From the Guidelines
For the evaluation and treatment of eructation, a comprehensive approach considering the type of belching, underlying causes, and impact on quality of life is essential, with the latest evidence suggesting that brain-gut behavior therapy may be beneficial for patients with excessive belching and reduced quality of life 1.
Evaluation of Eructation
The evaluation of eructation should start with a thorough medical history to identify potential triggers and underlying conditions such as gastroesophageal reflux disease (GERD), gastroparesis, or rumination disorder. Diagnostic tests like high-resolution manometry (HRM) with impedance can help differentiate between supragastric belching, gastric belching, and aerophagia, guiding the treatment approach 1.
Treatment Approaches
- Lifestyle Modifications: Initial management includes lifestyle modifications such as eating slowly, avoiding carbonated beverages, and reducing aerophagia by avoiding talking while eating and drinking through straws.
- Pharmacological Interventions: For patients with suspected GERD, proton pump inhibitors (PPIs) like omeprazole may be considered, while baclofen could be an option for those with excessive transient lower esophageal sphincter relaxations (TRLES) 1.
- Behavioral Therapy: Cognitive behavioral therapy (CBT) or brain-gut behavior therapy may be beneficial for patients with supragastric belching or those experiencing significant distress and reduced quality of life due to belching 1.
- Dietary Changes: Identifying and avoiding trigger foods, especially those high in fructans which can lead to bloating and discomfort, is crucial. A short-term dietary restriction followed by reintroduction can help identify problematic foods.
Special Considerations
- Rifaximin and Other Antibiotics: For patients suspected of having small intestine bacterial overgrowth (SIBO), rifaximin or other antibiotics may be considered, though careful patient selection is necessary due to the potential side effects and the lack of FDA approval for this indication.
- Alarm Symptoms: The presence of alarm symptoms such as weight loss, vomiting, or difficulty swallowing necessitates a thorough medical evaluation to rule out more serious underlying conditions.
By adopting a personalized approach based on the type of belching and underlying causes, and incorporating the latest evidence-based treatments, patients with eructation can experience significant improvements in symptoms and quality of life 1.
From the Research
Eructation Evaluation
- Eructation is composed of three independent phases: gas escape, upper barrier elimination, and gas transport phases 2
- The gas escape phase is the gastro-LES inhibitory reflex that causes transient relaxation of the lower esophageal sphincter, which is activated by distension of stretch receptors of the proximal stomach 2
- The upper barrier elimination phase is the transient relaxation of the upper esophageal sphincter along with airway protection, activated by stimulation of rapidly adapting mechanoreceptors of the esophageal mucosa 2
- The gas transport phase is esophageal reverse peristalsis mediated by elementary reflexes, and it is theorized that this phase is activated by serosal rapidly adapting tension receptors 2
Treatment of Gastro-Oesophageal Reflux Disease (GORD)
- Proton pump inhibitors (PPIs) are more effective than H2-receptor antagonists (H2RAs) in relieving heartburn in patients with GORD who are treated empirically and in those with endoscopy negative reflux disease (ENRD) 3, 4, 5
- The relative risk (RR) for heartburn remission for PPI versus placebo was 0.37 in empirical treatment of GORD, and 0.71-0.73 in treatment of ENRD 3, 4, 5
- H2RAs are effective for relief of heartburn episodes, but not as effective as PPIs in maintaining control in oesophagitis patients 6
- On-demand proton pump inhibitor therapy may work in a proportion of non-erosive GORD patients 6