Excessive belching

Specialty: Gastrointestinal.

• Pathological belching
• symptomatic aerophagia
• repetitive supragastric belching

Why it occurs

• Supragastric belching (voluntary or involuntary learned behavior where air enters the esophagus and is expelled immediately without reaching the stomach, common in anxiety disorders)
• Aerophagia (true swallowing of air that progresses towards the stomach due to rapid eating, chewing speech, or chronic mouth breathing)
• Gastroesophageal reflux disease (GERD) where the patient swallows saliva repetitively to calm heartburn, swallowing air secondarily
• Functional dyspepsia or active gastritis with slowed gastric emptying that favors gas accumulation.

Initial workup

Meticulous behavioral history (supragastric belching typically decreases with distraction, talking, and disappears completely during sleep) | Upper digestive endoscopy (EDA, to exclude mucosal pathology, esophagitis, stricture or hiatal hernia) | 24-hour esophageal pH-impedanciometry (allows differentiation of supragastric belching from true gastric belching and assessment of acid or non-acid reflux).

Standard management

• Proton pump inhibitors if concomitant GERD is documented — omeprazole 20 mg/day before breakfast to suppress reflux and the consequent stimulation of constant saliva swallowing
• Baclofen — GABA-B receptor antagonist, dose of 5-10 mg three times a day, useful for reducing the frequency of supragastric and gastric belching by inhibiting transient relaxations of the lower esophageal sphincter
• Anxiety modulators if associated with somatization or hyperventilation disorders — sertraline 50 mg/day or clonazepam at low doses of 0.25-0.5 mg at night
• Cognitive-behavioral therapy and speech therapy for pharyngeal respiratory reeducation (first-line therapies).