How should continuous belching be evaluated and managed?

Evaluation and Management of Continuous Belching

Continuous belching requires differentiation between supragastric belching (a behavioral disorder requiring psychological therapy) and gastric belching (often GERD-related requiring acid suppression), best accomplished through impedance monitoring with or without high-resolution manometry. 1

Initial Clinical Assessment

Determine the belching type through clinical features:

• Supragastric belching stops during sleep, distraction, or when speaking—this indicates a learned behavioral disorder rather than a physiological process 2
• Gastric belching occurs involuntarily and may be associated with GERD symptoms (heartburn, regurgitation) in up to 50% of cases 2
• Assess for anxiety and psychosocial stressors, as supragastric belching is strongly associated with anxiety and conditioned responses to physical symptoms 2
• Distinguish from aerophagia, where the primary symptoms are bloating, distention, and flatulence (not isolated belching), with visible intestinal gas on abdominal X-ray 2, 3

Diagnostic Testing

High-resolution esophageal manometry combined with impedance-pH monitoring definitively differentiates belching types: 1

• Gastric belching shows transient lower esophageal sphincter relaxation followed by air transport from stomach to esophagus 2
• Supragastric belching shows air entering the esophagus from the pharynx via UES relaxation or pharyngeal pressure elevation, then immediately expelled orally without reaching the stomach 2
• Consider 24-hour impedance monitoring if symptoms persist after 4 weeks of optimized therapy to definitively characterize belching patterns 1

Treatment Algorithm

For Supragastric Belching (Behavioral):

Brain-gut behavioral therapy (BGBT) or cognitive behavioral therapy (CBT) is the definitive treatment, as this is a learned behavioral disorder: 1

• Refer to GI psychology for formal CBT or esophageal-directed hypnotherapy if symptoms persist after 4 weeks 1
• Speech therapy and behavioral therapy have proven efficacy in reducing belching complaints 4, 5
• Explain to patients that the belching is a conditioned response to reduce bloating sensation, helping them understand the behavioral nature 2

For Gastric Belching (GERD-Associated):

Start PPI therapy (omeprazole 20 mg or equivalent once daily) combined with lifestyle modifications: 1

• Weight management if overweight or obese 1
• Eliminate carbonated beverages and avoid rapid eating 1
• Add alginate antacids (e.g., Gaviscon) for post-prandial breakthrough symptoms, particularly useful with hiatal hernia 1
• Consider nighttime H2-receptor antagonists for nocturnal symptoms, though limited by tachyphylaxis 1

If belching persists despite PPI optimization, add baclofen 10 mg three times daily, as it inhibits transient lower esophageal sphincter relaxations 1

Structural and Associated Conditions to Evaluate

Screen for underlying disorders that can cause or exacerbate belching:

• GERD is present in up to 50% of patients with gastric belching 2
• Functional dyspepsia and gastroparesis commonly present with belching symptoms 2
• Hiatal and paraesophageal hernias are structural causes requiring evaluation 2
• Post-Nissen fundoplication patients may develop belching from impaired gastric accommodation 2

Critical Pitfalls to Avoid

Do not empirically prescribe PPIs for all belching—they are only effective when gastric belching is associated with proven GERD, not for supragastric belching where reflux episodes are typically non-acidic 1, 6

Do not ignore the behavioral component of supragastric belching—treating it as a purely physiological disorder with medications alone will fail 1

Do not confuse aerophagia with excessive belching—aerophagia patients primarily complain of bloating and distention with flatulence, not isolated belching, and require different management 2, 3

When Symptoms Are Refractory

For PPI-refractory GERD with excessive belching:

• Recognize that hidden supragastric belching may be causing reflux symptoms through two mechanisms: SGB-induced gastroesophageal reflux or SGB-induced esophageal distension 7
• Combination therapy of psychological approach with conventional GERD treatment improves outcomes in this population 7
• Escalate to 24-hour impedance monitoring to definitively characterize the belching pattern 1