Belching, Air Swallowing, and Hiccups

David A. Johnson, MD


December 05, 2013

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A Very Common Set of Symptoms

Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another installment of GI Common Concerns -- Computer Consult.

Today I want to talk about a very common set of symptoms that every one of us has experienced: belching, air swallowing, and hiccups.[1] We see these referrals from primary care. What do we do with these patients? From a gastroenterologist's perspective, what do these symptoms mean?


Let's start with the issue of belching (eructation).

It is not uncommon for patients to describe occasional belching; in fact, it is physiologic. However, there is a difference between a gastric belch -- the normal physiologic response -- and a supragastric belch.

The gastric belch means that the air in the stomach is vented through transient relaxations of the lower esophageal sphincter. The air comes up, the upper esophageal sphincter relaxes, and the air is vented physiologically, a process that occurs 20-25 times every day. It is a normal reflex response.

However, most people who complain of excessive belching don't have gastric belching. They have supragastric belching, meaning that the source of air in the esophagus is not swallowed air; instead, it is transported in, and then by retrograde propulsion, it is driven back out into the pharynx and eructation occurs.

With esophageal impedance manometry, we are able to define this process much more clearly. We can tell when someone volitionally swallows air. We can see the changes in esophageal peristalsis with a volitional swallow.

In the case of supragastric belching, air is drawn back into the esophagus by a diaphragmatic contraction, which creates negative intrathoracic pressure. Thus, the air is sucked into the esophagus and expelled back out, without being swallowed. This is what occurs in most people who have supragastric belching.

The second component of supragastric belching is that these patients can coordinate the muscles at the base of the tongue with their pharyngeal muscles in a simultaneous contraction that draws air into the esophagus, from where it is expelled, without a volitional swallow. These patients are repetitive belchers, and typically, this is a behavioral problem. It is not uniquely tied to a specific disease, although we do see some diseases, such as functional dyspepsia, that are associated with a higher incidence of supragastric belching. You might discover this association by taking a good history.

The history will also reveal what happens when these patients go to sleep: The belching should stop. If you distract repetitive belchers by talking to them, the belching will often stop. Take a good history, assess the belching while the patient is distracted by speaking, and talk to the patient's bed partner to find out what happens at night, because this problem is typically behavioral.


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