Belching Disorder

Belching disorder is a functional gastroduodenal disorder in which repetitive, bothersome belching occurs more than 3 days per week for at least 3 months (symptom onset at least 6 months earlier).

• Two types:
  • Supragastric belching: air is sucked or injected into the oesophagus and expelled almost immediately before reaching the stomach, a learned behavioural response. Impedance studies show air entering the oesophagus then leaving within seconds.
  • Gastric belching: physiological venting of swallowed air from the stomach through transient lower oesophageal sphincter relaxation, exaggerated by aerophagia.
• Triggers: carbonated drinks, rapid eating, chewing gum, hard sweets, smoking, ill fitting dentures, anxiety, gastro oesophageal reflux, dyspepsia (patients learn that belching relieves discomfort and repeat the behaviour), eating while talking.
• Associated: functional dyspepsia, gastro oesophageal reflux disease, anxiety and depression, rumination syndrome (distinguish).
• Common in adults and in those with learning difficulty; generally benign with a chronic, relapsing pattern.

• Frequent, loud, audible belching, often in series, many times per hour; distressing socially.
• Supragastric belching: belches occur at rest, often during conversation or when anxious, abate during sleep and eating; the person may feel a sensation of air being drawn in just before the belch.
• Symptoms may include bloating, abdominal distension, epigastric fullness, chest pressure and throat discomfort.
• No weight loss or vomiting in primary belching disorder.
• Red flags: dysphagia, odynophagia, persistent vomiting, weight loss, anaemia, gastrointestinal bleeding, age over 55 with new onset symptoms, family history of upper gastrointestinal cancer, progressive symptoms.
• Examination is usually normal; observation may show air gulping, chest wall movement and neck muscle activity with each belch.

• Clinical diagnosis from the typical history (repetitive belching more than 3 days per week for at least 3 months, with onset at least 6 months earlier) and observation during the consultation.
• Limited investigation unless alarm features: full blood count, ferritin, coeliac serology, Helicobacter pylori stool antigen or urea breath test in dyspepsia, upper gastrointestinal endoscopy if alarm features or age over 55 with new dyspepsia.
• Specialist tests: oesophageal high resolution impedance manometry (confirms supragastric belching) and pH-impedance monitoring (identifies reflux association).
• Differential: rumination syndrome, gastroparesis, gastro oesophageal reflux disease, aerophagia from CPAP therapy, functional dyspepsia, giardiasis, small intestinal bacterial overgrowth.

• Explanation and reassurance that the behaviour is learned, harmless and reversible.
• Lifestyle: avoid carbonated drinks, chewing gum, hard sweets, drinking through straws; eat slowly with the mouth closed; avoid talking while eating; stop smoking; review dentures; limit alcohol.
• Behavioural therapy (first line for supragastric belching): speech language therapy or physiotherapy led diaphragmatic breathing. Technique: lie or sit, one hand on the abdomen and one on the chest, breathe in through the nose so the abdomen rises, exhale slowly through pursed lips with the abdomen falling; practise for 5 to 10 minutes, four times daily, then apply as soon as the urge to belch occurs; hold the jaw slightly open with the tongue tip behind the lower teeth to block air entry. Typically 4 to 6 sessions.
• Cognitive behavioural therapy or hypnotherapy for those with marked anxiety.
• Drug therapy where reflux or dyspepsia contributes:
  • Omeprazole 20 mg orally once daily before breakfast for 4 to 8 weeks.
  • Baclofen 5 mg orally three times daily, increased to 10 mg three times daily if needed (reduces transient lower oesophageal sphincter relaxation); caution in the elderly, renal impairment and epilepsy; withdraw gradually.
  • Simeticone 80 to 120 mg orally after meals and at bedtime (maximum 500 mg per day) has limited evidence.
• Avoid unnecessary repeated endoscopy.
• Follow up at 6 to 8 weeks; refer to a gastroenterologist for refractory cases or if rumination or diagnostic uncertainty.