What could be causing frequent burping, epigastric pain, and flatus?

Frequent Burping, Epigastric Pain, and Flatus: Likely Causes

The most likely cause of this symptom triad is gastroesophageal reflux disease (GERD) or peptic ulcer disease, as 66% of GERD patients present with both heartburn and epigastric pain, and belching occurs in up to 50% of GERD cases. 1, 2

Primary Differential Diagnoses

GERD/Esophagitis (Most Common)

• GERD affects 42% of Americans monthly and presents with epigastric pain frequently accompanied by belching. 2
• Belching has been reported in up to 50% of patients with GERD, making it a cardinal associated symptom. 1
• Approximately 66% of patients with GERD and heartburn also experience epigastric pain at baseline. 1, 2
• The epigastric pain in GERD improves with PPI therapy, though to a lesser extent than heartburn. 1

Peptic Ulcer Disease (PUD)

• Epigastric pain or discomfort, not heartburn, is the hallmark symptom of gastric ulcers. 3
• PUD has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases. 2
• Nearly two-thirds of peptic ulcer cases can be asymptomatic, making diagnosis challenging. 3

Functional Dyspepsia

• Dyspepsia describes a symptom complex including epigastric pain, excessive burping or belching, and bloating. 4
• Functional dyspepsia affects up to 16% of otherwise healthy individuals and includes epigastric pain or burning, postprandial fullness, or early satiety. 5
• Heartburn and epigastric pain coexist in 63-66% of patients with upper gastrointestinal symptoms. 1, 3

Excessive Belching Disorder

• Excessive belching is defined as bothersome belching that disrupts usual activities and occurs more than 3 days per week. 1
• Supragastric belching occurs in up to 3.4% of patients with upper GI symptoms and is more commonly associated with anxiety. 1
• Belching may be conditioned to reduce bloating sensation via air release, thereby reducing gastric wall tension. 1

Aerophagia (Less Likely Given Symptom Pattern)

• With aerophagia, excessive air swallowing increases intragastric and intestinal gas, leading to bloating, distention, and flatulence as main manifestations rather than excessive belching alone. 1
• Aerophagia is a behavioral disorder where patients belch in very high frequencies, up to 20 times per minute. 6

Critical Red Flags Requiring Immediate Evaluation

Rule out myocardial infarction first - obtain ECG and cardiac troponins immediately, as MI can present with isolated epigastric pain and has mortality of 10-20% if missed. 7, 2

Other Emergent Conditions

• Sudden severe epigastric pain with fever and abdominal rigidity suggests perforation with 30% mortality if treatment is delayed. 2, 3
• Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis. 2
• Hematemesis, melena, or occult blood in stool indicates GI bleeding requiring immediate investigation. 7, 3

Diagnostic Workup Algorithm

Initial Assessment

• Obtain ECG and cardiac troponins at 0 and 6 hours to exclude acute coronary syndrome. 2
• Perform physical examination looking for peritoneal signs, abdominal rigidity, and pain reproduced by palpation. 2
• Order complete blood count to assess for anemia from occult bleeding, and test stool for occult blood. 7
• Check serum amylase or lipase to exclude pancreatitis if pain radiates to back. 2

Esophageal Physiology Testing (If Belching is Predominant)

• High-resolution esophageal manometry combined with impedance monitoring differentiates gastric belching from supragastric belching and aerophagia. 1
• In gastric belching, spontaneous transient relaxation of the lower esophageal sphincter is followed by air transport from the stomach through the esophagus. 1
• Supragastric belching stops during sleep, distraction, or when the patient speaks, providing evidence that psychological factors modulate its occurrence. 1

H. pylori Testing

• Test for H. pylori infection using stool antigen test or urea breath test. 7
• Eradication therapy should be offered to patients with functional dyspepsia who test positive for H. pylori. 5

Endoscopy Indications

• Refer for endoscopy if symptoms persist after 4-8 weeks of PPI therapy. 7
• Patients ≥55 years with treatment-resistant dyspepsia despite PPI therapy should undergo endoscopy. 3
• All gastric ulcers require biopsy and histological examination to exclude malignancy. 3

Treatment Algorithm

First-Line Therapy

Start high-dose PPI therapy immediately with omeprazole 40 mg once daily before breakfast, achieving 70-80% healing rates for gastric ulcers and 80-90% for duodenal ulcers. 7, 2, 3

• PPIs should be taken 30-60 minutes before meals, preferably breakfast, for optimal acid suppression. 7
• Continue PPI therapy for 4-8 weeks before reassessing. 7

Symptomatic Relief for Gas/Bloating

• Simethicone is FDA-approved for relief of pressure and bloating commonly referred to as gas. 8
• Few therapies have been shown effective in treating gas-related symptoms; eructation can be treated by decreasing excessive air swallowing. 9

Behavioral Therapy (If Supragastric Belching Confirmed)

• Supragastric belching is responsive to brain-gut behavioral therapies such as cognitive behavioral therapy. 1
• Behavioral therapy and/or speech therapy is the therapy of choice for aerophagia. 6

Critical Lifestyle Modifications

• Advise immediate smoking cessation and counsel on alcohol reduction or cessation, as these have a synergistic dose-dependent effect on gastric ulcer risk. 2, 3
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure. 2, 3
• Eliminate carbonated beverages and spicy foods, as gastritis is commonly associated with these dietary triggers. 7
• Avoid NSAIDs completely as they worsen PUD and increase bleeding risk. 7, 3

Common Pitfalls to Avoid

• Never dismiss cardiac causes - always obtain ECG and troponins first, as MI mortality is 10-20% if missed. 7, 2
• Do not assume benign disease without excluding complications like perforation (sudden severe pain with fever/rigidity). 7
• Do not rely on antacid response to rule out serious pathology, as PUD often fails to respond to antacids but responds to PPIs. 7
• Patients with heartburn and epigastric pain find it difficult to describe their predominant symptom, with 19% unable to choose between symptoms. 1, 2, 3
• Recognize that psychological factors, including anxiety and life events, modulate the occurrence and frequency of supragastric belching. 1