What causes intense abdominal pain relieved by burping?

Intense Abdominal Pain Relieved by Burping

Intense abdominal pain relieved by burping most commonly indicates functional dyspepsia (specifically epigastric pain syndrome) or gastroesophageal reflux disease, both of which are associated with excessive belching in up to 50% of cases. 1, 2

Primary Diagnostic Considerations

Functional Dyspepsia with Belching

The British Society of Gastroenterology defines epigastric pain syndrome as bothersome epigastric pain or burning occurring at least 1 day per week, with symptoms active within the past 3 months and onset at least 6 months prior to diagnosis. 1 Critically, postprandial epigastric bloating, belching, and nausea are recognized supportive criteria for this diagnosis. 1

• Belching occurs through spontaneous transient relaxation of the lower esophageal sphincter, allowing air transport from the stomach through the esophagus and oral expulsion, as described by the American Gastroenterological Association. 2
• In patients with gastritis and GERD, gastric belching is reported in up to 50% of cases. 2
• Importantly, symptoms relieved by evacuation of gas (such as burping) generally should not be considered part of dyspepsia according to Rome IV criteria, though this creates diagnostic ambiguity when belching provides relief. 1

GERD-Associated Pain and Belching

GERD commonly coexists with belching symptoms, and one-third of functional dyspepsia patients have coexisting GERD symptoms. 3 The American Gastroenterological Association notes that belching is reported in up to 50% of GERD patients. 3

Essential Diagnostic Workup

Immediate Red Flags Requiring Urgent Evaluation

You must immediately assess for alarm features that mandate urgent investigation: 1, 3

• Weight loss in patients over 55 years requires 2-week wait endoscopy to exclude gastro-oesophageal malignancy. 3
• Abdominal pain with weight loss in patients over 60 years requires urgent CT scan. 3
• Persistent vomiting suggests another disorder and warrants further investigation. 1
• Family history of gastro-oesophageal malignancy requires urgent evaluation. 3

Laboratory Testing Algorithm

The following tests should be obtained systematically: 3

• H. pylori breath or stool testing for all patients with dyspepsia, as H. pylori infection alters gastric function and contributes to dyspeptic symptoms. 3
• Full blood count in patients aged ≥25 years. 3
• Coeliac serology if there are overlapping IBS-type symptoms. 3
• Serum lipase and liver function tests to evaluate pancreatic or hepatobiliary pathology. 3

Imaging Strategy

The American College of Radiology recommends CT abdomen/pelvis with IV contrast as the initial imaging study for abdominal pain triggered by eating, with a rating of 8/9 (usually appropriate). 4 However, for epigastric pain with belching relief and no alarm features, endoscopy is the preferred initial investigation to exclude structural disease. 1

Differential Diagnosis Framework

Distinguish Between Gastric and Supragastric Belching

This distinction is critical because management differs substantially: 3

• Gastric belching originates from the stomach and is less frequent but more forceful, occurring from spontaneous transient relaxation of the lower esophageal sphincter. 3
• Supragastric belching is the most common cause of excessive isolated belching (frequencies up to 20 times per minute) and is strongly associated with anxiety, involving air drawn into the esophagus and immediately expelled before reaching the stomach. 2, 3
• High-resolution esophageal manometry with impedance can definitively differentiate between these patterns. 2, 3

Consider Structural and Infectious Causes

Structural causes that may contribute to belching include: 2

• Hiatal hernias and paraesophageal hernias. 2
• H. pylori infection, which should be tested and treated with antibiotic eradication therapy if positive. 3

Dietary and Metabolic Triggers

The American Gastroenterological Association recommends a 2-week dietary elimination trial to reduce high-sulfur foods, as prolonged fermentation produces hydrogen sulfide gas. 3 Additionally, carbohydrate malabsorption (lactose intolerance, fructose intolerance, sucrase deficiency) can contribute to belching symptoms. 3

Treatment Algorithm

First-Line Pharmacotherapy

If H. pylori testing is positive, eradicate with triple therapy: 5

• Omeprazole 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days. 5
• This regimen achieves H. pylori eradication rates of 73-83% in intent-to-treat analyses. 5

If H. pylori is negative or after eradication, initiate proton pump inhibitor therapy: 4, 5

• Omeprazole 20 mg once daily before meals for 4-8 weeks. 4, 5
• Take omeprazole before a meal; antacids may be taken concurrently. 5
• Swallow capsules whole; if unable to swallow, open capsule and take contents in applesauce. 5

Second-Line and Adjunctive Therapies

If PPI therapy fails, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommends considering tricyclic antidepressants to modulate gut-brain axis pain perception. 4

For supragastric belching specifically (if confirmed by manometry): 2

• Behavioral strategies, including diaphragmatic breathing, are effective. 2
• Address underlying anxiety, as it is strongly associated with supragastric belching. 3

Lifestyle Modifications

The American College of Gastroenterology recommends avoiding trigger foods and regular exercise, but cautions against restrictive diets that can lead to malnutrition. 4

Common Pitfalls to Avoid

Do not dismiss symptoms as purely functional without excluding structural disease through endoscopy, especially in patients over 55 years or with alarm features. 1

Do not assume all belching is pathological—gastric belching is physiologically normal, and excessive belching should only be considered a disorder when it significantly impacts quality of life. 2, 3

Review recent medication changes, as NSAIDs and opioids can alter gut motility and contribute to dyspepsia. 3 The American College of Gastroenterology specifically notes that NSAID use is a risk factor for dyspepsia. 1

Consider anxiety and eating disorders in patients with belching and dyspepsia, as the American Psychiatric Association recognizes these are increasingly common in this population. 3