Aerophagia

Aerophagia is repetitive, excessive swallowing of air, causing visible abdominal distension, belching and flatulence.

• Rome IV classes it as a functional gastroduodenal disorder: belching disorders divided into excessive supragastric belching and gastric belching (aerophagia).
• Mechanism: air is swallowed (excessive aerophagia) or sucked into the oesophagus and expelled immediately (supragastric belching) through a learned behavioural response.
• Causes: anxiety, rapid eating, gum chewing, carbonated drinks, smoking, poorly fitting dentures, intellectual disability, nasogastric tubes, CPAP therapy, gastro oesophageal reflux disease.
• Prevalence is uncertain, up to 10% of patients with chronic abdominal bloating.
• Complications: severe bloating, abdominal pain, social embarrassment; no organic consequences.

• Frequent audible belching (supragastric belching, occurring multiple times per minute), abdominal distension and bloating, particularly after meals and later in the day.
• Flatulence, epigastric discomfort, nausea.
• Observable swallowing of air or sucking motions during interview.
• Symptoms disappear during sleep.
• Differential diagnosis: gastro oesophageal reflux, gastroparesis, functional dyspepsia, small bowel bacterial overgrowth, lactose intolerance, celiac disease, constipation.

• Clinical diagnosis based on history and observation of air swallowing.
• Esophageal impedance manometry confirms supragastric belching (rapid air influx into the oesophagus followed by expulsion).
• Abdominal radiograph: gaseous distension of the stomach and bowel.
• Exclude organic disease where alarm features exist: endoscopy, celiac serology, hydrogen breath tests, gastric emptying study.
• Review medications and device use (CPAP).

• Education and behavioural advice: eat slowly with the mouth closed, avoid gum chewing, carbonated beverages, hard sweets, straws, and smoking.
• Speech therapy or diaphragmatic breathing training with relaxation of the pharyngeal muscles; biofeedback improves supragastric belching (symptom reduction in over 50%).
• Treat anxiety or depression: cognitive behavioural therapy, SSRIs where indicated.
• Baclofen 5 to 10 mg three times daily can reduce supragastric belching.
• Simethicone 125 mg after meals has little evidence beyond placebo.
• Adjust dentures and CPAP pressure settings or use CPAP with heated humidity and expiratory relief.
• Treat coexisting gastro oesophageal reflux with a PPI (omeprazole 20 mg daily).
• Manage constipation, avoid lactose and fermentable carbohydrates (low FODMAP trial) if bloating persists.
• Review in 4 to 8 weeks.