S4508 Not a Happy Burp-Day: Exploring the Evaluation and Management of Supra-Gastric Belching (SGB)

Introduction: Often physiologic due to gastric venting, belching is a common gastrointestinal (GI) symptom. However, when persistent or bothersome, it may reflect underlying functional or behavioral disorders. Supra-gastric belching (SGB) is characterized by rapid, repetitive belching where air is drawn into the esophagus and expelled without reaching the stomach. It is considered a learned behavior and is often associated with refractory gastroesophageal reflux disease (GERD). Excessive SGB can significantly impair quality of life, contributing to embarrassment, anxiety, and depression. Management focuses on behavioral interventions such as cognitive behavioral therapy, diaphragmatic breathing, and biofeedback, with adjunctive pharmacologic options like baclofen, emphasizing the need for a comprehensive, patient-centered approach. Case Description: Patient is a 70-year-old man with a history of tobacco use, chronic obstructive pulmonary disease, chronic GERD due to Barrett's esophagus, chronic kidney disease stage 3, and bladder cancer who presented to the gastroenterology clinic for a second opinion regarding treatment-refractory belching. He had been burping multiple times a minute for months, leading to significant discomfort and dyspnea. A prior esophagogastroduodenoscopy (EGD) showed Barrett's esophagus and chronic GERD. He had trialed proton-pump inhibitors (PPI), prophylactic antibiotics for Helicobacter pylori and small intestinal bacterial overgrowth, and diazepam without relief. Esophageal manometry revealed normal peristalsis and confirmed persistent SGB. He was started on renally dosed baclofen (2.5 mg 3 times per day) and referred to GI psychology for initiation of diaphragmatic breathing techniques. Discussion: This case emphasizes the need to recognize SGB in patients with persistent belching that does not respond to standard treatments. Without considering SGB, patients may undergo unnecessary tests or receive ineffective treatments. While ruling out structural and motility issues is crucial, persistent belching should raise suspicion for SGB. Diagnostic tests like esophageal manometry and pH impedance can support the diagnosis, but clinical judgment is key. Effective management involves a multidisciplinary approach with behavioral therapies and medications when appropriate. Functional GI disorders can profoundly disrupt daily activities leading to emotional distress. Early recognition and targeted treatment can improve outcomes and prevent unnecessary interventions.