What are the treatment options for excess burping?

Treatment Options for Excess Burping

The most effective treatment for excess burping (belching) is behavioral therapy, particularly diaphragmatic breathing exercises, which should be the first-line approach for most patients with supragastric belching. 1

Types of Belching and Diagnosis

Belching can be classified into two main types, which require different treatment approaches:

1. Supragastric belching (voluntary) - Most common cause of excessive belching

   • Air is sucked or injected into the esophagus and immediately expelled
   • Often occurs frequently (up to 20 times per minute)
   • Stops during sleep, distraction, or speaking
   • Associated with psychological factors like anxiety
   • Diagnosed via impedance monitoring showing proximal-to-distal air movement

2. Gastric belching (involuntary) - Normal physiological process

   • Air originates from the stomach following transient relaxation of lower esophageal sphincter
   • Occurs less frequently and with greater force than supragastric belching
   • Often associated with GERD (occurs in up to 50% of GERD patients)
   • Diagnosed via impedance monitoring showing distal-to-proximal air movement

3. Aerophagia - Different from pure belching disorder

   • Excessive swallowing of air that accumulates in intestines
   • Primary symptoms are bloating and abdominal distention rather than belching
   • Can be identified by intestinal gas accumulation on abdominal X-rays

Treatment Algorithm

For Supragastric Belching (most common cause of excessive belching):

1. First-line: Behavioral strategies

   • Patient education and psychoeducation about the mechanism of belching 1
   • Diaphragmatic breathing exercises (increases vagal tone, induces relaxation) 1
   • Cognitive behavioral therapy (CBT) - reduces belching episodes and improves quality of life 1
   • Speech therapy to address the behavioral component 2, 3

2. For belching associated with GERD:

   • Combine diaphragmatic breathing with PPI therapy 1
   • Consider baclofen if related to excess transient relaxations of lower esophageal sphincter 1, 4

3. For refractory cases:

   • Consider other brain-gut behavioral therapies (BGBTs) such as relaxation training and gut-directed hypnotherapy 1
   • Central neuromodulators may be considered in combination with behavioral therapies 1

For Gastric Belching:

1. If associated with GERD:

   • Proton pump inhibitor (PPI) therapy 1
   • Lifestyle modifications for reflux 1
   • Consider fundoplication if severe pathologic GERD 1

2. If associated with gastroparesis:

   • Rule out gastroparesis in patients with nausea and vomiting 1
   • Treat the underlying gastroparesis

Special Considerations

• Diagnostic testing: For patients with persistent symptoms affecting quality of life, consider ambulatory impedance monitoring with or without high-resolution manometry (for at least 90 minutes; 24-hour impedance preferred) to differentiate between types of belching 1

• Associated conditions: Always evaluate for other conditions that may present with belching:

  • Gastroesophageal reflux disease (GERD)
  • Functional dyspepsia
  • Rumination syndrome (rule out with HRM with impedance) 1
  • Hiatal or paraesophageal hernias
  • Post-Nissen fundoplication issues 1

• Pitfalls to avoid:

  • Don't assume all belching is the same - treatment differs based on type
  • Avoid unnecessary medication if behavioral therapy can address the issue
  • Don't overlook psychological factors that may be triggering supragastric belching
  • Recognize that belching often stops during distraction, which supports its behavioral nature 1
  • Avoid treating with PPIs alone for supragastric belching as reflux episodes are typically nonacidic 1

The 2023 American Gastroenterological Association Clinical Practice Update strongly supports behavioral interventions as the most effective approach for most patients with excessive belching, particularly the supragastric type, which represents the majority of cases presenting for treatment 1.