Evaluation and Management of Belching
The primary investigations for patients with belching should include clinical history, physical examination, and impedance pH monitoring to differentiate between gastric and supragastric belching, with treatment focused on brain-gut behavioral therapies including cognitive behavioral therapy, diaphragmatic breathing, and speech therapy. 1
Diagnostic Approach
Differentiating Types of Belching
- Clinical history and physical examination findings combined with impedance pH monitoring help differentiate between gastric belching (physiological) and supragastric belching (behavioral) 1
- Impedance monitoring objectively demonstrates physical symptoms, serving as the first step toward treatment when belching is a behavioral disorder 1
- Supragastric belching is characterized by air being drawn into or injected into the esophagus and immediately expelled without reaching the stomach 2
- In supragastric belching, reflux episodes are typically non-acidic, explaining the poor response to proton pump inhibitors 1, 2
When to Consider Additional Testing
- Abdominal imaging and upper endoscopy should only be ordered in patients with alarm features, recent worsening symptoms, or abnormal physical examination 1
- For patients with concurrent bloating and distention, Rome IV criteria should be used to diagnose primary abdominal bloating 1
- Consider carbohydrate enzyme deficiencies with dietary restriction and/or breath testing 1
- In at-risk patients, small bowel aspiration and hydrogen breath testing may evaluate for small intestinal bacterial overgrowth 1
- Serologic testing may rule out celiac disease in patients with belching and bloating 1
Special Considerations
- If belching is associated with constipation or difficult evacuation, anorectal physiology testing is suggested to rule out pelvic floor disorder 1
- Gastric emptying studies should not be routinely ordered for bloating and distention but may be considered if nausea and vomiting are present 1
- Consider fructose intolerance if belching is associated with bloating after consuming fructose-containing foods 3
Management Strategies
First-Line Treatments for Supragastric Belching
- Brain-gut behavioral therapies are the most effective treatment for supragastric belching 1, 2
- Diaphragmatic breathing increases vagal tone, induces relaxation, and reduces stress response 1, 2
- Cognitive behavioral therapy (CBT) reduces supragastric belching episodes and improves quality of life 1, 2
- Speech therapy can help address the behavioral component of supragastric belching 1, 2
Adjunctive Therapies
- Central neuromodulators may be considered to reduce visceral hypersensitivity and improve psychological comorbidities 1, 2
- For belching associated with GERD symptoms, combine diaphragmatic breathing with proton pump inhibitor therapy 1, 4
- Simple office-based procedures based on sustained glottal opening (breathing slowly with mouth open) can be effective for chronic eructation secondary to repetitive air swallowing 5
Dietary Considerations
- When dietary modifications are needed, a gastroenterology dietitian should preferably monitor treatment 1
- For fructose intolerance, consider a low-FODMAP diet which restricts fermentable carbohydrates including fructose 3
- Avoid or limit sugar-sweetened beverages containing high-fructose corn syrup and foods with added fructose as sweeteners if fructose intolerance is suspected 3
Common Pitfalls to Avoid
- Relying solely on proton pump inhibitors for supragastric belching is ineffective unless associated with acid reflux 4, 2
- Failing to recognize that supragastric belching is a learned behavior that often stops during sleep, distraction, or when speaking 2, 6
- Not addressing psychological factors that may contribute to belching disorders, particularly anxiety 2, 7
- Ordering unnecessary tests like gastric emptying studies for isolated belching symptoms 1
- Overlooking the importance of patient education about the pathophysiology of belching as a crucial first step in treatment 1