Tag Archives: supragastric belching

Rome V Pediatric Upper Gastrointestinal Disorders of Gut-Brain Interaction (Part 1)

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R Rosen et al. Gastroenterol 2026; 170: 1347-1366. Open Access! Rome V Pediatric Upper Gastrointestinal Disorders of Gut-Brain Interaction

This article has a lot of useful information and I recommend reading the article in full. The disorders covered include the following:

Esophageal Disorders:

  • Reflux hypersensitivity
  • Reflux-negative esophageal pain disorder (similar to functional heartburn in adults)
  • Aerophagia syndrome
  • Supragastric belching syndrome

Functional Pediatric Feeding Disorders

  • Hypersensitvie dysphagia
  • Anticipatory Restrictive Feeding
  • Hunger dysregulation feeding disorder
  • Medically-triggered functional feeding disorder

Gastroduodenal Disorders

  • Rumination Syndrome
  • Cyclic Vomiting Syndrome
  • Cannabinoid hyperemesis subgroup
  • Chronic Nausea
  • Functional Dyspepsia
  • Postprandial Distress Syndrome
  • Epigastric Pain syndrome

The authors note that the Rome V criteria have expanded to include several more disorders. “This expansion provides a diagnostic framework for patients presenting with chest and throat pain, feeding difficulties, belching, pain with eating, nausea, and vomiting. Given the advances in impedance technology and high-resolution manometry, testing plays a greater role in many of these diagnostic criteria than they have in past Rome iterations. This harmony between symptoms and testing results in more precision in therapeutic approaches that are critically multidisciplinary. The ability to assign new, positive diagnoses across the upper gastrointestinal tract offers new opportunities for pediatric-focused therapeutic trials.”

With regard to esophageal disorders, the key points:

  • “In the past, nonerosive reflux disease was the all-encompassing diagnosis for children without pathologic amounts of gastroesophageal reflux. The use of pH-impedance testing has allowed for additional phenotyping of patients with significant symptoms that are typically associated with gastroesophageal reflux disease”
  • “PPI response does not reliably predict reflux phenotype…Empiric acid suppression trials should be time-limited up to 8 weeks and further diagnostic testing (ie, endoscopy, pH-impedance, and CYP2C19 gene testing if possible) should be pursued if there is no symptom improvement.20 Histamine-2 receptor antagonists can also treat esophageal hypersensitivity and are a first-line therapy for patients awaiting endoscopy.”
  • “Patients with reflux-negative esophageal pain disorder (RNEPD) have a visually normal upper endoscopy and no evidence of pathologic acid reflux with negative reflux-symptom correlation by pH-impedance (or pH-metry or wireless testing). This is equivalent to functional heartburn (FH) in adults. However, unlike adult FH, symptoms of RNEPD may include intermittent retrosternal pain, heartburn, throat pain, or burning sensation in the throat, at least 3 times per week for 2 months.31 Younger children may present with crying or repeatedly pointing to areas of discomfort. Two studies found that 38%–44% of pediatric patients with normal endoscopy undergoing pH-impedance testing met criteria for FH per the adult Rome IV definition.3,4…Because RNEPD falls on the spectrum of visceral hypersensitivity, neuromodulators should be the mainstay of therapy”
  • “Aerophagia, a normal physiologic phenomenon, should only be considered a syndrome if it impacts quality of life and causes symptoms. Previously, increased flatus was considered a major criterion but because flatus may go unnoticed, it is no longer a major criterion…Treatment No therapeutic trials exist. However, in patients with severe distention, a nasogastric tube or an existing gastrostomy tube can be used to vent air from the stomach.55 If colonic distention is present, rectal decompression may be appropriate. In patients with chronic stable symptoms, a conservative approach is sufficient. Speech therapy or CBT aimed at reducing the air swallowing may be tried. Benzodiazepines can be considered in severe cases. Circumstantial evidence suggests that infants swallow less air using different bottle or nipple systems.56“
  • Supragastric Belching Syndrome “SGB is a voluntary yet subconscious behavior…Most patients present with excessive belching as the primary symptom. However, the symptoms may sound like hiccups to patients or parents. Often no tests are needed, as the story of multiple repeated belches is nearly pathognomonic for SGB. SGB typically occurs outside of meal periods and does not occur during sleep. pH-impedance or HRIM can be performed to confirm the diagnosis. However, absence of belching during testing does not exclude the diagnosis, as events can be sporadic. Treatment In a single randomized trial of behavioral interventions in adults, which included education about the disorder, warning signs for oncoming events, and breathing exercises, patients who received the behavioral interventions had higher rates of symptom improvement lasting up to 6 months”

Related blog posts:

NASPGHAN Dysphagia Webinar: Dr. Khalil El-Chammas, Dr. Peter Osgood, and Dr. Jose Garza

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I signed up for this webinar mainly to hear my partner Jose Garza’s presentation (who presented last), though all the speakers were good. I took a couple screenshots on my phone during the presentations. The webinar is available/archived at NASPGHAN website.

  • Dr. El-Chammas’ presentation gave a quick review on normal swallowing physiology, modalities for evaluation (eg. VSS, FEES) and showed some cool slides particularly with regard to pharyngeal manometry.
  • Dr. Osgood reviewed the etiologies/workup for dysphagia including helpful slides on esophagrams, FLIP and manometry.
Manometry typical of Type 2 Achalasia
  • Dr. Garza provided insightful information on gastric vs supragastric belching. Supragastric belching can be treated with diaphragmatic breathing and cognitive behavioral therapy. Supragastric belching has shown poor response to pharmacologic therapy. He also explained the physiology behind the inability to burp.
Important to distinguish reason for belching as this affect management
This study shows that with gastric belching the air works its way from the stomach up and with supragastric belching air is swallowed and expelled from the esophagus

My take: Our motility colleagues have some cool toys. When the treatments are as good as the toys, being a motility specialist will be even more fun.

Expert Advice on Bloating, Belching and Distention

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B Moshiree, D Drossman, A Shaukat. Gastroenterol 2023; 165: 791-800. Open Access! AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review

Best Practice Advice:

  • #2: Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators.
  • #6: Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only.
  • #7: Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders.
  • #10: Probiotics should not be used to treat abdominal bloating and distention.
  • #11: Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities.
Gastric belching: tracing showing instead a distal to proximal increase in impedance with air clearing from the esophagus. Arrows indicate direction of air flow and high-resolution manometric view of gastric belching is shown with direction of air flow from stomach to upper esophagus seen (orange arrow)

Several points from review:

  • Belching can be from the esophagus or from the stomach.
  • Supragastric belching involves air clearing from the esophagus not from stomach and is frequently associated with anxiety.
  • Gastric belching is frequently associated with reflux and occurs after spontaneous transient relaxation of the lower esophageal sphincter.
  • Bloating is a subjective sensation of fullness, tightness or trapped gas. Food intolerances, bacterial overgrowth, and celiac disease need to be considered. If constipation is present, this should be treated.

My take: This is a good review with plenty of practical suggestions for management.

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