The inability to belch syndrome: A study using concurrent high‐resolution manometry and impedance monitoring

Abstract

Introduction Although inability to belch has previously been linked to dysfunction of the upper esophageal sphincter (UES), its underlying pathogenesis remains unclear. Our aim was to study mechanisms underlying inability to belch and the effect of UES botulinum toxin (botox) injections in these patients. Methods We prospectively enrolled consecutive patients with symptoms of inability to belch. Patients underwent stationary high‐resolution impedance manometry (HRIM) with belch provocation and ambulatory 24‐h pH‐impedance monitoring before and 3 months after UES botox injection. Results Eight patients (four males, age 18–37 years) were included. Complete and normal UES relaxation occurred in response to deglutition in all patients. A median number of 33(15–64) gastroesophageal gas reflux episodes were observed. Despite the subsequent increase in esophageal pressure (from −4.0 [−7.7–4.2] to 8 [3.3–16.1] mmHg; p < 0.012), none of the gastroesophageal gas reflux events resulted in UES relaxation. Periods of continuous high impedance levels, indicating air entrapment (median air presence time 10.5% [0–43]), were observed during 24‐h impedance monitoring. UES botox reduced UES basal pressure (from 95.7[41.2–154.0] to 29.2 [16.7–45.6] mmHg; p < 0.02) and restored belching capacity in all patients. As a result, esophageal air presence time decreased from 10.5% (0–43.4) to 0.7% (0.1–18.6; p < 0.02) and esophageal symptoms improved in all patients (VAS 6.0 [1.0–7.9] to 1.0 [0.0–2.5]; p < 0.012). Conclusion The results of this study underpin the existence of a syndrome characterized by an inability to belch and support the hypothesis that ineffective UES relaxation, with subsequent esophageal air entrapment, may lead to esophageal symptoms.

Retrograde upper esophageal sphincter function… and dysfunction

“…9,10 UES opening also occurs during belching 11 and vomiting 4 when its residual relaxation tone is overcome by intra-esophageal pressure; belching being of particular interest with respect to the work of Oude Nijhuis, et al published in this issue of the Journal. 1…”

“…The latter mechanism is clearly at play during swallowing wherein both laryngeal airway closure and UES opening occur through the coordinated contraction pattern of the pharyngeal swallow 9,10 . UES opening also occurs during belching 11 and vomiting 4 when its residual relaxation tone is overcome by intra‐esophageal pressure; belching being of particular interest with respect to the work of Oude Nijhuis, et al published in this issue of the Journal 1 …”

“…Over the years, this author has encountered several patients with self‐diagnosed R‐UESD, usually following Internet searches that unearthed the initial case report from 1987 14 . However, the number of such patients has increased substantially since the publication by Bastian and Smithson in 2019 17 and is likely to further increase now with the publication by Oude Nijhuis et al 1 The word is spreading among the afflicted, first through Reddit as noted by Bastian and more recently on TikToc. Of course, not all these self‐diagnosed individuals will prove to have R‐UESD making it so timely that we now have a diagnostic test to both verify the dysfunction and to monitor response to BT treatment.…”

“…Additionally, the application of topographic plotting and the addition of impedance sensors make it possible to detect the antegrade or retrograde movement of fluid and air through the esophagus and across its sphincters. An excellent clinical application of this technology appears in this issue of the Journal describing a case series of 8 individuals with long histories of an inability to belch who were shown to suffer from “partial belching” with air escaping the stomach but becoming trapped within the esophagus on account of failed UES relaxation in response to esophageal gaseous distention 1 . Associated symptoms included chest pain, gurgling noises within the chest, bloating, nausea, hiccups, and flatulence.…”

Retrograde Cricopharyngeus Dysfunction: An Orphan Disease?

“…Recently, the underlying pathophysiology of R-CPD has been validated by manometry by Oude Nijhuis et al (4) and additional studies are likely to follow. Kahrilas (5) has also written a helpful and thoughtful review of upper esophageal sphincter function and dysfunction in response to the manometry study.…”