#NASPGHAN17 Why Rome IV Criteria are important

More information from this year’s annual NASPGHAN meeting.

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

The following slides highlight a terrific lecture by Carlo DiLorenzo (Nationwide Children’s Hospital).  Subsequently, I’ve included slides from Miranda van Tilburg (UNC); I was unable to attend her lecture and found some of the slides via twitter.

Key points:

  • Rome IV criteria are helpful, particularly with less common presentations like rumination
  • There has been an increase in nausea.  Morning nausea can be equated as a marker of anxiety until proven otherwise.
  • There is improved wording. “After appropriate medical evaluation, the symptoms cannot be attributed to another condition” may help facilitate the diagnosis of irritable bowel syndrome, for example, in patients with IBD who are in remission.

From Miranda Tilburg:

Belching, Hiccups and Aerophagia

A useful review (Clin Gastroenterol Hepatol 2013; 11: 6-12) provides information on these clinical problems.

Belching or eructation can be divided into gastric belches which are normal and supragastric belching.  Supragastric belching which is a behavior (not a reflex), is often provoked by stress.  Air does not originate from the stomach or air swallowing (aerophagia).  The most common mechanism: a contraction of the diaphragm causes negative pressure in the chest and allows air to be suctioned into the esophagus.  It is expelled subsequently as a belch.  In some instances, it can occur up to 20 times a minute.  Supragastric belching does not occur during sleep and usually does not occur during speaking.

A clinical diagnosis usually is sufficient, though esophageal impedance can document these events as well.


  1. Explain physiology to patient
  2. Consider psychiatric evaluation when appropriate
  3. Glottis training by qualified speech therapist –needs to be aware of mechanism (that belching is not due to aerophagia).
  4. Alternative treatment could include cognitive behavior therapy, baclofen, hypnosis or biofeedback

Hiccups (singultus) are abnormal if lasting more than 48 hours.

Hiccups (at least in adults) have more likelihood of underlying pathology than belching.  This review suggests workup including blood tests (CBC, CMP, Amylase/lipase, CRP, Cortisol) and consideration of EKG, CT of chest, Upper endoscopy, MRI of brainstem, and esophageal impedance.

Physical maneuvers have usually been tried and include the following: scaring the patient, rapid drinking, eyeball compression, holding breath, biting a lemon, swallowing sugar, and sniffing vinegar.  A good differential diagnosis is given as well in this review -though many cases are idiopathic.

In the U.S. the only approved drug treatment is chlorpromazine.  Typical starting dose  for adults with this condition is 25 mg 3-4/day.  Potential side effects include drowsiness and rarely tardive dyskinesia.  Potential alternatives include baclofen and gabapentin.  Numerous other agents and even surgical options are listed in this review that have been reported in case studies.

Aerophagia indicates excessive swallowing of air (capable of inducing symptoms like bloating or pain).  No controlled studies have been completed.  Expert opinion suggests using a nasogastric tube and sedatives like lorazepam in severe acute cases.  In more typical chronic cases, advice includes restriction of carbonated beverages and possibly speech therapy.  Agents like simethicone may be helpful.  Laxatives may be helpful in some cases as well.

Related posts:

Treatment for rumination and belching | gutsandgrowth