What could be causing belching, fluttering and pulsating sensations in the right upper abdomen and right sternal border?

Differential Diagnosis and Evaluation of Right Upper Quadrant Pulsations with Belching

The combination of belching with pulsating sensations in the right upper abdomen and right sternal border most likely represents either excessive supragastric belching (a behavioral disorder) or, less commonly, abdominal aortic pulsations that are simply more perceptible, though cardiac causes including angina must be excluded given the atypical but documented presentation of belching as an angina symptom. 1, 2

Primary Diagnostic Considerations

Gastrointestinal Causes (Most Likely)

Excessive supragastric belching is the most probable diagnosis when belching is the predominant symptom, particularly if occurring at high frequency (up to 20 times per minute). 1, 3

• Supragastric belching occurs when air is sucked into the esophagus or injected by pharyngeal contraction and immediately expelled, rather than originating from the stomach. 3
• This is classified as a behavioral disorder and is commonly associated with anxiety and obsessive-compulsive disorder. 4
• The "fluttering" sensation may represent the repetitive esophageal contractions associated with the belching episodes. 1

High-frequency diaphragmatic flutter is a rare but specific cause of belching with pulsating sensations, characterized by involuntary diaphragmatic contractions at 9-15 Hz that can present with belching, hiccups, and epigastric pulsations. 5

• This diagnosis is established by electromyography showing repetitive discharges at 9-15 Hz in the diaphragm and intercostal muscles. 5
• Treatment with carbamazepine 200-400 mg three times daily leads to resolution or significant improvement. 5

Hepatobiliary Causes

Right upper quadrant ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology as the first-line imaging study for RUQ pain evaluation. 6, 7

• Biliary colic can be triggered by increased intra-abdominal pressure during Valsalva maneuvers (which occur during belching), precipitating gallbladder contraction if cholelithiasis is present. 7
• Ultrasound has 81% sensitivity and 83% specificity for acute cholecystitis. 7
• If ultrasound is negative or equivocal, cholescintigraphy (HIDA scan) has superior diagnostic accuracy with 96% sensitivity and 90% specificity. 7

Vascular Causes

Palpable abdominal aortic pulsations can be felt at the level of the umbilicus in normal individuals, and heightened awareness or anxiety can make these normal pulsations more perceptible in the right upper abdomen. 6

• The abdominal aorta is the lower part of the aorta prior to its bifurcation to the iliac arteries. 6
• Pulsations in the right upper quadrant specifically may represent transmitted aortic pulsations or hepatic artery pulsations. 6

Cardiac Causes (Critical to Exclude)

Belching can be an atypical presenting symptom of angina pectoris and must be excluded, particularly in patients with cardiac risk factors. 2

• A documented case report describes a 62-year-old male presenting with belching as the chief and only complaint who was found to have angina requiring surgical treatment. 2
• Angina can present with vague symptoms including belching, nausea, and mild chest discomfort rather than classic chest pain. 2
• The right sternal border location of symptoms raises concern for cardiac origin. 2

Recommended Diagnostic Algorithm

Step 1: Immediate Clinical Assessment

Obtain a detailed history focusing on the frequency and timing of belching episodes, cardiac risk factors, and relationship to meals or exertion. 1, 2

• If belching occurs at very high frequency (>20 times per minute) and is reproducible during examination, supragastric belching is most likely. 3
• If symptoms occur with exertion or are associated with dyspnea, chest discomfort, or diaphoresis, cardiac evaluation takes priority. 2
• Assess for anxiety, obsessive-compulsive behaviors, or other psychiatric comorbidities that suggest behavioral etiology. 4

Step 2: Initial Diagnostic Testing

Order an electrocardiogram and consider cardiac biomarkers if any concern for cardiac etiology exists, as belching can mask angina. 2

Obtain right upper quadrant ultrasound as the first-line imaging study to evaluate for biliary pathology. 6, 7

• This should specifically evaluate for cholelithiasis, gallbladder wall thickening, and bile duct dilatation. 7
• Complete metabolic panel including liver function tests should be obtained concurrently. 7

Step 3: Advanced Testing if Initial Workup is Negative

If cardiac and biliary causes are excluded and belching remains the predominant symptom, consider multichannel intraluminal impedance and pH testing to definitively diagnose gastric versus supragastric belching. 4

• Gastric and supragastric belching have distinct appearances on impedance tracing. 4
• This testing can quantify belching frequency and guide behavioral therapy. 4

If the "fluttering" sensation is prominent, consider electromyography of the diaphragm and intercostal muscles to evaluate for high-frequency diaphragmatic flutter. 5

• Look for repetitive discharges at 9-15 Hz on EMG. 5
• Spirographic tracings showing high-frequency oscillations (9-15 Hz) superimposed on tidal breathing support this diagnosis. 5

If ultrasound is equivocal or negative but biliary symptoms persist, proceed to CT abdomen/pelvis with IV contrast or cholescintigraphy. 7

• CT has greater than 95% sensitivity for detecting colonic pathology and alternative diagnoses. 7
• HIDA scan is superior to ultrasound for acute cholecystitis diagnosis. 7

Treatment Approach

For Supragastric Belching (Behavioral Disorder)

Behavioral therapy is the treatment of choice for excessive supragastric belching, not pharmacologic therapy. 1, 4, 3

• Speech therapy, cognitive-behavioral therapy, and diaphragmatic breathing exercises have shown promise in management. 4
• There are no pharmacologic therapies specifically targeted toward belching disorders. 4
• Treatment of underlying anxiety or obsessive-compulsive disorder may improve symptoms. 4

For High-Frequency Diaphragmatic Flutter

Carbamazepine 200-400 mg three times daily is the treatment of choice if high-frequency diaphragmatic flutter is confirmed by EMG. 5

• This leads to disappearance or great improvement of flutter and clinical symptoms. 5

For Biliary Pathology

If cholelithiasis or cholecystitis is identified, standard surgical or medical management should be pursued according to severity. 7

Critical Pitfalls to Avoid

Do not dismiss belching as a trivial symptom without excluding cardiac causes, particularly in patients over 60 or with cardiac risk factors. 2

• Belching can be the sole presenting symptom of angina pectoris requiring surgical intervention. 2

Do not proceed directly to CT imaging without first obtaining ultrasound, unless the patient is hemodynamically unstable. 7

• Ultrasound is more appropriate for initial evaluation and avoids unnecessary radiation exposure. 7

Do not perform exploratory laparotomy in patients with aerophagia and abdominal distention, as they do not have ileus. 1

• This is a behavioral disorder requiring behavioral interventions, not surgical exploration. 1

Recognize that belching disorders are commonly associated with gastroesophageal reflux disease and functional dyspepsia. 4, 3

• Treat these predominant symptoms first before focusing on belching as an isolated complaint. 3

Understand that while belching is not associated with increased mortality, it significantly impairs health-related quality of life and warrants appropriate evaluation and treatment. 4