What are the common causes of excessive burping and nausea?

Common Causes of Excessive Burping and Nausea

Excessive burping with nausea most commonly results from gastroesophageal reflux disease (GERD), gastroparesis, functional dyspepsia, or behavioral disorders like supragastric belching—each requiring distinct diagnostic and treatment approaches. 1

Primary Causes When Both Symptoms Coexist

GERD-Related Gastric Belching

• Gastric belching occurs in up to 50% of patients with GERD and involves spontaneous transient relaxation of the lower esophageal sphincter, allowing air and gastric contents to move from stomach to esophagus 1
• Nausea accompanies GERD when acid reflux triggers vagal stimulation or when delayed gastric emptying coexists 1
• Start PPI therapy (omeprazole 20 mg daily) combined with lifestyle modifications for reflux if GERD is the suspected cause 1, 2

Gastroparesis (Delayed Gastric Emptying)

• Gastroparesis is a common cause of nausea, vomiting, and upper gut symptoms, occurring in 20-40% of diabetic patients and 25-40% of functional dyspepsia patients 1
• Clinical symptoms include nausea, vomiting, postprandial abdominal fullness, and early satiety 1
• Belching occurs when impaired gastric accommodation leads to increased intragastric pressure 1
• Diagnosis requires gastric emptying scintigraphy of a radiolabeled solid meal performed for 4 hours (2-hour tests are inaccurate) 1
• The radioisotope must be cooked into the solid portion of the meal for accurate results 1

Functional Dyspepsia

• Functional dyspepsia presents with chronic upper abdominal pain/discomfort, early satiety, nausea, and postprandial fullness/bloating 1
• Idiopathic gastroparesis may be one cause of functional dyspepsia, creating symptom overlap 1
• Belching is reported as a common associated symptom in these patients 1

Supragastric Belching (Behavioral Disorder)

• Supragastric belching occurs in up to 3.4% of patients with upper GI symptoms and is more commonly associated with anxiety 1
• Air is sucked or injected into the esophagus from the pharynx and expelled immediately orally—it never reaches the stomach 3, 4
• These patients are often misdiagnosed as PPI-refractory GERD because they present with reflux-like symptoms 3
• Nausea can accompany this when patients also have functional dyspepsia or anxiety disorders 1
• High-resolution esophageal manometry with impedance monitoring differentiates supragastric from gastric belching 1, 3

Secondary Causes to Consider

Food Intolerances and Carbohydrate Malabsorption

• Carbohydrate enzyme deficiencies (lactase, sucrase) and artificial sweeteners (sugar alcohols, sorbitol) commonly cause bloating and nausea 1, 5
• Undigested sugars create osmotic effects in the colon due to malabsorption 1
• Implement a 2-week dietary elimination trial targeting suspected foods as first-line diagnostic approach 6

Small Intestinal Bacterial Overgrowth (SIBO)

• SIBO increases sulfate-reducing bacteria producing excess hydrogen sulfide, causing nausea and belching 5
• High-risk patients include those with chronic watery diarrhea, malnutrition, weight loss, and systemic diseases causing small bowel dysmotility 6
• Hydrogen-based breath testing with glucose or lactulose confirms diagnosis 6

Helicobacter pylori Infection

• All patients with functional dyspepsia should receive stool or breath testing for H. pylori 6
• If positive, provide antibiotic eradication therapy 6

Aerophagia

• With aerophagia, excess swallowed air moves to intestines and colon, causing bloating and flatulence as main manifestations rather than excessive belching alone 1
• Nausea occurs when massive air accumulation causes abdominal distention 7
• Abdominal X-rays show excessive intestinal gas accumulation 1

Diagnostic Algorithm

Initial Clinical Assessment

• Differentiate vomiting from regurgitation, rumination, and bulimia through careful history 1
• Determine duration, frequency, severity of symptoms and associated features 1
• Identify if belching is bothersome enough to disrupt usual activities and occurs more than 3 days per week (meets Rome IV criteria for excessive belching) 1

Diagnostic Testing Based on Presentation

For predominant belching with nausea:

• Ambulatory impedance monitoring ± high-resolution manometry for at least 90 minutes (24-hour preferred) differentiates gastric from supragastric belching 1, 3
• Upper esophageal sphincter relaxation with air flowing into esophagus then expelled orally indicates supragastric belching 1
• Consider 24-hour impedance-pH monitoring if GERD suspected 1

For predominant nausea with belching:

• Gastric emptying scintigraphy (4-hour study) to evaluate for gastroparesis 1
• Rule out structural obstruction with upper endoscopy if alarm features present 1
• H. pylori testing (stool or breath test) 6

For refractory symptoms:

• Breath testing for carbohydrate malabsorption or SIBO 6
• Celiac serologic screening (tissue transglutaminase IgA and total IgA) 6

Treatment Approach

GERD-Related Gastric Belching

• PPI therapy (omeprazole 20 mg daily) with lifestyle modifications 1, 2
• Consider baclofen if related to excess transient lower esophageal sphincter relaxations 1
• Consider fundoplication if severe pathologic GERD 1

Supragastric Belching (Behavioral)

• Brain-gut behavioral therapy (BGBT) is first-line treatment 1
• Diaphragmatic breathing techniques stop the abnormal muscle contractions generating supragastric belches 3, 6
• Psychoeducation by communicating impedance findings to patient 1
• PPIs are typically ineffective as reflux episodes are usually non-acidic 2

Gastroparesis

• Dietary modifications (small, frequent meals; low fat, low fiber) 1
• Prokinetic agents may be considered, though metoclopramide carries risk of extrapyramidal symptoms (0.2% with standard dosing, 25% in patients <30 years with high doses) 8
• Antiemetics for nausea control 1

Food Intolerance/Malabsorption

• 2-week dietary restriction trial with symptom resolution as positive predictor 6
• Avoid lactose, fructose, FODMAPs, sugar alcohols, sorbitol based on suspected trigger 1, 5
• Reserve breath testing for patients refractory to dietary restrictions 6

SIBO

• Rifaximin is most studied antibiotic, though systemically absorbed alternatives exist—requires careful patient selection 6

Red Flags Requiring Urgent Evaluation

• Age ≥55 years with new-onset symptoms 6
• Weight loss >10% or signs of malnutrition 6
• GI bleeding or iron-deficiency anemia 6
• Family history of inflammatory bowel disease or GI malignancy 6
• Severe abdominal pain or progressive symptoms 5

Common Pitfalls to Avoid

• Do not misdiagnose supragastric belching as PPI-refractory GERD—these patients need behavioral therapy, not escalating acid suppression 3
• Do not perform exploratory laparotomy in aerophagia patients—they do not have ileus despite abdominal distention 7
• Do not use 2-hour gastric emptying studies—they are inaccurate for diagnosing gastroparesis 1
• Do not assume all belching responds to PPIs—only GERD-related gastric belching benefits 2
• Recognize that bloating with belching suggests aerophagia rather than isolated belching disorder 1