#GITwitter, #MedTwitter, after enjoying a hearty meal, it feels appropriate to do a #tweetorial on belching.

Belching is common, yet it is what one of those symptoms that are often ignored

So how do we evaluate and mx belching?

@MedTweetorials

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https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Belching affects quality of life, as excessive belching can disrupt social lives

https://journals.lww.com/eurojgh/Abstract/2010/12000/Impaired_health_related_quality_of_life_in.5.aspx

https://journals.lww.com/eurojgh/A... class="Emoji" style="height:16px;" src=" https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Up to 50% with dyspepsia have belching

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">40-49% GERD pts have belching, and pts with belchinghttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">severe GERD sx

https://pubmed.ncbi.nlm.nih.gov/19455107/ 

So">https://pubmed.ncbi.nlm.nih.gov/19455107/... we need to help them

2/11

Supragastric belching in patients with reflux symptoms - PubMed

Supragastric belches occur more frequently in patients with typical reflux symptoms than in healthy subjects. These belches often occur in close association with acid and weakly acidic reflux...

https://journals.lww.com/eurojgh/Abstract/2010/12000/Impaired_health_related_quality_of_life_in.5.aspx

2 types of belching, differentiated with esophageal impedance studies

The first (on the left) is typical gastric belch that we get after a gassy drink due to reflex from gastric distension

Dotted lines show air direction from stomach (distally) to esophagus (proximally)

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The second belch (on the right) is a supragastric belch (SGB)

Air is seen to be swallowed first, dotted lines moving from esophagus (proximal) to stomach (distal), and then belched out. It doesn& #39;t originate from stomach, but rather esophagus and hence termed supragastric

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SGB can be associated with GERD with more SGB being symptomatic than gastric belching & more reflux episodes associated with SGB

On the picture on the right, the pH in the distal esophagus (bottom row) dropped as the SGB occurred, demonstrating SGB inducing GERD

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Qns to look in the history

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">predominant sx (since belching can be sx of conditions causing dyspepsia)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel"> chronology of sx (did the belch cause reflux or vice versa)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel"> clues to suggest SGB = anxious personality, distractability, rapid, repetitive, "aura" prior to belch

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Once endoscopy is done and is normal, and esophageal physiological studies show supragastric belching, what would you try?

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We did prospective study using waitlist controls @AGA_CGH and showed diapragmatic breathing (DB) improves belching, GERD sx and QoL after rx and 4 months post rx

https://pubmed.ncbi.nlm.nih.gov/29104130/ 

Rx">https://pubmed.ncbi.nlm.nih.gov/29104130/... protocol and videos available in article for those interested in trying this out

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How does DB work?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Abolish air swallowing. Try opening your mouth and swallowing air. You can& #39;t. Without air swallowing, you can& #39;t do a SGB

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Strengthen the crura. This may rx GERD due to barrier issues independent of belching

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Relaxation technique. May stimulate vagus

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Conclusions:

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Belching has 2 types (gastric, supragastric)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">The hx can distinguish but impedance testing often needed

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Treat primary causes of dyspepsia if any

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">Give DB a try, especially for SGB

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🍎" title="Roter Apfel" aria-label="Emoji: Roter Apfel">A subset of refractory GERD have SGB and hence treatable w/o PPI

10/11

Thank you for reading this.

Please review my other #tweetorial on using neuromodulating drugs for #FGID

https://twitter.com/AndrewOngML/status/1311658585026224129?s=20

11/11">https://twitter.com/AndrewOng...