What is the differential diagnosis for a patient presenting with burping?

Differential Diagnosis for Burping (Belching)

The differential diagnosis for burping depends critically on distinguishing between gastric belching (involuntary air from the stomach) and supragastric belching (voluntary behavioral disorder where air is sucked into the esophagus then immediately expelled), as these require completely different management approaches. 1

Primary Categories of Belching Disorders

Supragastric Belching (Behavioral)

• Most common cause of excessive isolated belching with frequencies up to 20 times per minute 1, 2
• Air is voluntarily sucked or injected into the esophagus from the pharynx and expelled immediately without reaching the stomach 3, 2
• Prevalence of 3.4% in patients with upper GI symptoms, strongly associated with anxiety 1
• Often misdiagnosed as PPI-refractory GERD 4

Gastric Belching (Physiologic)

• Occurs from spontaneous transient relaxation of the lower esophageal sphincter with air transport from stomach 1, 5
• Less frequent but more forceful than supragastric belching 1
• Can be normal or excessive depending on frequency and impact on daily activities 1

Aerophagia (Distinct from Belching)

• Excessive swallowing of air that moves to intestines and colon 1, 3
• Primary symptoms are bloating, distention, and flatulence rather than belching 1, 3
• Excessive intestinal gas visible on plain abdominal radiographs 3, 6

Associated Gastrointestinal Disorders

Gastroesophageal Reflux Disease (GERD)

• Belching reported in up to 50% of GERD patients 1
• Gastric belching can contribute when GERD causes transient lower esophageal sphincter relaxations 5
• Consider PPI therapy if GERD-related gastric belching is present 1, 5

Functional Dyspepsia (FD)

• Belching commonly coexists with FD symptoms 1
• Up to 50% overlap with IBS 1
• One-third have coexisting GERD symptoms 1
• Eating disorders increasingly recognized in FD patients 1

Gastroparesis

• Delayed gastric emptying allows prolonged bacterial fermentation producing gas 5
• Consider in subset with nausea and vomiting 1
• Rule out with appropriate testing if suspected 1

Post-Surgical Causes

• Post-Nissen fundoplication with impaired gastric accommodation 1
• Hiatal and paraesophageal hernias 1
• Previous surgical interventions for misattributed symptoms 1

Infectious and Microbial Causes

H. pylori Infection

• Alters gastric function and contributes to dyspeptic symptoms 5
• Breath or stool testing recommended 1, 5
• Eradication with appropriate antibiotic regimen if positive 5

Post-Infectious

• Previous acute enteric infection in ~10% of FD patients 1
• Associated pathogens: Norovirus, Giardia lamblia, Salmonella, E. coli O157, Campylobacter 1, 5

Small Intestinal Bacterial Overgrowth (SIBO)

• Increases sulfate-reducing bacteria producing excess hydrogen sulfide 5
• Consider in high-risk patients with chronic diarrhea, malnutrition, weight loss 7

Dietary and Metabolic Causes

High-Sulfur Food Intake

• Prolonged fermentation of sulfur-containing foods produces hydrogen sulfide gas 5
• 2-week dietary elimination trial recommended 5, 7

Carbohydrate Malabsorption

• Lactose intolerance, fructose intolerance, sucrase deficiency 1, 5
• Sugar alcohols and sorbitol increase bacterial fermentation 5, 7

Medication-Related Causes

• NSAIDs: Associated with dyspepsia in multiple population studies 1
• Opioids: Alter gut motility and delay gastric emptying 1
• Recent medication changes should be reviewed 1

Psychological and Behavioral Factors

• Anxiety: Strongly associated with supragastric belching 1
• Eating disorders: Increasingly recognized in patients with belching and dyspepsia 1
• Other functional disorders: Presence of non-GI chronic painful conditions supports functional diagnosis 1

Diagnostic Approach Algorithm

Step 1: Characterize the Belching Pattern

• Frequency (>3 days per week suggests disorder) 1
• Timing (during consultation suggests supragastric) 2
• Force (greater force suggests gastric) 1
• Associated symptoms (bloating/distention suggests aerophagia) 1, 3

Step 2: High-Resolution Manometry with Impedance

• Differentiates gastric from supragastric belching definitively 1
• Gastric: Shows transient lower esophageal sphincter relaxation with air from stomach 1
• Supragastric: Shows upper esophageal sphincter opening with air propagating through esophagus 1
• Aerophagia: Shows influx of air into esophagus with swallowing 1

Step 3: Rule Out Underlying Disorders

• H. pylori testing (breath or stool) in all patients 1, 5
• Endoscopy if age ≥40 years with family history of gastro-esophageal malignancy 1
• Full blood count if age ≥25 years 1
• Coeliac serology if IBS-type symptoms overlap 1
• Gastroparesis testing if nausea/vomiting present 1

Step 4: Consider Dietary Triggers

• 2-week trial reducing high-sulfur foods 5
• Avoid sugar alcohols and sorbitol 5
• Breath testing for carbohydrate malabsorption if dietary restriction fails 5, 7

Red Flags Requiring Urgent Evaluation

• Weight loss with dyspepsia if age ≥55 years 1
• Age >40 years from high-risk gastric cancer area 1
• Family history of gastro-oesophageal malignancy 1
• Abdominal pain with weight loss if age ≥60 years (urgent CT scan) 1

Common Pitfalls to Avoid

• Do not assume all excessive belching is GERD-related - supragastric belching will not respond to PPIs 4
• Do not confuse aerophagia with belching disorders - aerophagia presents primarily with bloating/distention, not belching 1, 3
• Do not perform exploratory laparotomy for aerophagia - these patients do not have ileus 6
• Do not overlook behavioral/psychological components - supragastric belching requires behavioral therapy, not acid suppression 1, 4