GIT Kurdistan GEH Board J club belching.

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GIT Kurdistan GEH Board J club belching.

Transcript of GIT Kurdistan GEH Board J club belching.

  • 1. Dr. Mohamed Alshekhani 09/20/14 Brain Abscess 1
  • 2. INTRODUCTION: An oral expulsion of a gas bolus from the UGIT audible or in some cases silently. In most individuals, it occurs as a physiological event & not perceived as a symptom. Some consult because of excessive belching complaints or complaints by those surrounding the patients. Excessive belching may appear harmless complaint at first, but may be responsible for a decreased QOL. Rreported by 50 % of the general population with dyspepsia& 20 % of them experiences moderate-to-severe interference with daily activities. Impedance monitoring &high-resolution manometry, have greatly enhanced our understanding of belching. 09/20/14 Belching 2
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  • 5. PATHOPHYSIO: Gastric belching( Physiological) occurs in almost every individual 30 times / 24 h prevents the accumulation of excess gas in the stomach or duodenum, because with each swallow, a variable volume of air is ingested&transported to the stomach& carbonated beverages use results in an increase of gastric air. Manometry showed that it occurs mainly during spontaneous (not-swallow induced) transient relaxations of the lower esophageal sphincter (TLESR).,triggered by distention of the stomach, such as caused by intragastric air, allowing this air to be vented from the stomach into the esophagus. Several neurotransmitters that influence the rate of TLESRs as gamma-aminobutyric acid , metabotropic glutamate receptors, cannabinoid receptor 1, nitric oxide & cholecystokinin. 09/20/14 Belching 5
  • 6. PATHOPHYSIO: Isolated excessive belching The gastric belching can be recognized with impedance monitoring as an increase in impedance starting in the distal channel& progressing to the most proximal channel. Supragastric belching: With the use of eso impedance monitoring, a different type of belch was identified in patients with isolated excessive belching. During this second type of belch, air is rapidly brought into the esophagus & immediately followed by a rapid expulsion&the air neither originates from the stomach nor does it reach the stomach Combined high-resolution manometry &impedance monitoring further elucidated two mechanisms of this type: 09/20/14 Belching 6
  • 7. PATHOPHYSIO: Isolated excessive belching 1. The most common mechanism ,so-called air-suction method characterized by a movement of the diaphragm in aboral direction resulting in a negative intra-thoracic pressure as would occur during deep inspiration ,UES relaxation occurs during which the glottis is closed& air flows from the atmospheric pressure in the pharynx to the subatmospheric pressure in the esophagus&the esophageal air is immediately expulsed orally as a result of straining that is perceived by the patient as a belch. UES relaxation during supragastric belching occurs before the influx of air in the esophagus in contrast to gastric belching during which UES relaxation is a late event in response to the influx of air. The driving force behind the air inflow during supragastric belching is a pressure gradient, the air flows into the esophagus much faster than would occur during air swallowing in which the driving force is esophageal peristalsis. 09/20/14 Belching 7
  • 8. PATHOPHYSIO: Isolated excessive belching 2. The air-injection method, characterized by a simultaneous pressure increase in the pharynx most likely caused by a contraction of the base of the tongue & not a peristaltic contraction of the pharynx initiating the influx of air into the esophagus & the driving force behind the influx of air is the pressure gradient between the elevated pharyngeal pressure & unchanged intra-esophageal pressure. SHB may start as a voluntary response to an unpleasant GI sensation as a deliberate attempt to reduce symptoms. Patients are not aware that SGB is under voluntary control, but evidences for this are: Do not occur during sleep. Frequency decreases while a patient is distracted. often observed in healthy Persons, suggesting a learned behavior. 09/20/14 Belching 8
  • 9. PATHOPHYSIO: Isolated excessive belching Although the common belching in pregnancy can be due to GERD, but most are supragastric, supporting the idea that it occurs as a response to find relief a sensation of fullness. 09/20/14 Belching 9
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  • 23. PATHOPHYSIO: GERD-related Belching Common, reported by 40 49 %. Most of the belches are supragastric & not gastric. No study assessed the response to behavioral therapy, but PPI shown a modest decrease in belching complaints. In a subgroup of patients with GERD, supragastric belches can induce reflux pisodes. 09/20/14 Belching 23
  • 24. PATHOPHYSIO: FD-related Belching Belching is also common in pother functional GIT disorders. Gas reflux episodes occur more frequently in patients FD. Patients with FD experienced troublesome belching. 09/20/14 Belching 24
  • 25. PATHOPHYSIO: Rumination syndrome-related. Persistent or recurrent regurgitation of recently ingested food into the mouth. Rumination episodes are induced by a rise in intra-gastric pressure generated by a voluntary, but often not intentional, contraction of the abdominal wall musculature. A subgroup of patients identified who exhibit a typical behavior that is characterized by a supragastric belch immediately followed by a quick rise in intragastric pressure that forces gastric content into the esophagus & cause symptoms of regurgitation , suggest that supragastric belching underlies rumination episodes in a subgroup of patients. In patients with symptoms of belching & regurgitation, supragastric belch-induced rumination should be considered. 09/20/14 Belching 25
  • 26. PATHOPHYSIO: Aerophagia-related. A disorder characterized by increased swallowing of air resulting in increased intragastric/ intraintestinal gas, observed by abd X-ray. Patients with aerophagia seldom complain of excessive belching &main complaint is abdominal bloating & abdominal distension. 09/20/14 Belching 26
  • 27. PATHOPHYSIO: Pediatric belching. Excessive belching can also occur in children. Mechanism are yet not studied. There are currently no proven therapeutic options &more research is warranted to determine etiology&treatment of belching complaints in children. 09/20/14 Belching 27
  • 28. Diagnosis. A similar frequency of gastric belches but an increased number of supragastric belches. Supragastric belching can oft en be diagnosed without invasive A patient exhibits excessive, repetitive belching during a consultation. The absence of belches during speaking. Typically, a patient belches while the physician is asking questions, whereas a patient does not belch while responding to these questions&frequency of supragastric belches decreases when a patient is actively distracted. 09/20/14 Belching 28
  • 29. D