What is the best treatment approach for a patient with refractory belching, considering their past medical history and potential underlying gastrointestinal conditions?

Treatment of Refractory Belching

The most effective treatment for refractory belching is behavioral therapy with psychoeducation after confirming the diagnosis of supragastric belching through impedance monitoring with or without high-resolution manometry. 1

Diagnostic Differentiation is Critical

Before treating refractory belching, you must distinguish between two mechanistically distinct types:

• Gastric belching (involuntary): Air originates from the stomach due to transient lower esophageal sphincter relaxations (TLESRs), occurs less frequently but with greater force 1
• Supragastric belching (voluntary/behavioral): Air is sucked or injected into the esophagus from the pharynx and immediately expelled orally before reaching the stomach—this is the mechanism in virtually all patients with excessive, refractory belching 2, 3

Ambulatory impedance monitoring (preferably 24-hour) with or without high-resolution manometry for at least 90 minutes is required to differentiate these two types. 1 This is not optional for refractory cases, as treatment differs fundamentally.

Treatment Algorithm for Refractory Belching

Step 1: Rule Out GERD-Related Belching

• If belching is associated with heartburn, regurgitation, or occurs after reflux episodes, initiate PPI therapy with lifestyle modifications 1
• Supragastric belching that occurs after reflux episodes may respond to PPI therapy, whereas supragastric belching before reflux activity does not 1
• Consider baclofen if belching is related to excessive TLESRs in gastric belching 1
• Consider fundoplication only if severe pathologic GERD is documented and medical therapy fails 1

Step 2: Confirm Supragastric Belching and Initiate Behavioral Therapy

Once impedance monitoring confirms supragastric belching (the typical pattern in refractory cases):

• Communicate findings to the patient (psychoeducation): Show them the impedance tracings demonstrating that they are unconsciously sucking air into the esophagus and immediately expelling it—this biofeedback-like approach is the critical first step 1
• Diaphragmatic breathing exercises: This increases vagal tone, induces relaxation, reduces stress response, and directly interrupts the supragastric belching behavior 1
• Cognitive behavioral therapy (CBT): Reduces supragastric belching episodes, improves esophageal acid exposure, and enhances quality of life 1
• Brain-gut behavioral therapies (BGBTs): Including relaxation training and gut-directed hypnotherapy, combined with central neuromodulators if needed 1

Step 3: Rule Out Rumination Syndrome

• Use high-resolution manometry with impedance to exclude rumination disorder, as supragastric belches can trigger regurgitation episodes in rumination syndrome 1

Step 4: Consider Aerophagia if Intestinal Gas Accumulation is Present

• Aerophagia is distinct from supragastric belching: patients swallow air frequently and in large quantities, leading to excessive intestinal gas visible on abdominal X-rays, with bloating and distension as primary symptoms (not belching) 1, 2
• If aerophagia is confirmed, dietary modifications to avoid gas-producing foods (sugar alcohols, sorbitol) and behavioral therapy are indicated 1

Common Pitfalls to Avoid

• Do not treat refractory belching with PPIs alone unless GERD is documented and belching occurs after reflux episodes—most refractory belching is supragastric and behavioral, not acid-related 1
• Do not pursue invasive interventions (fundoplication, endoscopic therapies) without first confirming the mechanism via impedance monitoring—supragastric belching will not respond to anti-reflux surgery 1
• Do not confuse supragastric belching with aerophagia—they are distinct disorders with different presentations and treatments 2
• Do not skip psychoeducation—showing patients their impedance tracings is therapeutic in itself and essential for behavioral modification 1

When Behavioral Therapy Fails

If behavioral therapy and diaphragmatic breathing fail after adequate trial:

• Reassess for gastroparesis in the subset of patients with nausea and vomiting 1
• Consider central neuromodulators (tricyclic antidepressants at low doses, e.g., amitriptyline 10-30 mg daily) to modulate visceral hypersensitivity and central processing abnormalities 1
• Refer to a multidisciplinary team including gastroenterology, psychology, and speech therapy for severe refractory cases 1