How can I reduce belching (burping)?

Strategies to Reduce Belching (Burping)

The most effective treatment for reducing belching is behavioral strategies, particularly diaphragmatic breathing, which increases vagal tone, induces relaxation, and reduces stress response. 1

Understanding Types of Belching

Different types of belching require different management approaches:

• Supragastric belching: Air is sucked into the esophagus or injected by pharyngeal contraction and immediately expelled without reaching the stomach 2, 3

  • Often a behavioral disorder
  • Can occur at very high frequencies (up to 20 times per minute)
  • Typically stops during sleep, distraction, or when speaking 1

• Gastric belching: Physiological venting of excessive gastric air 2

  • Associated with transient relaxation of the lower esophageal sphincter
  • Often associated with GERD 1

• Aerophagia: Excessive swallowing of air that moves to intestines and colon 1

  • Primarily causes bloating and abdominal distention
  • Belching is a less prominent symptom 2

First-Line Treatment Approaches

For Supragastric Belching (Most Common Type of Excessive Belching)

1. Patient education and awareness:

   • Explain the mechanism of belching to establish understanding 1
   • Help patients recognize when they are engaging in the behavior 1

2. Diaphragmatic breathing exercises:

   • Most effective behavioral strategy for supragastric belching 1
   • Increases vagal tone and induces relaxation 1
   • Video resource available at: https://romedross.video/3azBfEE 1

3. Cognitive Behavioral Therapy (CBT):

   • Reduces supragastric belching episodes 1
   • Improves quality of life 1
   • Addresses psychological factors that modulate belching frequency 1

4. Other brain-gut behavioral therapies:

   • Relaxation training 1
   • Gut-directed hypnotherapy 1

For Gastric Belching Associated with GERD

1. Proton Pump Inhibitor (PPI) therapy:

   • Particularly when belching is associated with GERD symptoms 1
   • Most effective when combined with diaphragmatic breathing 1

2. Lifestyle modifications for reflux:

   • Address underlying GERD if present 4
   • May include dietary changes and positional therapy 4

3. Consider baclofen:

   • May help if related to excess transient relaxation of lower esophageal sphincter 1

For Aerophagia

1. Address air swallowing behavior:

   • Increase awareness of swallowing patterns 4
   • Behavioral techniques to reduce air swallowing 4

2. Simethicone:

   • FDA-approved for relief of pressure and bloating commonly referred to as gas 5
   • Dosage: 1-2 softgels as needed after meals and at bedtime, not exceeding 2 softgels in 24 hours unless advised by physician 5

Diagnostic Considerations

If belching is severe and persistent:

• High-resolution esophageal manometry with impedance monitoring: Differentiates between gastric and supragastric belching 1
• 24-hour impedance pH monitoring: Preferred for accurate diagnosis 1
• Rule out rumination disorder: Can present with similar symptoms 1

Special Considerations

• Inability to belch (Retrograde Cricopharyngeal Dysfunction): Some patients may have the opposite problem - inability to burp, causing bloating, gurgling, and chest pain 6

  • Treatment may involve botulinum toxin injection into the cricopharyngeus muscle 6

• Belching with GERD: When belching coexists with GERD, address both conditions simultaneously 7

  • PPI-refractory GERD with excessive belching may benefit from combined psychological approach and conventional treatment 7

Common Pitfalls to Avoid

• Overuse of simethicone: While helpful for gas symptoms, it doesn't address the behavioral component of supragastric belching 5

• Focusing only on medication: Behavioral strategies are more effective than medications for supragastric belching 8

• Ignoring psychological factors: Anxiety and stress can significantly contribute to belching disorders 1

• Misdiagnosing aerophagia as requiring surgical intervention: Patients with aerophagia should not undergo explorative laparotomy as they do not have ileus 8