What is the best course of action for a patient with abdominal pain, burping, and dyspnea (difficulty breathing), who is already on medication (e.g. proton pump inhibitors (PPIs)) that is not providing relief?

Management of Refractory Abdominal Pain, Burping, and Dyspnea on Current Medication

You need to immediately escalate to twice-daily PPI dosing for 8-12 weeks (taken 30-60 minutes before meals), and if symptoms persist, proceed to upper endoscopy to rule out structural disease, followed by esophageal pH-impedance monitoring to confirm or exclude GERD as the cause. 1

Initial Medication Optimization

Before pursuing diagnostic workup, optimize your current therapy:

• Escalate to twice-daily PPI if currently on once-daily dosing, and continue for a full 8-12 weeks before declaring treatment failure 1, 2
• Verify proper PPI timing: Must be taken 30-60 minutes before meals, not with or after meals, as this significantly impacts efficacy 2, 1, 3
• Any commercially available PPI is acceptable initially, though if inadequate response occurs, consider switching to more potent agents less metabolized through CYP2C19 (rabeprazole, esomeprazole) or extended-release formulations (dexlansoprazole) 2

Diagnostic Evaluation Pathway

When to Pursue Testing

Proceed with objective testing if:

• Symptoms persist despite optimized twice-daily PPI for 8-12 weeks 1, 2
• Alarm symptoms are present (dysphagia, weight loss, bleeding, anemia) 2
• You need to establish appropriateness of long-term PPI therapy 2

Step 1: Upper Endoscopy

Perform endoscopy first to evaluate for: 1, 2

• Erosive esophagitis (Los Angeles classification)
• Barrett's esophagus (Prague classification with biopsies)
• Peptic stricture
• Hiatal hernia (Hill grade, measure axial length)
• Alternative diagnoses like eosinophilic esophagitis 1, 4

Step 2: Esophageal Manometry and pH-Impedance Monitoring

If endoscopy is normal or shows only mild findings: 1, 2

• Perform esophageal manometry to assess motility
• Follow with ambulatory pH-impedance monitoring (96-hour wireless preferred if available) 2
• Timing matters: Perform off PPI for 2-4 weeks if no prior objective GERD confirmation; perform on PPI if previous pathological findings exist 2, 1

Understanding Your Symptom Complex

Belching (Burping) Evaluation

Your burping likely represents supragastric belching rather than gastric belching, especially if: 2

• It stops during sleep, distraction, or when speaking
• It does not respond to PPI therapy
• It occurs as a behavioral/conditioned response to reduce bloating sensation

Key distinction: Supragastric belching involves swallowing air into the esophagus then immediately expelling it, whereas gastric belching involves air from the stomach 2. This explains why PPIs are ineffective for this symptom.

Dyspnea Assessment

The dyspnea requires careful evaluation to determine if it is: 2

• Related to the underlying etiology (cardiac, pulmonary pathology requiring disease-specific treatment)
• Anxiety-related (often accompanies functional GI disorders and supragastric belching)
• Positional (worse when supine, suggesting GERD-related aspiration)

Treatment Based on Diagnostic Results

If Pathological GERD Confirmed

• Continue twice-daily PPI as the lowest effective dose that controls symptoms 1
• Add adjunctive therapy for breakthrough symptoms: baclofen or alginate-containing antacids 1
• Consider antireflux surgery only if you have some response to PPI therapy and objective GERD confirmation 1
• Implement lifestyle modifications: weight loss if BMI >25, avoid food 2-3 hours before bed, elevate head of bed, use left lateral decubitus sleeping position 1

If Reflux Hypersensitivity or Functional Heartburn

• Initiate tricyclic antidepressants as neuromodulators for centrally mediated pain 1, 2
• Provide cognitive-behavioral therapy and stress-reduction techniques 2
• Avoid continuing PPI without objective evidence of acid-related disease 2

For Supragastric Belching

The most effective treatment is behavioral therapy, not medications: 2

• Diaphragmatic breathing exercises to increase vagal tone and reduce stress response 2
• Cognitive behavioral therapy to address conditioned behavioral responses 2
• Patient education using impedance monitoring as biofeedback to demonstrate the mechanism 2
• Combine with PPI only if concurrent GERD symptoms are present 2

For Dyspnea Management

Treat the underlying etiology first (optimize heart failure with diuretics/inotropes, treat pulmonary disease): 2

• Opioids are first-line for refractory dyspnea not responding to disease-modifying treatment, using "low and slow" IV titration every 15 minutes until relief 2
• Oxygen therapy is standard for hypoxemia, though benefit is less clear in non-hypoxemic patients 2
• Non-invasive ventilation may help if hypercarbia is present, but effectiveness for symptom relief alone is less established 2
• Benzodiazepines or propofol as second-line if anxiety/fear is contributing and opioids are inadequate 2

Critical Pitfalls to Avoid

• Do not continue empiric PPI indefinitely without objective confirmation of acid-related disease, as this leads to inappropriate long-term polypharmacy 3, 5
• Do not use opioids for functional abdominal pain or disorders of gut-brain interaction, as they worsen outcomes and create dependency 2, 6
• Do not assume all symptoms are GERD-related just because some respond to PPI; the burping and dyspnea may have entirely different etiologies requiring separate evaluation 2
• Do not ignore rare diagnoses like eosinophilic gastroenteropathy in patients with therapy-resistant ulcers and abdominal pain, which require corticosteroids/immunosuppression rather than PPIs 4
• Do not perform pH testing on PPI if you've never objectively confirmed GERD before, as this will miss the diagnosis 2, 1

Establishing a Collaborative Approach

Develop an empathic, culturally sensitive patient-provider relationship to address the complex biopsychosocial factors contributing to persistent symptoms: 2

• Explain the brain-gut axis and how psychological factors modulate symptom perception
• Set realistic expectations that complete symptom elimination may not be achievable
• Integrate stress-reduction activities and mindfulness into daily routines
• Consider multidisciplinary pain management if symptoms remain refractory 2, 6