What is the cause of constant belching without heartburn or chest pain?

Constant Belching Without Heartburn or Chest Pain: Diagnosis and Management

This patient most likely has supragastric belching, a behavioral disorder where air is sucked into the esophagus from the pharynx and immediately expelled, rather than originating from the stomach. 1

Understanding the Two Types of Belching

The key to diagnosis is distinguishing between two mechanistically distinct disorders:

• Gastric belching (involuntary): Air transported from the stomach through the esophagus due to transient lower esophageal sphincter relaxation, often associated with GERD 1, 2
• Supragastric belching (voluntary/behavioral): Air flows into the esophagus then is expelled orally through the pharynx before reaching the stomach—this is a behavioral disorder, not a reflux problem 1, 2, 3

Since this patient denies heartburn and chest pain, GERD is unlikely to be the primary driver, making supragastric belching the most probable diagnosis. 1, 4

Clinical Features That Support Supragastric Belching

Look for these specific characteristics during evaluation:

• Extremely high frequency: Patients may belch up to 20 times per minute, often demonstrating this behavior during the consultation itself 1, 3, 5
• Absence of typical GERD symptoms: No heartburn, regurgitation, or chest pain suggests this is not gastric belching related to reflux 1
• Isolated symptom: Belching is the predominant or sole complaint without other gastrointestinal symptoms 1, 3
• Behavioral pattern: The belching is often worse during stress or when attention is focused on it 1, 6

Diagnostic Approach

For isolated excessive belching without heartburn, skip the empiric PPI trial and proceed directly to impedance-pH monitoring if available, or treat as a behavioral disorder based on clinical presentation. 1

The diagnostic pathway should be:

• Rule out cardiac causes first if any chest discomfort is present, even if the patient denies typical chest pain 1
• Impedance-pH monitoring can definitively classify belching type by showing whether air originates from the stomach or esophagus 1, 4
• Plain abdominal radiograph should be obtained to distinguish from aerophagia (excessive air swallowing with intestinal gas accumulation and abdominal distension) 1, 2, 3
• Do NOT perform empiric PPI therapy for isolated belching without reflux symptoms, as PPIs are ineffective for supragastric belching since reflux episodes are typically non-acidic 1, 7

Treatment Algorithm

The primary treatment for supragastric belching is behavioral therapy, specifically diaphragmatic breathing exercises and speech therapy—not acid suppression. 1

First-Line Treatment (Behavioral Interventions)

• Diaphragmatic breathing exercises: This is the most effective intervention for supragastric belching 1, 8
• Speech therapy or behavioral therapy: Addresses the underlying behavioral pattern of air intake 1, 3, 6, 5
• Cognitive behavioral therapy: May be beneficial when psychological comorbidities like anxiety are present 1

When to Consider Pharmacotherapy

Baclofen should be considered only if there is evidence of coexistent GERD with regurgitation, not for isolated supragastric belching. 1

• Baclofen: Reserved for regurgitation or belch-predominant symptoms when GERD is proven 1
• PPIs: Only effective if gastric belching related to GERD is documented, not for supragastric belching 1, 7

Critical Pitfalls to Avoid

Do not perform exploratory laparotomy or extensive gastrointestinal workup in patients with isolated excessive belching—this is a behavioral disorder requiring behavioral treatment. 1, 6

Common mistakes include:

• Prescribing long-term PPIs empirically: This is ineffective for supragastric belching and delays appropriate behavioral treatment 1, 7
• Extensive diagnostic testing: Barium studies, endoscopy, and esophageal manometry have little value in diagnosing belching disorders 1, 9
• Surgical intervention: Never indicated for supragastric belching or aerophagia 1, 6
• Treating as GERD without confirmation: The absence of heartburn and chest pain makes GERD unlikely as the primary cause 1

When to Investigate Further

Consider additional evaluation only if:

• Alarm symptoms develop: Weight loss >10%, dysphagia, odynophagia, or gastrointestinal bleeding 1, 2
• Coexistent symptoms emerge: Heartburn, regurgitation, or chest pain suggesting GERD 1
• Abdominal distension is prominent: Obtain plain abdominal X-ray to rule out aerophagia with intestinal gas accumulation 1, 2, 3
• Treatment failure: If behavioral therapy fails after adequate trial, consider impedance-pH monitoring to confirm diagnosis 1, 4