Diagnostic and Management Review of Gastric and Supragastric Belching, Aerophagia, and Rumination Syndrome

Abstract

Supragastric belching and rumination syndrome are distressing and potentially debilitating gastrointestinal disorders. Though related, these conditions are distinct from aerophagia and excessive gastric belching. Although diagnostic standards and effective treatment strategies are emerging, formal guideline-directed treatment and validated measurement tools to demonstrate efficacy of interventions are lacking. This narrative review synthesizes current evidence in presentation, pathophysiology, diagnosis, and treatment through a systematic search of the literature over the past 2 decades.

Supragastric belching, rumination syndrome, excessive gastric belching, and aerophagia have distinct physiologies and vary in symptomatic and psychosocial burden. Although clinical evaluation plays a key role in diagnosis, supragastric belching and rumination syndrome can be objectively confirmed through pH-impedance testing or high-resolution impedance manometry. Supragastric belching and rumination syndrome can be managed effectively with psychoeducation and behavioral treatment strategies. These strategies are underexplored in excessive gastric belching, for which baclofen remains a primary therapy. Aerophagia is rarely symptomatic, and management is comprised of behavioral modifications.

Further studies evaluating multidisciplinary behavioral therapy strategies with validated outcome measurement tools are needed to develop management guidelines and improve the lives of patients with these complex conditions. Evaluation for secondary causes is key to well-rounded, effective treatment.

Belching is a general term for the venting of air that accumulates in the esophagus or stomach into the pharynx^1-3 that can arise from supragastric belching (SGB) or gastric belching (GB), respectively. It is differentiated by physiology and distal extent of peroral air transport. Although SGB and GB are unique in their pathophysiology, the relationship between SGB and rumination syndrome (RS), is significant due to a shared mechanism arising from unintentional behavioral dysfunction. Both are associated with decreased quality of life, daily function,⁴ disorders of gut-brain interaction, mental health conditions (eg, depression and anxiety), and gastroesophageal reflux disease (GERD).³ Notably, aerophagia—although often used interchangeably with these terms—represents a distinct physiological process. A thorough understanding of the overlapping features and distinguishing characteristics of these conditions is critical for appropriate symptom triage and optimal therapeutic intervention.

The aim of this review is to summarize current understanding of pathophysiology, diagnosis, and treatment and to identify gaps in knowledge for belching disorders, aerophagia, and rumination.

Methods

A systematic review of all articles from 2000 to December 2024 was performed using the keywords, “gastric belching,” “supragastric belching,” “rumination,” and “aerophagia.” Articles were assessed for relevance to the review by the authors, with only pertinent topics included in the ultimate collection of references. The references of the selected articles were also examined to consider additional articles relevant to the review.

Rumination Syndrome

Presentation

RS is the voluntary repetitive regurgitation of recently ingested food into the oral cavity followed by spitting or remastication and swallowing. It is marked by an absence of nausea or retching, although patients may often say ‘vomiting’ or ‘spitting’ to describe the experience.⁵ This is notably different than regurgitation in GERD, which is a common misdiagnosis.^6,7 In some patients, RS and SGB coexist in a pattern where the SGB induces the abdominal strain that triggers rumination.^8,9 It may start after a noxious oral, esophageal, or gastric exposure as a subconscious learned reflex.

Diagnosis

The Rome Criteria are the primary diagnostic criteria utilized to diagnose RS, though a Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria also exists. The Rome Criteria defines RS as repetitive, effortless regurgitation of recently digested contents followed by expulsion or remastication and swallowing in the absence of retching for at least 2 months.¹⁰ Supportive criteria include absence of nausea and the presence of recognizable, nonacidic, possible pleasant-tasting regurgitant.¹¹ Per the DSM-5, regurgitation must occur more than once per month and may be rechewed, swallowed, or spit out. Symptoms cannot be explained by another medical condition or be present in a patient with a coexisting eating disorder.¹¹ There is no criteria regarding symptom frequency.

In cases where RS is unclear, postprandial high-resolution impedance manometry (HRIM) may be used, in which, following a standard HRIM protocol, the patient consumes a meal and is monitored on HRIM in the postprandial state for up to 60 minutes. On HRIM, a significant esophageal pressure gradient >30 mmHg (‘R’ wave), created by an abdominal wall and intercostal muscle contraction-induced increase in gastric pressure, immediately after swallowing and preceding retrograde flow is diagnostic for RS (Figure 1).¹² An accompanying decreased lower esophageal sphincter (LES) pressure or pseudo-hiatal hernia may also be seen (patients may also develop a hiatal hernia from abdominal strain) followed by upper esophageal sphincter (UES) relaxation.⁷ On ambulatory pH impedance testing, patients with RS exhibit increased proximal reflux events, postprandial early nonacid reflux events, and symptom burden compared with those with GERD. However, although certain patterns are recognized, pH impedance lacks the sensitivity to reliably distinguish between these 2 disorders.¹³ Combining ambulatory pH impedance monitoring with ambulatory manometry may resolve this, as it allows demonstration of the typical R-wave triggering the retrograde flow and makes it possible to differentiate from GERD.

Figure 1.

Rumination episode on HRIM in which there is increased intra-abdominal pressure with >30 mmHg increase in intrathoracic pressure (R wave), followed by retrograde flow of bolus from stomach to hypopharynx.

Management

Treatment for RS primarily consists of behavioral strategies targeting abnormal learned behaviors. In SGB, strategies target frequent strained mouth and/or glottal closures and abnormal respirations patterns.^1,3 Other modalities may be considered if this fails (Table 1).

Table 1.

Summary of Syndromes and Management Considerations

Syndrome	Therapeutic considerations
	Behavioral	TLESR mediated	Psychotherapy	Other modalities
SGB	Symptom recognition, habit reversal (avoid glottal and mouth closure), slow diaphragmatic breathing to induce parasympathetic state	None	Psychoeducation and treatment to address the psychological processes impacting symptom perception (eg, symptom-specific anxiety and hypervigilance)	PPI if + reflux symptoms
Rumination	Physiotherapy for abdominal muscles, diaphragmatic breathing, distraction, mindfulness, and guided eating	Baclofen ± tricyclic antidepressants		Buspirone
GB	Cessation of smoking, gum chewing, eating too quickly, drinking carbonated beverages; inhibiting dysregulated swallowing patterns that pose air ingestion	Baclofen	None	None
Aerophagia		None	None	Simethicone

GB, gastric belching; PPI, proton pump inhibitor; SGB, supragastric belching; TLESR, transient lower esophageal sphincter relaxation.

Behavioral Therapy in Rumination Syndrome

Therapeutic options for RS include a combination of behavioral and pharmacologic techniques to reduce intragastric pressure and increase LES pressure. The need for surgical management is best avoided and only considered in the most severe cases. The primary treatment modality recommended is behavioral with diaphragmatic breathing supported by cognitive behavioral therapy (CBT) or biofeedback. Diaphragmatic breathing extends the abdominal wall, therefore increasing volume and decreasing pressure in the abdominal cavity with a reduction in intragastric pressure. Concurrent increase in tone of the crural diaphragm increases the LES pressure.¹² The simplest form of biofeedback therapy is implementation of effective diaphragmatic breathing in the office following a meal demonstrating resolution of regurgitation episodes. A study utilizing CBT with electromyography-guided biofeedback found a significant reduction in rumination activity that persisted at 6 to 12 months.¹⁴ Similarly, another study reported a behavioral and psychotherapy regimen to significantly reduce self-assessed frequency of rumination,¹⁰ whereas another found diaphragmatic breathing with manometric biofeedback increased esophagogastric junction (EGJ) pressure and decreased intragastric pressure.¹⁵ An uncontrolled trial using a CBT protocol for RS found that participants decreased their daily regurgitation frequency by 87.7% on average.¹⁶ Insufficient improvement in symptoms with diaphragmatic breathing or CBT may be technique-driven and supports a role for reevaluation in nonresponsive patients. Use of the validated Rumination Questionnaire should be utilized to formally assess the efficacy of behavioral interventions.¹⁷

Other Therapeutic Considerations in Rumination Syndrome

Evidence on the role of pharmacological therapy is limited in RS. Several studies found baclofen to significantly reduce rumination episodes as well as symptom burden.^6,18 In another study combining diaphragmatic breathing and tricyclic antidepressants, 90.9% of patients demonstrated symptom improvement, with 45.5% of these patients reporting ≥80% improvement.¹⁹ Buspirone has been considered in RS due to its ability to reduce intragastric pressure by increasing gastric compliance through relaxing the gastric fundus; however, its use has been investigated in the setting of reducing functional dyspepsia, and no trials have been conducted for RS outcomes.¹²

Surgically, 5 cases of RS have been successfully treated with Nissen fundoplication,²⁰ and 1 case of RS with delayed gastric emptying was relieved by subtotal gastrectomy with Roux-en-Y reconstruction. Overall, there is limited evidence for the recommendation of surgery to treat RS.²¹ Additionally, ongoing behavioral abnormalities with abdominal straining risk surgical site integrity and symptom exacerbation due to loss of compensatory responses (worsening existing psychosocial distress) are significant contraindications. In the rare circumstance where RS exists in the presence of a disrupted anti-reflux barrier due to a large hiatal hernia and/or markedly low LES pressure or severe GERD, fundoplication may be considered but must be accompanied by pre-, peri-, and postoperative behavioral interventions.

Supragastric Belching

Presentation

SGB presents as frequent and often repetitive belching due to air being drawn into the esophagus and then orally expelled quickly after, without reaching the stomach. During SGB, peristaltic waves are absent, distinguishing it from swallow-induced primary peristalsis.¹ SGB typically occurs without relation to meals and is absent during sleep and/or functions that supersede the mechanisms of SGB (eating and speaking).²² The inciting event for continued SGB may be an initial voluntary attempt to relieve an unpleasant sensation (eg, chest/epigastric discomfort), with the rapid air expulsion providing transient relief. Persistent symptoms lead to repeated compensatory, compulsive behavior, that develops into an uncontrolled and involuntary disorder.^1,23,24 Esophageal hypersensitivity to distension may also be present, with transient relief following esophageal air venting, but symptoms often recur with subsequent air swallowing and the compulsion to belch.

Diagnosis

Belching disorder can be clinically diagnosed per the Rome Criteria if bothersome belching occurs >3 days a week for the last 3 months with symptom onset ≥6 months prior to diagnosis.^7,25 Speech-language pathologists can detect SGB through observation (ie, vertical laryngeal movements with tense mouth closure and tightening of facial musculature before belching and/or sudden breath stops after deep inspiration by tight glottal closure just before belching).¹ Validated clinical criteria do not exist, and formal differentiation between SGB and GB must be made using esophageal HRIM or pH-impedance monitoring, with the latter considered the gold standard (Figure 2).^24,26 Esophagogastroduodenoscopy is not routinely recommended in these patients as it is usually normal unless accompanied by findings of GERD.¹

Figure 2. Depiction of the clinical and objective diagnostic criteria for SGB, GB, aerophagia, and RS.

*After appropriate evaluation, symptoms cannot be fully explained by another medical condition

**Though no formal guidelines exist, SGB can be successfully diagnosed through observation of tense mouth closure and tightening of facial musculature prior to belching and/or sudden breath stops after deep inspiration by tight glottal closure prior to belching

Two patterns of SGB can be identified on HRIM: air suction or injection. Suctioning, the most common, is characterized by a negative pressure gradient created by UES relaxation on deep inspiration followed by prompt expulsion of air by increased intrathoracic pressure from straining.²⁷ Injection is visualized as air being pushed into the esophagus via an elevated pharyngeal pressure from voluntary contraction of the tongue base (Figure 3).³ On pH-impedance monitoring, SGB is visualized as a sequentially rapid rise in impedance (≥1000 Ω) moving in towards the LES followed by a reverse flow impedance in the oral direction >13 times a day.^4,23,25

Figure 3.

SGB on HRIM in which there is deep inspiration, abdominal straining, with air suctioning in an aboral direction and expulsion of air in retrograde direction (A). (B) pH impedance monitoring in which there is a rise in impedance (>1000 Ohms) beginning in an aboral direction followed by rapid decrease in impedance back to baseline in a retrograde direction.

Management

Behavioral therapy and SGB.

The keystone for treating patients with SGB is to provide psychoeducation on the pathophysiology of SGB and role of learned behaviors, as well as to teach behavioral modification in the form of diaphragmatic breathing (controlled breath exercises with intentional inhalation/exhalation timing and oral mechanisms).²⁸ Punkkinen et al prospectively randomized 42 patients with SGB into diaphragmatic breathing exercises or follow-up without intervention. The therapy group achieved significantly lower SGB frequency and severity at 6-month follow up. At 6 months, the control group was offered behavioral therapy, and at 12 months, the control group maintained the initial findings, demonstrating 72% with improvement in frequency and 89% improvement intensity in the total 36 patients who received behavioral therapy.²⁹

Ong et al completed a randomized trial evaluating the efficacy of diaphragmatic breathing in patients with proton pump inhibitor (PPI)-refractory GERD and belching or a control group. Sixty percent of patients in the initial treatment group achieved significant reduction on their belching Visual Analog Scale (VAS) score (reported symptoms) and frequency. No one in the control group achieved this reduction until after being offered therapy, in which initial findings were maintained.³⁰ Another prospective study investigated the role of speech therapy in SGB and found the intensity and frequency of SGBs reduced >30% after 10 sessions. Notably, in the 2 patients who underwent repeat impedance testing, SGBs decreased from 164 and 150 to 6 and 19, respectively.³¹

Katzka completed an in-office instruction on diaphragmatic breathing with 5 patients. No formal questionnaires were utilized to measure outcomes; however, at 1 month, 4 of the patients reported elimination of belching.²² With this protocol, patients were instructed to keep their mouth open to further prevent glottic opening and swallowing. In a retrospective review on 48 patients with SGB who underwent a multifaceted program consisting of education, counseling, and exercise instruction, an improvement in SGBs was seen in 83% of patients, with 20 having a sufficient improvement, 11 a minor improvement, and 9 a large improvement.¹

Glasinovic et al had 39 patients with SGB complete CBT sessions focused on warning signal recognition and preventative exercises in a modified protocol described by Katzka. Patients who underwent post-treatment impedance testing saw a significant reduction in the median number of episodes, with 52% of patients having a >50% reduction in SGB. Patients also experienced improvement in perception of the severity of their belching symptoms and quality of life.³² In a continuation of this study, Sawada et al included the addition of a proficiency score and the examination of pre and post treatment factors follow-up at 6 and 12 months using the same 39 patients. A lower number of SGBs and lower hypervigilance score and a higher proficiency score were associated with better outcomes. The positive changes in SGB persisted at 6- and 12-month follow-up. Improved outcomes with a higher ‘proficiency’ score, a measurement of understanding and adherence, emphasize the importance of effective teaching in achieving successful management of these patients³³ and a potential need for reevaluation. Similarly, other studies underscored the importance of patient education though identifying precipitating sensations³² or understanding the diagnosis and committing to the therapy goal.¹ Although it may seem intuitive that therapists should be well-informed on the pathophysiology of the presenting disorder, this is not guaranteed, and therefore it should be a requirement for practitioners to know and educate. Ultimately, behavioral modification and psychoeducation are the foundation of effective SGB treatment.^1,8

Other therapeutic considerations in SGB.

Limited evidence supports medication to treat SGB. Blondeau et al did not find symptom improvement with baclofen, an inhibitor of transient lower esophageal sphincter relaxation (TLESR), in 2 patients with SGB.⁶ However, a different case report found a combination of baclofen and pregabalin successfully treated a patient with severe SGB.³⁴ Limited evidence and the sedative effects of these drugs limit chronic use of these medications. Alternative medications such as lesogaberan and arbaclofen placarbil have yielded modest results at best, and further development of these agents has been abandoned by pharmaceutical companies.⁸ Nonpharmacologic interventions, including empiric behavioral strategies to reduce aerophagia (as discussed later), may decrease intraluminal gastrointestinal air and are likely to alleviate symptoms.

Notably, SGB often coexists with esophageal hypomotility, GERD, and psychiatric conditions, suggesting phenotypes in this heterogenous patient group.^8,26 Treating baseline behavioral dysfunction and understanding concurrent comorbidities is key to successful management of these patients.

Psychosocial Distress, SGB, and Treatment Implications

There is increasing evidence that psychological factors play a significant role in the initiation and perpetuation of SGB, warranting evaluation of psychosocial factors.³⁰ Psychological factors include processes specific to SGB, such as symptom-specific anxiety (eg, fear/worry about SGB and its perceived consequents) or esophageal hypervigilance (eg, increased attention/focus on the chest/esophagus in response to anticipated symptoms).³⁵

These processes can influence how symptoms are perceived and reinforce behaviors (eg, belching) that lead to persistent symptomatology. Alternatively, comorbid psychiatric conditions such as generalized anxiety disorder and major depressive disorder, can cooccur with SGB, which can negatively contribute to the disease experience and health-related quality of life (HRQOL).³⁶ Patients with SGB have demonstrated severely impaired HRQOL with work/school absenteeism, difficulty with household chores, decreased social activities,²⁵ and higher levels of anxiety.^3,8,26 Punkkinen et al found decreased HRQOL in 92%, increased anxiety in 48%, and increased depression scores in 30% of patients with SGB, all of which were higher as compared with the general population. After behavioral therapy, depression scores significantly improved, with modest change in anxiety and HRQOL.²⁹ A different study found that patients with lower baseline hypervigilance had better outcomes after CBT than those with a greater level of hypervigilance.³³

In contrast, a separate study found anxiety and depression status to have no significant effect on the severity of belch.³⁷ Bredenoord et al similarly found no elevation in anxiety or depression in patients with SGB,² which was paralleled by another study that found hypervigilance in patients with SGB and GERD to be within the average normal range.³⁰

Overall, evidence of psychosocial burden in patients with SGB is inconsistent, suggesting it may not apply to all patients. Further studies are needed to evaluate the relationship between SGB and psychiatric comorbidities. Early evaluation of psychosocial burden should be considered and treated appropriately in these patients who screen positive or endorse a mental health condition. Psychoeducation and reassurance in all patients with belching should also be considered to help reduce psychological distress that may be secondary to or contributing to disease burden, maladaptive coping, and trigger symptoms (eg, chest discomfort, bloating).^3,25

GERD, Supragastric Belching, and Treatment Implications

GERD and SGB have significant overlap,^29,30,38 and often, patients have PPI-refractory symptoms that respond to behavioral interventions ^4,23,39,40

Keeratichananont et al found that the frequency of SGB positively correlated with frequency of reflux episodes preceded by SGBs, with nearly 50% of reflux episodes preceded by SGBs. Patients with positive pH-impedance testing (defined per the impedance criteria above) had a significantly higher rate of SGBs and reflux episodes preceded by SGBs compared with patients with negative testing.²³ Another study found SGB related to 53.6% of acid reflux events and 27% of acid exposure in all patients.³⁹ Similarly, Punkkinen et al found that 54% of patients with reflux associated SGB were induced by an SGB, opposed to 30% with reflux preceding the SGB.²⁹ Similarly, Kessing et al analyzed pH-impedance monitoring in patients with belching and found that a greater presence of severe reflux symptoms was associated with an increased number of SGBs that coincided with reflux. The authors concluded that the increased burden of disease in SGB-associated GERD was likely a result of excessive SGB.⁴¹ Several other studies also found an increased prevalence of SGB episodes in patients with SGB and pathological reflux, with a positive relationship demonstrated between reflux severity and SGB burden.^26,31 Notably, one study found that, in contrast to previous assumptions, air swallowing was a more dominant mechanism for reflux than belching.⁴²

Similarly, other studies show intervention aimed at reducing SGB reduced gastroesophageal reflux. Glasinovic et al found that CBT improved acid exposure time (AET) in patients with SGB and an elevated baseline AET. In all patients, total number of acid and nonacid reflux episodes after therapy was significantly decreased.³² Another study randomized patients with PPI-refractory GERD (twice-daily PPI >12 weeks) and SGB into a treatment group with diaphragmatic breathing or a control/waitlist group. The treatment group had significantly improved GERD severity and markedly reduced belching frequency compared with the control group.³⁰

Whether or not SGB causes GERD or vice versa is not well-understood. One study found that only 1.8% of patients had SGB episodes preceded by reflux events, which led investigators to opine that SGB is likely not a behavioral consequence to the discomfort due to acid exposure.²⁵ In contrast, another study discussed reduced frequency of compensatory air injection in patients in GERD with acid suppression therapy, suggesting that heartburn may be the unpleasant sensation that drives SGB.⁴³ Kessing et al found that SGB elicits reflux in some cases and is the patient’s response to an unpleasant esophageal sensation in others.⁴⁴ Ultimately, treating both conditions concurrently yields the most favorable results.

These studies demonstrate a distinct subset of patients with SGB-associated GERD.³⁸ Whether this relationship is unidirectional or bidirectional requires further research. Regardless, a role for SGB in patients presenting with reflux symptoms refractory to PPI should be assessed.²⁴ In this subset of patients identified as SGB-associated GERD, targeted behavioral and speech therapy should be initiated to improve both SGB and GERD symptoms in conjunction with PPI use as indicated.

Ineffective Esophageal Motility, Supragastric Belching, and Treatment Implications

Ineffective esophageal motility (IEM) has been correlated with higher rates of SGB, possibly due to delayed esophageal clearance contributing to symptom persistence.^25,39

In patients with SGB, Keeratichananont et al identified 50% of patients with IEM and 11% of patients with major esophageal motility disorders. In patients with dysmotility, the reflux episodes associated with SGBs extended more proximal than reflux unassociated with SGB with longer acid and bolus contact time. Another study found that in patients with SGB, the 44% of patients with esophageal hypomotility had a significantly higher frequency of SGB compared with those with normal motility even when pathologic reflux was excluded from the analysis.²⁶ A positive relationship between incidence of IEM and SGB severity was suggested, although this did not achieve statistical significance.³⁹

Although a relationship of IEM and SGB has been established, it is unclear if esophageal gaseous distention from SGB may be contributing to dysmotility or if hypomotility is lending itself to increased SGB frequency. Further investigation is needed to guide treatment in patients with coexisting IEM and SGB, as no specific therapeutic strategy currently exists.

Gastric Belching

Presentation

Unlike SGB, GB is a natural, physiological response to distention that releases excess gas from the stomach into the esophagus through TLESR.¹ It is normal to belch up to 30 times daily. As such, the presence of GB is normal and only when it is excessive and/or bothersome is GB considered a disorder. There is no behavioral or voluntary component identified in GB. There may also be an increased feeling of needing to emit a gastric belch in patients with increased sensitivity to gastric stretch and/or decreased gastric accommodation.

Diagnosis

GB occurs from a efferent motor vagal reflex causing a TLESR.²⁶ This is followed by oral air flow into the esophagus followed by the oropharynx through the relaxation of the UES, which can be visualized on HRIM.^3,4 On pH-impedance testing, this is seen as a spiked transient elevation in intraluminal impedance (≥1000 Ω) starting from the distal most channel proximal to the LES, sequentially moving in the oral direction passing the most proximal impedance sensor.⁴ Notably, prior studies have also utilized a rapid rise of >3000 Ω over 2 consecutive impedance sites as diagnostic.²⁷

Management

Treatment for GB focuses on reducing air swallowing and TLESRs (Table 1).^7,24 Baclofen remains the mainstay of treatment; by causing a slight elevation in LES pressure, it is thought to reduce the numbers of both TLESRs and acid reflux episodes.²² For patients who also display increased air swallowing, behavior modification is recommended.²⁴ There is limited evidence into laparoscopic fundoplication as a surgical intervention for GB. Although it has been found to cause less bloating and flatulence among patients with GB, increased rates in SGBs have been noted.⁷ Furthermore, persistently increased swallowing of air could lead to severe post-fundoplication gas bloat syndrome. Due to lack of evidence, surgical intervention to treat GB is not routinely recommended.

Due to common comorbidity of GB and reflux, patients are recommended to be evaluated and treated appropriately for concurrent GERD.⁷ For patients with nausea and vomiting, gastroparesis should be ruled out.³ GB is less behavioral in nature and stems from the LES not the UES, which suggests that patients may not respond to behavioral regimens. One study found that belching-focused CBT did not alleviate symptoms in GB.^30,32 As such, the role of behavioral therapy for GB is unclear. It is our experience that treating some patients for deceased gastric accommodation and/or increased sensitivity to stretch may help reduce the drive to vent gastric air. Pharmacologic therapies that may achieve this include buspirone and low doses of tricyclic antidepressants.

Aerophagia

Presentation

Aerophagia is an increase in air swallowing that accumulates in the stomach and intestine without a reflexive immediate and repetitive oral expulsion of air.^2,3 Consequently, patients with aerophagia typically have more bloating and flatulence than patients with SGB.⁸

Diagnosis

Esophageal physiologic testing is not routinely used for aerophagia, with clinical evaluation as the primary diagnostic modality. The Rome Criteria defines aerophagia as >2 months of excessive air swallowing, abdominal distention from intraluminal air that increases during the day, and repetitive belching and/or increased flatus not explained by another medical condition.⁴⁵ Abdominal radiographs may show a large volume of intestinal air, and physical exam may reveal tympany over the abdomen and normal or increased bowel sounds that may be higher pitched. On both exams, it is key to rule out signs of ileus.⁴³ If utilized, HRIM will demonstrate air swallowed into the esophagus through a relaxed UES, transported through esophageal peristalsis, and then passed into the stomach during natural LES relaxation.³ On ambulatory impedance monitoring, excessive air swallowing can be demonstrated.⁴⁴

Management

There is limited evidence and no controlled trials available on the management of aerophagia; treatment recommendations largely stem from expert opinion.⁴³ Aerophagia treatment is targeted at reducing increased air accumulation and gastric distention. In turn, behavioral modifications that reduce air swallowing such as cessation of smoking, gum chewing, eating too quickly, beverage sipping, using a straw, and drinking carbonated beverages remain the mainstay treatment (Table 1).⁴⁶

For acute symptoms related to aerophagia, patients should be evaluated to assure another more concerning process is not present like gastric volvulus or obstruction. For chronic symptoms, the most common presentation, behavioral modifications are recommended. Trialing dimethicone, simethicone, or laxatives if indicated in the appropriate case is not unreasonable.⁴³ Another case report found that baclofen reduced swallowing frequency and therefore the ingestion of air. The author concluded that this may be a potential source of treatment, but this was not directly tested in this study.⁶

Conclusion and Future Directions

Belching is a common symptom that is predominantly secondary to SGB and closely related to RS. GB and aerophagia are commonly used interchangeably with SGB, though they are distinct entities of air physiology and infrequently symptomatic. Belching, RS, and aerophagia can be diagnosed clinically, but SGB and GB require objective testing for formal differentiation. Altogether, these conditions share complex relationships with one another, with overlap in physiology, comorbidities, and treatment strategies (Figure 4). Physiology-directed treatment strategies utilized are often multifactorial and include disease education, medication, behavioral therapy, and infrequently, surgery.

Figure 4.

Diagram of the complex relationships between SGB, GB, aerophagia, and RS, highlighting the areas of overlap as well as intervention.

Ultimately, an algorithm for approaching a patient with belching is lacking. The Rome Criteria describe the clinical diagnosis, and there is a general consensus on parameters for diagnosis on pH-impedance and manometry; however, these have not been formally published together in a single document, and there are no validated criteria for evaluating the response to therapy in patients with belching.²⁹ Developing an algorithm for approaching a patient with belching is key to streamlining effective and efficient diagnosis and treatment of these complex patients.

Abbreviations used in this paper:

AET

acid exposure time

CBT

cognitive behavioral therapy

DSM-5

Diagnostic and Statistical Manual of Mental Disorders Fifth Edition

EGJ

esophagogastric junction

GB

gastric belching

GERD

gastroesophageal reflux disease

HRIM

high-resolution impedance manometry

HRQOL

health-related quality of life

IEM

ineffective esophageal motility

LES

lower esophageal sphincter

PPI

proton pump inhibitor

RS

rumination syndrome

SGB

supragastric belching

TLESR

transient lower esophageal sphincter relaxation

UES

upper esophageal sphincter

VAS

Visual Analog Scale