What causes excessive burping?

Causes of Excessive Burping

Excessive burping is primarily caused by supragastric belching—a behavioral disorder where air is sucked into the esophagus from the pharynx and immediately expelled without reaching the stomach—rather than true gastric belching from swallowed air accumulation. 1

Primary Mechanisms

Supragastric Belching (Most Common in Excessive Belchers)

• Patients who belch excessively invariably exhibit an increased incidence of supragastric, not gastric belches. 2
• Air is sucked or injected into the esophagus from the pharynx and expelled immediately before reaching the stomach 1, 2
• Occurs in up to 3.4% of patients with upper GI symptoms and is strongly associated with anxiety 1
• This is a behavioral disorder, not a physiological problem 3, 4

Gastric Belching (Less Common but Physiologic)

• Results from spontaneous transient relaxation of the lower esophageal sphincter, allowing air transport from the stomach through the esophagus 1, 5
• Occurs less frequently and with greater force than supragastric belching 1
• This is the normal physiological mechanism for venting excessive gastric air 3

Associated Medical Conditions

Gastroesophageal Reflux Disease (GERD)

• Present in up to 50% of patients with GERD 1, 5
• Forward-leaning position facilitates transient lower esophageal sphincter relaxation, triggering gastric belching 5

Functional Dyspepsia

• Belching commonly occurs with functional dyspepsia, particularly when impaired gastric accommodation is present 1, 5

Gastroparesis

• Delayed gastric emptying allows prolonged bacterial fermentation and gas accumulation 6, 5
• Should be ruled out in patients with concomitant nausea and vomiting 1

Structural Abnormalities

• Hiatal and paraesophageal hernias can cause belching 1
• Post-Nissen fundoplication patients may develop belching due to impaired gastric accommodation 1

Psychological Factors

• Anxiety is strongly associated with supragastric belching 1

Distinguishing Aerophagia from Excessive Belching

Aerophagia is distinct from excessive belching and should not be confused. 4

• In aerophagia, excessive swallowing of air increases intragastric and intestinal gas 1
• Primary symptoms are bloating, abdominal distention, and flatulence—not belching 1, 4
• Excess air moves to the intestines and colon rather than being expelled orally 1
• Abdominal X-rays show excessive intestinal gas accumulation 1

Diagnostic Approach

When to Pursue Diagnostic Testing

• Belching is bothersome enough to disrupt usual activities and occurs more than 3 days per week 1, 5
• Rome IV defines this threshold as "excessive belching" warranting evaluation 1

Esophageal Physiology Testing

• High-resolution esophageal manometry with impedance monitoring differentiates gastric from supragastric belching 1, 6, 5
• Ambulatory impedance monitoring for at least 90 minutes (24-hour preferred) provides definitive diagnosis 1
• In supragastric belching, manometry shows upper esophageal relaxation with air flowing into the esophagus then expelled orally before reaching the stomach 1

Additional Testing for Associated Conditions

• Consider PPI trial if GERD-related gastric belching is suspected 1, 5
• Rule out gastroparesis with gastric emptying study if nausea and vomiting are present 1
• H. pylori stool or breath testing should be offered, as this infection can alter gastric function 6

Red Flags Requiring Further Evaluation

• Age ≥55 years with new-onset symptoms 6, 5
• Weight loss >10% or signs of malnutrition 6, 5
• GI bleeding or iron-deficiency anemia 7, 5
• Severe dysphagia suggesting structural obstruction 5
• Chronic diarrhea or constipation suggesting underlying bowel disorder 6

Common Pitfalls

• Do not confuse excessive belching with aerophagia—they have different mechanisms, symptoms, and treatments 1, 4
• Do not perform exploratory laparotomy in patients with aerophagia, as they do not have ileus despite abdominal distention 8
• Most patients with excessive belching have supragastric belching (behavioral), not gastric belching (physiologic) 2
• Belching may be a concomitant symptom rather than the primary problem—address underlying GERD or functional dyspepsia first 3, 9