measurement were referred to a speech and language pathologist (SLP). The SLP was familiar with the concept of supragastric belching. Before the start of the therapy, the SLP was informed about the manometrical mechanism (pharyngeal contraction and/or air-sucking) through which the influx of air during supragastric belches was brought about in each patient.

The therapy focused on explanation and on creating awareness of the belching mechanism. The first step consisted of a description of the behaviour that caused the injection or sucking of air (increased pharyngeal pressure or reduced intrathoracic reduced pressure respectively). During both periods the patient briefly closed his or her glottis at rest (non-speech), accompanied by tight closing of the mouth. As soon as this behaviour was understood, the patient was trained to refrain from these glottal closures and to acquire a normal fluent breathing pattern without these moments of closure. This was practised by conventional breathing and vocal exercises. As early as possible in the therapy, attention on belching was moved to attention on the periods of tight glottal and mouth closure. The cognitive process was regarded as an important aspect in the therapy.

At the beginning and at the end of the speech therapy, patients filled in a 6-item VAS scale regarding the severity of their symptoms (see below). Speech therapy treatment was discontinued after resolution of the patient’s symptoms or after 10 one-hour treatment sessions.

Data analysis

In the impedance tracings, reflux episodes were identified and classified according to previously described criteria into liquid, mixed liquid-gas and pure gas reflux episodes.9 Gastric belches were defined as air-containing reflux episodes (gas and mixed gas-liquid reflux episodes) with the air component reaching the most proximal recording segment.10

Swallows were defined as a drop in impedance moving in aboral direction. An air swallow was defined as a swallow accompanied by an increase in impedance (≥1000 Ω) in the most distal recording segment.11

Supragastric belches were defined as a rapid and pronounced rise in impedance (≥1000 Ω) moving in aboral direction, followed by a rapid return to baseline in opposite direction.5

Concurrent high-resolution manometry was used to assess the mechanism of the influx of air during each supragastric belch. Influx of air into the oesophagus was either induced by creating a negative intrathoracic pressure (air-sucking) or by an increase of pharyngeal pressure (air-pushing), both shortly before the influx of air.5,6

High-resolution manometry allowed detection of transient lower oesophageal sphincter relaxations, as defined by previously published criteria.12,13

Ambulatory pH-impedance tracings were analysed manually and reflux episodes were detected as described above. Oesophageal acid exposure was calculated as the percentage of time with a pH below four at 5 cm above the upper border of the LOS. Swallows and air swallows were identified using the impedance tracings as described previously.11

Symptom association analysis was performed using the symptom index (SI) and symptom association probability (SAP).14,15 A positive relationship between reflux episodes and symptoms was defined as SI≥50% and SAP≥95%.

Before and after the speech therapy, patients filled in a short questionnaire (6-item VAS scale) regarding the severity of their belching symptoms. The items focused on severity of the symptoms, the daily inconvenience caused by frequent belching, interference with normal functioning and level of control of belching. The following items were scored: (i) How bothering do you experience your symptom of excessive belching? (ii) How bothering do you think your environment experiences your excessive belching? (iii) Can you suppress belching? (iv) Does excessive belching hamper your work/daily activities? (v) Are your social activities hampered by excessive belching? (vi) Do you experience any level of control over your excessive belching? All six items (scored in millimetres) were cumulated and compared before and after the treatment sessions.

Major improvement was considered as a >30% decrease of symptom severity. Minor improvement was defined as a 0–30% decrease of symptom severity. The 30% threshold for decrease of symptom severity was considered to be clinically relevant.

Statistical analysis

Throughout the manuscript, data are presented as mean ± SEM (or SD as described otherwise) or median and interquartile range. Reflux episodes and swallowing frequencies during the pre- and postprandial recording period were compared using the paired Student’s t-test. VAS scores (cumulative score of a 6-item questionnaire, in millimetres) at the start and end of the therapy were compared using Wilcoxon signed rank test. Differences were considered statistically significant when P ≤ 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

Patients

Seventeen consecutive patients (age: 58.1 ± 12.3 y (SD); eight females) with excessive belching as primary and presenting symptom were recruited between August 2006 and August 2008. Patients had symptoms of excessive belching for a mean period of 2.1 ± 1.4 years (SD). None of the included patients had a history of gastrointestinal surgery.

Five of the 17 patients reported no other symptoms than excessive belching. Besides excessive belching, nine patients reported symptoms suggestive of GORD, three patients reported symptoms suggestive of functional dyspepsia and six patients reported symptoms suggestive of irritable bowel syndrome.

Stationary impedance and high-resolution manometry

In all 17 patients, supragastric belches were identified as the dominant mechanism of belching. Supragastric belches occurred at a frequency of 32 (8–68) h−1 pre- and 41 (28–191) h−1 postprandially (P = 0.18).

In 14 patients, a decrease of intrathoracic pressure was observed prior to the influx of air, indicating that air was sucked into the oesophagus (Fig. 2A). An increase in pharyngeal pressure prior to the influx of air was observed in two patients (air-pushing) (Fig. 2B). In one patient, both patterns were observed.

image

Figure 2.  Simultaneous impedance and manometric recordings during a supragastric belch. Two patterns were observed: (A) a decrease in intrathoracic pressure (arrow) preceded the influx of air and was followed by an increase of pressure in all channels expelling intra-oesophageal air (air-sucking) and (B) a rise in pharyngeal pressure (arrow), not followed by a peristaltic contraction wave, preceding the influx of air (air-pushing) into the oesophagus.

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Neither the numbers of mixed liquid-gas reflux episodes, gas reflux episodes or gastric belches, nor the number of swallows and air swallows differed between the pre- and postprandial stationary recording periods. After the meal, patients had more TLOSRs and more liquid reflux episodes compared to the preprandial recording period (Table 1).

Table 1.   Median (interquartile range) number of supragastric belches, and mean (±SEM) number and type of reflux episodes, gastric belches, swallows, air swallows and TLOSRs h−1 during the pre- (30 min) and postprandial (1 h) recording period
 Preprandial (h−1)Postprandial (h−1) P-value
  1. TLOSRs, transient lower oesophageal sphincter relaxations.

No. supragastric belches32 (8–68)41 (28–191)ns
No. liquid reflux episodes4 ± 17 ± 2<0.05
No. mixed liquid-gas reflux episodes4 ± 23 ± 1ns
No. gas reflux episodes2 ± 11 ± 0ns
No. gastric belches5 ± 35 ± 1ns
No. swallows91 ± 898 ± 16ns
No. air swallows34 ± 1025 ± 5ns
No. TLOSRs4 ± 05 ± 1<0.05

Ambulatory 24-h pH-impedance monitoring

In seven consecutive patients, an ambulatory 24-h pH-impedance monitoring was performed with a net recording period of 21.9 ± 0.2 h. During this period, a total of 141 (122–1356) supragastric belches were identified with 99 (98–100)% occurring in upright position.

Swallows and air swallows were present at rates of 625 ± 110 24 h−1 and 199 ± 55 24 h−1 respectively.

In these patients, 39 ± 5 liquid reflux episodes, 28 ± 5 mixed liquid-gas reflux episodes and 22 ± 8 gas reflux episodes were identified. The number of gastric belches (air-containing reflux episodes with the impedance rise reaching the proximal impedance recording segment) was 50 ± 14 24 h−1. Total oesophageal acid exposure time was 6.0 ± 2.5% (upright: 7.6 ± 2.7%; supine: 2.8 ± 2.6%).

Three of the seven patients reported reflux symptoms (epigastric pain and chest pain) during the 24-h recording period. Symptom association analysis resulted in a negative SI (SI < 50%) and SAP (<95%) in these patients.

After completion of the speech therapy sessions, only two patients agreed to undergo a second 24-h pH-impedance measurement. Both patients had a significant symptom reduction (>30%) after the speech therapy sessions. In these patients, the number of supragastric belches 24 h−1 decreased from 164 and 150 to 6 and 19 respectively.

Speech therapy

Of the 17 investigated patients, 11 patients were referred to the SLP. The other six patients were not able (n = 4) or willing (n = 2) to comply with repetitive treatment sessions. All 11 patients referred completed treatment in 10 (8–10) therapy sessions.

The VAS scores before and after the treatment sessions are shown in Fig. 3. Overall, VAS scores decreased significantly [34 (9–73) %] after therapy sessions [before: 420 (214–555) mm vs after 228 (79–436) mm; P < 0.05].

image

Figure 3.  Severity of symptoms of excessive belching (cumulative VAS scores, in mm) of each patient at the start and end of treatment by the speech language pathologist.

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In six of the 11 patients, speech therapy resulted in major symptom reduction, four patients had a modest (0–30%) symptom improvement. One patient reported an increase (50%) in symptoms after the speech therapy sessions.

No differences were found between responders and non-responders with regard to sex and age.

Only one of the three patients who pushed air into the oesophagus (pharyngeal contractions) was treated by the SLP. This patient reported a 48% decrease of symptoms after the speech therapy.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

Although every gastroenterologist is confronted occasionally with patients who complain about frequent belching, little research has been done in this field. Even less is known about the treatment strategies for belching disorders, and both patients and physicians are frustrated by this lack of information. Behavioural therapy and speech therapy have been proposed as treatment options in patients with excessive belching. However apart from case reports, little is known about the results of these treatment strategies.16–18

This is the first study that describes an effective therapy for excessive belching. Although the speech therapy was not equally successful in every patient, a significant number of patients (55%) reported major symptom reduction after the treatment sessions.

All patients who presented with isolated excessive belching exhibited supragastric belches during the stationary measurement. In addition, very large numbers of supragastric belches were observed during the ambulatory measurement. In some patients incidences exceeded 1300 supragastric belches day−1, reflecting the severity of the patients’ symptoms. In agreement with a previous study, these patients did not exhibit excessive numbers of (air) swallows or TLOSRs, indicating that (air) swallowing is not the cause of their symptoms.5

Interestingly, patients had increased numbers of liquid-containing reflux episodes. This may be explained by the observation that supragastric belches can elicit reflux episodes.19 Only three patients exhibited (atypical) reflux symptoms during the ambulatory measurement, and none of these patients had a good relationship between reflux symptoms and reflux episodes, underlining that these patients are different patients than reflux patients.

In our study, patients were treated by a speech and language pathologist who was familiar with the supragastric belching disorder. Therapy was focused on awareness and regaining control of supragastric belching and normalizing breathing patterns. As the therapy concerns mostly a behavioural change, it may be argued that therapy by a behavioural therapist may be of benefit as well. Because speech therapists have much knowledge in pharyngeal and laryngeal anatomy and function, we preferred treatment by an expert in this field.

The question remains why patients exhibit these supragastric belches and in such high frequencies. We hypothesize that these patients start with inducing supragastric belches consciously, probably in response to an unpleasant sensation, and lose control afterwards. Theoretically, this unpleasant sensation may be some kind of discomfort associated with functional oesophageal disorders, dyspepsia or irritable bowel syndrome. This is supported by the significant number of our patients reporting other gastrointestinal symptoms.

This study has some limitations. Firstly, the study is hampered by a relatively low number of patients with isolated excessive belching, and it does not include a control group. However, it is not likely that the belching symptoms would resolve spontaneously as most patients had symptoms for several years. Secondly, a relatively large group of patients dropped out of the study because they were not able or willing to comply with repetitive visits to the speech therapist. In most cases this was due to long travel distances that are inherent to tertiary referrals. Finally, the effect of the speech therapy was assessed using VAS scales regarding the patients’ symptoms only. No objective parameters were obtained. However, this is the first study that investigated the effect of speech therapy systematically in a group of patients. Symptom reduction by speech therapy is feasible in the majority patients with excessive supragastric belching.

In conclusion, this is the first study that describes speech therapy as treatment for supragastric belching. In well-motivated patients, this approach can lead to a significant symptom reduction. Further research on the effect of speech therapy in patients with excessive supragastric belching is warranted.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

G. J. M. Hemmink is supported by a clinical research trainee grant from Janssen-Cilag, Tilburg, The Netherlands.

Conflict of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References

The authors have no conflict of interest to disclose.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Conflict of interest
  9. References
  • 1
    Martin CJ, Patrikios J, Dent J. Abolition of gas reflux and transient lower esophageal sphincter relaxation by vagal blockade in the dog. Gastroenterology 1986; 91: 8906.
  • 2
    Holloway RH, Hongo M, Berger K, McCallum RW. Gastric distention: a mechanism for postprandial gastroesophageal reflux. Gastroenterology 1985; 89: 77984.
  • 3
    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: 4754.
  • 4
    Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology 2006; 130: 146679.
  • 5
    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: 15615.
  • 6
    Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Psychological factors affect the frequency of belching in patients with aerophagia. Am J Gastroenterol 2006; 101: 277781.
    Direct Link:
  • 7
    Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006; 130: 148091.
  • 8
    Vakil N, Van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101: 190020.
    Direct Link:
  • 9
    Sifrim D, Holloway R, Silny J, et al. Acid, nonacid, and gas reflux in patients with gastroesophageal reflux disease during ambulatory 24-hour pH-impedance recordings. Gastroenterology 2001; 120: 158898.
  • 10
    Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol 2006; 101: 17216.
    Direct Link:
  • 11
    Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Reproducibility of multichannel intraluminal electrical impedance monitoring of gastroesophageal reflux. Am J Gastroenterol 2005; 100: 2659.
    Direct Link:
  • 12
    Holloway RH, Penagini R, Ireland AC. Criteria for objective definition of transient lower esophageal sphincter relaxation. Am J Physiol 1995; 268: G12833.
  • 13
    Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Sleeve sensor versus high-resolution manometry for the detection of transient lower esophageal sphincter relaxations. Am J Physiol Gastrointest Liver Physiol 2005; 288: G11904.
  • 14
    Wiener GJ, Richter JE, Copper JB, Wu WC, Castell DO. The symptom index: a clinically important parameter of ambulatory 24-hour esophageal pH monitoring. Am J Gastroenterol 1988; 83: 35861.
  • 15
    Weusten BL, Roelofs JM, Akkermans LM, Van Berge-Henegouwen GP, Smout AJ. The symptom-association probability: an improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology 1994; 107: 17415.
  • 16
    Cigrang JA, Hunter CM, Peterson AL. Behavioral treatment of chronic belching due to aerophagia in a normal adult. Behav Modif 2006; 30: 34151.
  • 17
    Garcia D, Starin S, Churchill RM. Treating aerophagia with contingent physical guidance. J Appl Behav Anal 2001; 34: 8992.
  • 18
    Chitkara DK, Bredenoord AJ, Talley NJ, Whitehead WE. Aerophagia and rumination: recognition and therapy. Curr Treat Options Gastroenterol 2006; 9: 30513.
  • 19
    Hemmink GJ, Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Supragastric belching in patients with reflux symptoms. Neurogastroenterol Motil 2008; 20: A84.