Sour morning belches

Specialty: Gastrointestinal.

• Acid belch upon waking up
• sour morning taste
• morning acid reflux

Why it occurs

• Severe nocturnal gastroesophageal reflux disease (GERD) with poor esophageal clearance
• Large sliding hiatal hernia with loss of the anatomical barrier of the lower sphincter during the night
• Delayed gastric emptying secondary to heavy late intakes or gastroparesis in the initial phase
• Physiological increase in nocturnal basal gastric acid secretion.

Initial workup

Upper gastrointestinal endoscopy (EDA) to evaluate esophagitis, stricture or Barrett's esophagus | 24-hour pH-metry with impedanciometry | High resolution esophageal manometry.

Standard management

• Proton pump inhibitors — esomeprazole 40 mg or pantoprazole 40 mg administered in the afternoon, 30-60 minutes before dinner
• Sodium alginate plus potassium bicarbonate — 10-20 ml at bedtime to form a physical barrier against nocturnal acid reflux
• Hygienic-dietary measures (raise the head of the bed 15-20 cm and have dinner at least 3 hours before going to bed).