GIT Kurdistan GEH Board J club belching.

1. Dr. Mohamed Alshekhani
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2. INTRODUCTION:
• An oral expulsion of a gas bolus from the UGIT audible or in some
cases silently.
• In most individuals, it occurs as a physiological event & not
perceived as a symptom.
• Some consult because of excessive belching complaints or
complaints by those surrounding the patients.
• Excessive belching may appear harmless complaint at first, but may
be responsible for a decreased QOL.
• Rreported by 50 % of the general population with dyspepsia& 20 %
of them experiences moderate-to-severe interference with daily
activities.
• Impedance monitoring &high-resolution manometry, have greatly
enhanced our understanding of belching.
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5. PATHOPHYSIO:
• Gastric belching( Physiological) occurs in almost every individual 30
times / 24 h prevents the accumulation of excess gas in the
stomach or duodenum, because with each swallow, a variable
volume of air is ingested&transported to the stomach& carbonated
beverages use results in an increase of gastric air.
• Manometry showed that it occurs mainly during spontaneous (not-swallow
induced) transient relaxations of the lower esophageal
sphincter (TLESR).,triggered by distention of the stomach, such as
caused by intragastric air, allowing this air to be vented from the
stomach into the esophagus.
• Several neurotransmitters that influence the rate of TLESRs as
gamma-aminobutyric acid , metabotropic glutamate receptors,
cannabinoid receptor 1, nitric oxide & cholecystokinin.
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6. PATHOPHYSIO: Isolated excessive belching
• The gastric belching can be recognized with impedance monitoring
as an increase in impedance starting in the distal channel&
progressing to the most proximal channel.
• Supragastric belching: With the use of eso impedance monitoring, a
different type of belch was identified in patients with isolated
excessive belching.
• During this second type of belch, air is rapidly brought into the
esophagus & immediately followed by a rapid expulsion&the air
neither originates from the stomach nor does it reach the stomach
• Combined high-resolution manometry &impedance monitoring
further elucidated two mechanisms of this type:
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7. PATHOPHYSIO: Isolated excessive belching
• 1. The most common mechanism ,so-called air-suction method
characterized by a movement of the diaphragm in aboral direction
resulting in a negative intra-thoracic pressure as would occur during
deep inspiration ,UES relaxation occurs during which the glottis is
closed& air flows from the atmospheric pressure in the pharynx to
the subatmospheric pressure in the esophagus&the esophageal air
is immediately expulsed orally as a result of straining that is
perceived by the patient as a belch.
• UES relaxation during supragastric belching occurs before the influx
of air in the esophagus in contrast to gastric belching during which
UES relaxation is a late event in response to the influx of air.
• The driving force behind the air inflow during supragastric belching
is a pressure gradient, the air flows into the esophagus much faster
than would occur during air swallowing in which the driving force is
esophageal peristalsis.
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8. PATHOPHYSIO: Isolated excessive belching
• 2. The air-injection method, characterized by a simultaneous
pressure increase in the pharynx most likely caused by a
contraction of the base of the tongue & not a peristaltic contraction
of the pharynx initiating the influx of air into the esophagus & the
driving force behind the influx of air is the pressure gradient
between the elevated pharyngeal pressure & unchanged intra-esophageal
pressure.
• SHB may start as a voluntary response to an unpleasant GI
sensation as a deliberate attempt to reduce symptoms.
• Patients are not aware that SGB is under voluntary control, but
evidences for this are:
• Do not occur during sleep.
• Frequency decreases while a patient is distracted.
• often observed in healthy Persons, suggesting a learned behavior.
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9. PATHOPHYSIO: Isolated excessive belching
• Although the common belching in pregnancy can be due to GERD,
but most are supragastric, supporting the idea that it occurs as a
response to find relief a sensation of fullness.
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23. PATHOPHYSIO: GERD-related Belching
• Common, reported by 40 – 49 %.
• Most of the belches are supragastric & not gastric.
• No study assessed the response to behavioral therapy, but PPI
shown a modest decrease in belching complaints.
• In a subgroup of patients with GERD, supragastric belches can
induce reflux épisodes.
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24. PATHOPHYSIO: FD-related Belching
• Belching is also common in pother functional GIT disorders.
• Gas reflux episodes occur more frequently in patients FD.
• Patients with FD experienced troublesome belching.
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25. PATHOPHYSIO: Rumination syndrome-related.
• Persistent or recurrent regurgitation of recently ingested food into
the mouth.
• Rumination episodes are induced by a rise in intra-gastric pressure
generated by a voluntary, but often not intentional, contraction of
the abdominal wall musculature.
• A subgroup of patients identified who exhibit a typical behavior
that is characterized by a supragastric belch immediately followed
by a quick rise in intragastric pressure that forces gastric content
into the esophagus & cause symptoms of regurgitation , suggest
that supragastric belching underlies rumination episodes in a
subgroup of patients.
• In patients with symptoms of belching & regurgitation, supragastric
belch-induced rumination should be considered.
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26. PATHOPHYSIO: Aerophagia-related.
• A disorder characterized by increased swallowing of air resulting in
increased intragastric/ intraintestinal gas, observed by abd X-ray.
• Patients with aerophagia seldom complain of excessive belching
&main complaint is abdominal bloating & abdominal distension.
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27. PATHOPHYSIO: Pediatric belching.
• Excessive belching can also occur in children.
• Mechanism are yet not studied.
• There are currently no proven therapeutic options &more research
is warranted to determine etiology&treatment of belching
complaints in children.
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28. Diagnosis.
• A similar frequency of gastric belches but an increased number of
supragastric belches. Supragastric belching can oft en be diagnosed
without invasive
• A patient exhibits excessive, repetitive belching during a
consultation.
• The absence of belches during speaking.
• Typically, a patient belches while the physician is asking questions,
whereas a patient does not belch while responding to these
questions&frequency of supragastric belches decreases when a
patient is actively distracted.
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29. Diagnosis.
• Although a thorough history & clinical observation can often
identify patients with supragastric belching, the gold standard for
the diagnosis is impedance monitoring, allowing a differentiation
between gastric belching & supragastric belching.
• Ambulatory monitoring , can report symptomatic belches, allowing
the clinician to pinpoint specific belch events & determine the type
of belch.
• Impedance monitoring during a 90-min period identifies
supragastric belches in the majority of patients with excessive
belching but 24-h ambulatory impedance monitoring therefore
remains the diagnostic modality of choice, because it allows
differentiation with GERD.
• Impedance monitoring can show increased frequency of air
swallowing in aerophagia but no supragastric belches.
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30. Treatment:
• The cornerstone of treatment is a thorough explanation of the
underlying mechanism.
• patients often expect that an organic cause for their disease can be
found&reluctant to accept that their complaints are due to
abnormal behavior.
• So Impedance monitoring, not only aids in the diagnosis but also
provides an indisputable confirmation of the underlying behavioral
disorder.
• As supragastric belching is a behavioral disorder, behavioral
therapy is the therapy of choice.
• Speech therapy reduces symptoms in patients with excessive
belching.
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31. Treatment:
• The first step is description of the behavior that underlies the
sucking or injection of air into the esophagus.&the patient is
trained to refrain from this behavior& to acquire a fluent breathing
pattern , practiced by conventional breathing and vocal exercises.
• As the diaphragm is the cause of supragastric belches in the
majority of patients, the applied behavioral therapy should rely
heavily on abdominal breathing exercises.
• Learn abdominal breathing exercises to the patient by placing a
hand on the abdomen during respiration& explaining that the hand
on the abdomen should move with breathing.
• Attention on belching is moved to attention on the behavior
underlying their belching.
• 10-20 sessions of behavioral therapy is oft ensufficient to provide a
significant decrease in belching complaints.
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32. Treatment:
• ? Baclofen.
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33. Conclusion:
• Supragastric belching appears to be the most important factor in
the etiology of excessive belching complaints&this disorder can be
treated with behavioral therapy.
• Additional studies, such as those assessing the effect of behavioral
therapy in patients with GERD,rumination, or functional dyspepsia
& determining the pathophysiology of excessive belching in
children, are needed.
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34. Conclusion:
• Excessive belching is a commonly observed complaint in clinical
practice that can occur as an isolated symptom or as a concomitant
symptom in patients with (GERD) or FD.
• Impedance monitoring has revealed two mechanisms through
which belching can occur: the gastric & supragastric belch.
• The gastric belch is the result of a vagally- mediated reflex leading
to relaxation of LES &venting of gastric air.
• The supragastric belch is a behavioral peculiarity, During which,
pharyngeal air is sucked or injected into the esophagus, after which
it is immediately expulsed before it has reached the stomach.
• Patients who belch excessively invariably exhibit an increased
incidence of supragastric, not of gastric belches.
• Supragastric belches can elicit regurgitation episodes in rumination
syndrome & sometimes induce reflux episodes as well.
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35. Conclusion:
• Behavioral therapy has been proven to decrease belching
complaints in patients with isolated excessive belching, but its
effect is unknown in frequently belching patients with GERD,
functional dyspepsia or rumination.
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36. CME:
• 1. Which one of the following neurotransmitters that influences the
rate of transient lower esophageal sphincter relaxations has been
studied most extensively?
• A. Metabotropic glutamate receptors
• B. Gamma-aminobutyric acid (GABA-B)
• C. Cannabinoid receptor 1
• D. Nitric oxide (NO)
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37. CME:
• 1. Which one of the following neurotransmitters that influences the
rate of transient lower esophageal sphincter relaxations has been
studied most extensively?
• A. Metabotropic glutamate receptors
• B. Gamma-aminobutyric acid (GABA-B)
• C. Cannabinoid receptor 1
• D. Nitric oxide (NO)
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38. CME:
• 2. Which one of the following diagnostic modalities is the gold
standard for diagnosing supragastric belching?
• A. Barium esophagram
• B. Esophageal manometry
• C. Esophagogastroduodenoscopy
• D. Esophageal impedance monitoring
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39. CME:
• 2. Which one of the following diagnostic modalities is the gold
standard for diagnosing supragastric belching?
• A. Barium esophagram
• B. Esophageal manometry
• C. Esophagogastroduodenoscopy
• D. Esophageal impedance monitoring
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40. CME:
• 3. How many behavioral speech therapy sessions is sufficient for
most patients to experience a significant decrease in belching
complaints?
• A. 1 – 5
• B. 10 – 20
• C. 20 – 30
• D. Speech therapy is ineffective.
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41. CME:
• 3. How many behavioral speech therapy sessions is sufficient for
most patients to experience a significant decrease in belching
complaints?
• A. 1 – 5
• B. 10 – 20
• C. 20 – 30
• D. Speech therapy is ineffective.
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42. CME:
• 4. Most of the belching spisodes are:
• A. Gastric
• B. Supragastric
• C. Mixed
• D. None.
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43. CME:
• 4. Most of the belching spisodes are:
• A. Gastric
• B. Supragastric
• C. Mixed
• D. None.
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44. CME:
• 5. Most of the belching spisodes in GERD patients are:
• A. Gastric
• B. Supragastric
• C. Mixed
• D. None.
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45. CME:
• 5. Most of the belching spisodes in GERD patients are:
• A. Gastric
• B. Supragastric
• C. Mixed
• D. None.
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46. CME:
• 6. The following GIT disorders proved be associated with belching
except:
• A. GERD
• B. Aerophagia.
• C. Rumination syndrome.
• D. IBD.
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47. CME:
• 6. The following GIT disorders proved be associated with belching
except:
• A. GERD
• B. Aerophagia.
• C. Rumination syndrome.
• D. IBD.
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48. CME:
• 7. The drug showing benefit in belching patients in some studies is:
• A. Metclopromide.
• B. Erythromycin.
• C. PPI.
• D. Baclofen.
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49. CME:
• 7. The drug showing benefit in belching patients in some studies is:
• A. Metclopromide.
• B. Erythromycin.
• C. PPI.
• D. Baclofen.
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50. CME:
• 8. The effect of belching on patients:
• A. Increase Barrets prevalence in GERD patients.
• B. Increase PPI dose requirements.
• C. Low quality of life score.
• D. Increase depression episodes.
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51. CME:
• 8. The effect of belching on patients:
• A. Increase Barrets prevalence in GERD patients.
• B. Increase PPI dose requirements.
• C. Low quality of life score.
• D. Increase depression episodes.
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52. CME:
• 9. The minimum time required for ambulatory impedence monitoring
to diagnose belching syndrome is:
• A. 24 hours.
• B. ½ hour.
• C. 1.5 hours.
• D. 1 hour.
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53. CME:
• 9. The minimum time required for ambulatory impedance monitoring
to diagnose belching syndrome is:
• A. 24 hours.
• B. ½ hour.
• C. 1.5 hours.
• D. 1 hour.
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54. CME:
• 10. The primary site responsible in initiating the supra gastric
belching behavior is:
• A. esophagus.
• B. Stomach.
• C. Diaphragm.
• D. Abd muscles.
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55. CME:
• 10. The primary site responsible in initiating the supra gastric
belching behavior is:
• A. esophagus.
• B. Stomach.
• C. Diaphragm.
• D. Abd muscles.
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