What causes belching that feels like something is stuck in the throat?

Belching with Throat Sensation: Causes and Clinical Approach

The sensation of something stuck in the throat with belching most commonly represents either supragastric belching (a behavioral disorder where air is sucked into the esophagus and immediately expelled) or globus sensation associated with gastroesophageal reflux disease (GERD), with anxiety frequently contributing to both conditions. 1

Understanding the Two Main Mechanisms

Supragastric Belching (Most Common Isolated Cause)

• This is a behavioral disorder where air flows into the esophagus from the pharynx and is expelled immediately, never reaching the stomach. 1
• The air-suction method involves upper esophageal sphincter (UES) relaxation occurring before air enters the esophagus, creating a pressure gradient that pulls air in. 1
• The air-injection method uses elevated pharyngeal pressure from tongue base contraction to push air into the upper esophagus. 1
• Patients can belch up to 20 times per minute, and the throat sensation results from the repetitive air movement through the pharyngeal and upper esophageal region. 2
• This occurs in up to 3.4% of patients with upper GI symptoms and is strongly associated with anxiety. 1

Gastric Belching with GERD (When Associated with Reflux)

• In gastric belching, air originates from the stomach through transient lower esophageal sphincter relaxation, then travels up the esophagus. 1
• The globus sensation (lump in throat) occurs when GERD causes referred pharyngeal symptoms, even though the pathology is in the distal esophagus or gastric cardia. 1
• This occurs in up to 50% of patients with GERD. 1

Critical Diagnostic Distinctions

Key Clinical Features to Identify

• Supragastric belching: Belching frequency is extremely high (multiple times per minute), occurs during consultation, worsens with stress, and patients have minimal other GI symptoms. 2, 3
• GERD-related: Heartburn, regurgitation, or epigastric pain accompany the throat sensation; belching is less frequent and involuntary. 1, 4
• Aerophagia (different entity): Primary symptoms are bloating and abdominal distension with visible intestinal gas on X-ray; belching is secondary, and flatulence is prominent. 1, 5, 6

Oropharyngeal Dysphagia Considerations

• Patients with true oropharyngeal dysphagia complain of food sticking in the throat or globus sensation, often with coughing/choking during swallowing. 1
• However, abnormalities of the distal esophagus or gastric cardia can cause referred dysphagia to the pharynx, whereas pharyngeal abnormalities rarely cause referred symptoms. 1
• If dysphagia accompanies the belching and throat sensation, a biphasic esophagram with video fluoroscopy of the pharynx AND complete esophageal evaluation is mandatory to avoid missing distal pathology. 1

Diagnostic Algorithm

Step 1: Clinical History Determines Next Steps

• If belching is extremely frequent (>10/minute), voluntary, and worsens during conversation: Supragastric belching is the diagnosis; proceed directly to behavioral therapy without extensive testing. 1, 2
• If heartburn, regurgitation, or epigastric pain are present: GERD is likely contributing; trial PPI therapy and consider upper endoscopy if alarm features exist. 4
• If bloating and abdominal distension predominate with visible abdominal distension: Consider aerophagia or functional bloating; obtain plain abdominal X-ray. 5, 6

Step 2: When Diagnostic Testing Is Needed

• High-resolution esophageal manometry with impedance monitoring definitively differentiates supragastric from gastric belching and aerophagia. 1
• This testing is indicated when: the diagnosis is uncertain, symptoms are refractory to empiric treatment, or the patient requires objective confirmation before committing to behavioral therapy. 1
• For unexplained throat symptoms with belching, combined video fluoroscopy of the pharynx with complete esophageal evaluation has higher diagnostic yield than either test alone. 1

Step 3: Rule Out Rare Structural Causes

• Retrograde cricopharyngeal dysfunction (RCPD) causes inability to belch normally, leading to chest pain, gurgling noises, and gas returning to the stomach. 7
• RCPD is validated by manometry showing failed cricopharyngeus relaxation during belching attempts (though normal during swallowing). 7
• Hiatal hernias and paraesophageal hernias can cause belching with throat symptoms through impaired gastric accommodation. 1

Treatment Approach

For Supragastric Belching (Primary Treatment)

• Speech therapy or cognitive behavioral therapy is first-line treatment, as this is fundamentally a behavioral disorder. 1, 2, 8
• Diaphragmatic breathing techniques reduce the frequency of supragastric belching episodes. 4
• PPIs are ineffective for isolated supragastric belching because reflux episodes are typically non-acidic. 4
• Address underlying anxiety, as it is strongly associated with supragastric belching. 1

For GERD-Associated Belching

• Full-dose PPI therapy (e.g., omeprazole 20 mg daily) combined with lifestyle modifications for reflux. 4
• Diaphragmatic breathing combined with PPI therapy improves symptoms when belching is associated with GERD. 4
• If epigastric pain is the predominant symptom with belching, PPI therapy is specifically recommended. 4

For Retrograde Cricopharyngeal Dysfunction

• Botulinum toxin injection into the cricopharyngeus muscle is first-line treatment. 7

Common Pitfalls to Avoid

• Do not perform exploratory laparotomy in patients with aerophagia and abdominal distension—they do not have ileus. 8
• Do not assume all throat sensations with belching represent local pharyngeal pathology—distal esophageal or gastric cardia lesions commonly cause referred pharyngeal symptoms. 1
• Do not prescribe PPIs for isolated supragastric belching without GERD—they will not work and delay appropriate behavioral intervention. 4
• Do not overlook anxiety as a contributing factor—it is present in the majority of supragastric belching cases and must be addressed for successful treatment. 1