#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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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

Up to 50% with dyspepsia have belching

40-49% GERD pts have belching, and pts with belchingsevere GERD sx

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

So we need to help them

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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'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

predominant sx (since belching can be sx of conditions causing dyspepsia)

chronology of sx (did the belch cause reflux or vice versa)

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 protocol and videos available in article for those interested in trying this out

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How does DB work?

Abolish air swallowing. Try opening your mouth and swallowing air. You can't. Without air swallowing, you can't do a SGB

Strengthen the crura. This may rx GERD due to barrier issues independent of belching

Relaxation technique. May stimulate vagus

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Conclusions:

Belching has 2 types (gastric, supragastric)

The hx can distinguish but impedance testing often needed

Treat primary causes of dyspepsia if any

Give DB a try, especially for SGB

A subset of refractory GERD have SGB and hence treatable w/o PPI

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Thank you for reading this.

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

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

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