Download - GIT Kurdistan GEH Board J club belching.

Dr. Mohamed Alshekhani

04/08/23 1Brain Abscess

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.

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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.

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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:

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• 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.

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• 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.

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• 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.

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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 épisodes.

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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.

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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.

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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.

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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.

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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.

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Diagnosis.

• Although a thorough history & clinical observation can often identify patients with supragastric belching, the gold standard for the diagnosis is impedance monitoring, allowing a differentiation between gastric belching & supragastric belching.

• Ambulatory monitoring , can report symptomatic belches, allowing the clinician to pinpoint specific belch events & determine the type of belch.

• Impedance monitoring during a 90-min period identifies supragastric belches in the majority of patients with excessive belching but 24-h ambulatory impedance monitoring therefore remains the diagnostic modality of choice, because it allows differentiation with GERD.

• Impedance monitoring can show increased frequency of air swallowing in aerophagia but no supragastric belches.

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Treatment:

• The cornerstone of treatment is a thorough explanation of the underlying mechanism.

• patients often expect that an organic cause for their disease can be found&reluctant to accept that their complaints are due to abnormal behavior.

• So Impedance monitoring, not only aids in the diagnosis but also provides an indisputable confirmation of the underlying behavioral disorder.

• As supragastric belching is a behavioral disorder, behavioral therapy is the therapy of choice.

• Speech therapy reduces symptoms in patients with excessive belching.

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Treatment:

• The first step is description of the behavior that underlies the sucking or injection of air into the esophagus.&the patient is trained to refrain from this behavior& to acquire a fluent breathing pattern , practiced by conventional breathing and vocal exercises.

• As the diaphragm is the cause of supragastric belches in the majority of patients, the applied behavioral therapy should rely heavily on abdominal breathing exercises.

• Learn abdominal breathing exercises to the patient by placing a hand on the abdomen during respiration& explaining that the hand on the abdomen should move with breathing.

• Attention on belching is moved to attention on the behavior underlying their belching.

• 10-20 sessions of behavioral therapy is oft ensufficient to provide a significant decrease in belching complaints.

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Treatment:

• ? Baclofen.

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Conclusion:

• Supragastric belching appears to be the most important factor in the etiology of excessive belching complaints&this disorder can be treated with behavioral therapy.

• Additional studies, such as those assessing the effect of behavioral therapy in patients with GERD,rumination, or functional dyspepsia & determining the pathophysiology of excessive belching in children, are needed.

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Conclusion:• Excessive belching is a commonly observed complaint in clinical

practice that can occur as an isolated symptom or as a concomitant symptom in patients with (GERD) or FD.

• Impedance monitoring has revealed two mechanisms through which belching can occur: the gastric & supragastric belch.

• The gastric belch is the result of a vagally- mediated reflex leading to relaxation of LES &venting of gastric air.

• The supragastric belch is a behavioral peculiarity, During which, pharyngeal air is sucked or injected into the esophagus, after which it is immediately expulsed before it has reached the stomach.

• Patients who belch excessively invariably exhibit an increased incidence of supragastric, not of gastric belches.

• Supragastric belches can elicit regurgitation episodes in rumination syndrome & sometimes induce reflux episodes as well.

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Conclusion:

• Behavioral therapy has been proven to decrease belching complaints in patients with isolated excessive belching, but its effect is unknown in frequently belching patients with GERD, functional dyspepsia or rumination.

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CME:

• 1. Which one of the following neurotransmitters that influences the rate of transient lower esophageal sphincter relaxations has been studied most extensively?

• A. Metabotropic glutamate receptors• B. Gamma-aminobutyric acid (GABA-B)• C. Cannabinoid receptor 1• D. Nitric oxide (NO)

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CME:

• 1. Which one of the following neurotransmitters that influences the rate of transient lower esophageal sphincter relaxations has been studied most extensively?

• A. Metabotropic glutamate receptors• B. Gamma-aminobutyric acid (GABA-B)• C. Cannabinoid receptor 1• D. Nitric oxide (NO)

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CME:

• 2. Which one of the following diagnostic modalities is the gold standard for diagnosing supragastric belching?

• A. Barium esophagram• B. Esophageal manometry• C. Esophagogastroduodenoscopy• D. Esophageal impedance monitoring

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CME:

• 2. Which one of the following diagnostic modalities is the gold standard for diagnosing supragastric belching?

• A. Barium esophagram• B. Esophageal manometry• C. Esophagogastroduodenoscopy• D. Esophageal impedance monitoring

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CME:

• 3. How many behavioral speech therapy sessions is sufficient for most patients to experience a significant decrease in belching complaints?

• A. 1 – 5• B. 10 – 20• C. 20 – 30• D. Speech therapy is ineffective.

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CME:

• 3. How many behavioral speech therapy sessions is sufficient for most patients to experience a significant decrease in belching complaints?

• A. 1 – 5• B. 10 – 20• C. 20 – 30• D. Speech therapy is ineffective.

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CME:

• 4. Most of the belching spisodes are:• A. Gastric• B. Supragastric• C. Mixed• D. None.

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CME:

• 4. Most of the belching spisodes are:• A. Gastric• B. Supragastric• C. Mixed• D. None.

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CME:

• 5. Most of the belching spisodes in GERD patients are:• A. Gastric• B. Supragastric• C. Mixed• D. None.

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CME:

• 5. Most of the belching spisodes in GERD patients are:• A. Gastric• B. Supragastric• C. Mixed• D. None.

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CME:

• 6. The following GIT disorders proved be associated with belching except:

• A. GERD• B. Aerophagia.• C. Rumination syndrome.• D. IBD.

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CME:

• 6. The following GIT disorders proved be associated with belching except:

• A. GERD• B. Aerophagia.• C. Rumination syndrome.• D. IBD.

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CME:

• 7. The drug showing benefit in belching patients in some studies is:• A. Metclopromide.• B. Erythromycin.• C. PPI.• D. Baclofen.

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CME:

• 7. The drug showing benefit in belching patients in some studies is:• A. Metclopromide.• B. Erythromycin.• C. PPI.• D. Baclofen.

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CME:

• 8. The effect of belching on patients:• A. Increase Barrets prevalence in GERD patients.• B. Increase PPI dose requirements.• C. Low quality of life score.• D. Increase depression episodes.

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CME:

• 8. The effect of belching on patients:• A. Increase Barrets prevalence in GERD patients.• B. Increase PPI dose requirements.• C. Low quality of life score.• D. Increase depression episodes.

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CME:

• 9. The minimum time required for ambulatory impedence monitoring to diagnose belching syndrome is:

• A. 24 hours.• B. ½ hour.• C. 1.5 hours.• D. 1 hour.

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CME:

• 9. The minimum time required for ambulatory impedance monitoring to diagnose belching syndrome is:

• A. 24 hours.• B. ½ hour.• C. 1.5 hours.• D. 1 hour.

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CME:

• 10. The primary site responsible in initiating the supra gastric belching behavior is:

• A. esophagus.• B. Stomach.• C. Diaphragm.• D. Abd muscles.

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CME:

• 10. The primary site responsible in initiating the supra gastric belching behavior is:

• A. esophagus.• B. Stomach.• C. Diaphragm.• D. Abd muscles.

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