How to manage belching?

Management of Belching

Behavioral strategies, particularly diaphragmatic breathing and cognitive behavioral therapy, are the most effective treatments for belching, especially for supragastric belching which is often a learned behavior. 1

Types of Belching and Their Mechanisms

• Gastric belching: Physiological venting of swallowed air from the stomach, characterized by transient relaxation of the lower esophageal sphincter followed by air transport from stomach through esophagus 1
• Supragastric belching: A behavioral disorder where air is sucked into the esophagus and immediately expelled without reaching the stomach, often occurring through two mechanisms:
  • Air-suction method: Air flows through pressure gradient from UES relaxation 1
  • Air-injection method: Air influx into upper esophagus via elevated pharyngeal pressure 1
• Aerophagia: Excessive swallowing of air that enters the stomach and intestines, causing bloating and abdominal distention 2

Diagnostic Approach

• Distinguish between gastric and supragastric belching, as treatment approaches differ 1
• Note that supragastric belching stops during sleep, distraction, or when speaking, indicating psychological factors 1
• Consider association with GERD, as gastric belching may be clinically associated with reflux disease 1
• High-resolution esophageal manometry with impedance monitoring can differentiate between types of belching 1

Treatment Algorithm

Step 1: Patient Education

• Explain the pathophysiology of belching to establish understanding and collaborative treatment 1
• Help patients become aware of the reasons for their symptoms, especially for supragastric belching which is often a learned behavior 1

Step 2: Behavioral Interventions (First-Line)

• Diaphragmatic breathing: Increases vagal tone, induces relaxation, reduces stress response 1
  • Video resource available at: https://romedross.video/3azBfEE 1
• Cognitive behavioral therapy (CBT): Reduces supragastric belching episodes and improves quality of life 1
• Speech therapy: Particularly helpful for excessive belching 3, 4

Step 3: Additional Therapies Based on Type

• For gastric belching associated with GERD:
  • Combine diaphragmatic breathing with proton pump inhibitor therapy 1
  • Note that supragastric belching before reflux activity does not respond to PPI therapy, while supragastric belching after reflux episodes may respond 1
• For supragastric belching:
  • Brain-gut behavioral therapies (BGBTs) such as relaxation training and gut-directed hypnotherapy 1
  • Central neuromodulators may be combined with behavioral therapies 1
• For aerophagia:
  • Address air swallowing behavior through awareness techniques 5
  • Focus on treating bloating and abdominal distention rather than belching 2

Special Considerations

• Psychosocial factors often trigger supragastric belching, including anxiety and life events 1
• Belching may be conditioned to reduce bloating sensation via air release 1
• In belching disorder due to supragastric belching, reflux episodes are typically nonacidic, explaining lack of response to PPIs 1
• Avoid exploratory laparotomy in patients with aerophagia as they do not have ileus 6

Treatment Efficacy

• Recent studies show behavioral strategies are most effective for supragastric belching 1
• For GERD with belching, combination therapy (behavioral + medication) shows better outcomes than medication alone 7
• In PPI-refractory GERD with excessive supragastric belching, psychological approaches combined with conventional treatment improve outcomes 7