What causes aerophagia (swallowing of air)?

What Causes Aerophagia

Aerophagia occurs through excessive swallowing of air that enters the esophagus via upper esophageal sphincter opening, then travels down through esophageal peristalsis, followed by lower esophageal sphincter relaxation allowing the air to enter the stomach and subsequently move into the intestines and colon. 1

Physiologic Mechanism

The specific sequence distinguishes aerophagia from other belching disorders 1:

• Air enters through swallowing, leading to opening of the upper esophageal sphincter (UES) 1
• Air clears the esophagus via peristalsis (unlike supragastric belching which is independent of peristalsis) 1
• Lower esophageal sphincter relaxes and air enters the stomach 1
• Excess air moves beyond the stomach into the intestines and colon, which is the key distinguishing feature 1

Primary Contributing Factors

Behavioral and Psychological Triggers

• Anxiety and psychological stress are major precipitants of excessive air swallowing 1, 2, 3
• Conditioned behavioral responses to physical stressors can perpetuate the pattern 1
• Obsessive-compulsive disorder has been associated with pathologic aerophagia 4

Neurologic and Developmental Conditions

• Mental retardation or developmental delay increases risk of persistent pathologic aerophagia 4, 5
• Neurologic disease can lead to chronic, severe forms that may cause serious complications 4

Repetitive Air Swallowing Pattern

• Repetitive, excessive air swallowing is the core behavioral mechanism 2, 3, 4
• This differs from normal physiologic swallowing that occurs with eating and drinking 2

Clinical Presentation That Distinguishes Aerophagia

The symptom pattern helps identify aerophagia versus other belching disorders 1:

• Bloating is the main manifestation rather than excessive belching alone 1
• Flatulence is commonly reported because excess air reaches the colon 1
• Abdominal distention occurs from intragastric and intestinal gas accumulation 1, 2
• Belching occurs less often compared to supragastric belching disorders 1

Diagnostic Confirmation

High-resolution esophageal manometry with impedance monitoring definitively diagnoses aerophagia by showing the characteristic pattern 1:

• Influx of air into esophagus with swallowing 1
• Esophageal peristalsis clearing the air distally 1
• Lower esophageal sphincter relaxation allowing gastric entry 1

Abdominal X-rays demonstrate intestinal gas accumulation, confirming that swallowed air reaches beyond the stomach 1

Common Clinical Pitfalls

• Do not confuse with supragastric belching, where air is immediately expelled from the esophagus before reaching the stomach and belching is the predominant symptom 1
• Do not confuse with gastric belching, which involves air coming up from the stomach (not down into it) and is associated with GERD in up to 50% of cases 1, 6
• Recognize that aerophagia can simulate motility disorders like gastroparesis, megacolon, or intestinal pseudo-obstruction, particularly in children 5

Treatment Implications Based on Mechanism

Since aerophagia is fundamentally a behavioral disorder of excessive air swallowing 2, 3, 7:

• Brain-gut behavioral therapy is the primary treatment approach 1
• Diaphragmatic breathing techniques that minimize swallowing can reduce air intake 6, 7
• Behavioral modification targeting the repetitive swallowing pattern is essential 7
• Psychotherapy or cognitive behavioral therapy addresses underlying anxiety and stress triggers 1, 2, 3

In severe, refractory cases with neurologic or psychiatric comorbidities, decompressive gastrostomy may be required when conservative measures fail 4