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Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease.

OBJECTIVES: Belching and gastroesophageal reflux share a common physiological mechanism. The aim of this study was to investigate whether air swallowing leads to both belching and reflux. METHODS: Esophageal impedance, pH, and pressure were measured during two 20-min recording periods in 12 controls and 12 patients with gastroesophageal reflux disease (GERD), before and after intragastric inflation of 600 mL of air. This was repeated after a meal. Subsequently, ambulatory 24-h impedance-pH measurement was performed. RESULTS: During the 24-h study, patients showed a higher incidence of air swallows (287 +/- 45 vs 176 +/- 24, p < 0.05), belches (52.4 +/- 6.6 vs 32.7, p < 0.01), and acid reflux (42.3 +/- 7.6 vs 19.1 +/- 2.8, p < 0.01) than controls. After air infusion the incidence of gas reflux episodes was increased, both in patients (0.58 +/- 0.36 vs 3.50 +/- 0.61, p < 0.01) and in controls (0.75 +/- 0.67 vs 4.08 +/- 0.59, p < 0.01). In contrast, the incidence of acid and weakly acidic reflux episodes was not increased after air infusion, neither in patients (acid: 1.25 +/- 0.37 vs 1.20 +/- 0.33, weakly acidic: 1.08 +/- 0.40 vs 0.80 +/- 0.23) nor in controls (acid: 0.72 +/- 0.34 vs 0.50 +/- 0.23, weakly acidic: 0.80 +/- 0.35 vs 0.33 +/- 0.19). Air infusion increased transient lower esophageal sphincter relaxations (TLESR) frequency in patients and controls, but this was entirely because of an increase in gas reflux-associated TLESRs. CONCLUSIONS: Patients with GERD swallow air more frequently and belch more frequently than healthy subjects. However, air swallowing is not the cause of their increase in reflux.

Adult↗

Psychological factors affect the frequency of belching in patients with aerophagia.

BACKGROUND: In patients with aerophagia and excessive belching an organic cause is seldom found and a psychogenic cause is often suspected. AIM: To investigate the effects of attention and distraction on the frequency of belching in patients with aerophagia. METHODS: In 10 patients with aerophagia, combined esophageal manometry and impedance monitoring was performed for 2 h, consisting of four 30-minute recording periods. Period I: patient unaware that recording had commenced. Period II: patient informed of recording in progress. Period III: distraction by filling in questionnaires. Period IV: no distraction. RESULTS: A total of 1,258 belches was measured, 51 of which were the result of air that escaped from the stomach (gastric belches). A total of 1,207 belches (96%) were events during which air was expelled in the oral direction almost immediately after entering the esophagus from there (supragastric belches). Gastric belches were distributed equally over the first (1.5 [0.5-2.0]), second (1.5 [0.5-2.0]), third (1.0 [0-2.0]), and fourth (1.0 [0-2.0]) recording periods. In contrast, the incidence of supragastric belches increased significantly from 0 (0-32) in period I to 30 (18-60) in period II, after patients were told that recording was started. During period III (questionnaires) the incidence of supragastric belches decreased to 14 (4-30). In period IV the incidence of supragastric belches increased to 21 (10-49). CONCLUSIONS: When patients with excessive belching are unaware that they are being studied or when they are distracted, the incidence of belching is significantly reduced. These findings underline the importance of psychological factors and provide rationale for behavioral therapy.

Adult↗

Ruminant methane delta(13C/12C) values: relation to atmospheric methane.

The delta(13C/12C)--values of methane produced by fistulated steers, dairy cattle, and wethers, and dairy and beef cattle herds show a bimodal distribution that appears to be correlated with the plant type (C3 or C4, that is, producing either a three- or a four-carbon acid in the first step of photosynthesis) consumed by the animals. These results indicate that cattle and sheep, on a global basis, release methane with an average delta(13C/12C) value of -60 and -63 per mil, respectively. Together they are a source of atmospheric methane whose delta(13C/12C) is similar to published values for marsh gas and cannot explain the 20 per mil higher values for atmospheric methane.

Animals↗

Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring.

BACKGROUND: Patients with aerophagia are believed to have excessive belches due to air swallowing. Intraluminal impedance monitoring has made it possible to investigate the validity of this concept. METHODS: The authors measured oesophageal pH and electrical impedance before and after a meal in 14 patients with excessive belching and 14 healthy controls and identified patterns of air transport through the oesophagus. The size of the gastric air bubble was measured radiographically. In four patients prolonged oesophageal manometry was performed simultaneously. RESULTS: In all subjects, impedance tracings showed that a significant amount of air is propulsed in front of about a third of the swallow induced peristaltic waves. Two types of retrograde gas flow through the oesophagus (belch) were observed. In the first type air flowed from the stomach through the oesophagus in oral direction ("gastric belch"). In the second type air entered the oesophagus rapidly from proximal and was expulsed almost immediately in oral direction ("supragastric belch"). The incidence of air-containing swallows and gastric belches was similar in patients and controls but supragastric belches occurred exclusively in patients. There was no evidence of lower oesophageal sphincter relaxation during supragastric belches. Gastric air bubble size was not different between the two groups. CONCLUSIONS: In patients with excessive belching the incidence of gaseous reflux from stomach to oesophagus is similar to that in healthy subjects. Their excess belching activity follows a distinct pattern, characterised by rapid antegrade and retrograde flow of air in the oesophagus that does not reach the stomach.

Adult↗

Control of belching by the lower oesophageal sphincter.

The mechanism that controls venting of gas from the stomach into the oesophagus was studied manometrically in 14 healthy subjects. The stomach was distended abruptly with one litre of carbon dioxide. Gas reflux was characterised by an abrupt increase in basal oesophageal body pressure to intragastric pressure. Reflux of gas from the stomach into the oesophagus occurred during transient lower oesophageal sphincter relaxations that generally had a pattern distinctly different from swallow-induced lower oesophageal sphincter relaxation. Thus, at the onset of an episode of gas reflux lower oesophageal sphincter pressure had relaxed to 3 mmHg, or less, in 96% of instances. After gas loading of the stomach the prevalence of gas reflux was significantly less when the subjects were supine (1.2/10 min) than when they were sitting (6.8/10 min) (p less than 0.001). The lower oesophageal sphincter relaxations associated with most episodes of gas reflux had a distinctive pattern that resembled those of the lower oesophageal sphincter relaxations associated with acid gastro-oesophageal reflux.

Adult↗

Precipitating causes of acid reflux episodes in ambulant patients with gastro-oesophageal reflux disease.

Previous studies of the mechanisms that precipitate acid reflux episodes have used short term hospital based measurements. A 24 hour pH and motility recording system, incorporating a sphincter monitoring device, has been developed to study naturally occurring acid reflux episodes in control subjects and patient groups with different grades of oesophagitis. Lower oesophageal sphincter relaxations related to episodes of acid reflux were common in control subjects (67% of episodes) but became more difficult to detect as the grade of oesophagitis increased (grade 0/1 - 67%, grade 2/3 - 35%, grade 4 - 13%). A variety of events that produced recognisable transdiaphragmatic pressure patterns were associated with acid reflux episodes. In control subjects 74% of acid reflux episodes were precipitated by belching but this mechanism became less evident as the grade of oesophagitis increased (grade 0/1 - 43%, grade 2/3 - 40%, grade 4 - 29%). Activities that produced a pressure gradient across the diaphragm became increasingly important as events precipitating acid reflux as oesophagitis became more severe (controls--2%, grade 0/1 - 15%, grade 2/3 - 11%, grade 4 - 22%). This study has shown the pressure events surrounding acid reflux in fully ambulant patients with gastro-oesophageal reflux disease.

Adult↗

Patterns of gas and liquid reflux during transient lower oesophageal sphincter relaxation: a study using intraluminal electrical impedance.

BACKGROUND: Belching has been proposed as a major mechanism underlying acid gastro-oesophageal reflux in normal subjects. However, the presence of oesophageal gas has not been measured directly but only inferred from manometry. AIMS: To investigate, using intraluminal electrical impedance, the patterns of gas and liquid reflux during transient lower oesophageal sphincter (LOS) relaxations, the main mechanism of acid reflux in normal subjects. METHODS: Impedance changes associated with the passage of gas were studied in vitro, and in vivo in cats. Oesophageal manometry, pH, and intraluminal electrical impedance measurements were performed in 11 normal subjects after a meal. RESULTS: Gas reflux caused a sudden increase in impedance that propagated rapidly to the proximal oesophagus whereas liquid reflux induced a retrogressively propagated fall in impedance. Impedance showed gas or liquid reflux during most (102/141) transient LOS relaxations. When acid reflux occurred, impedance showed evidence of intraoesophageal retrograde flow of liquid in the majority (78%) of events. Evidence of gas retroflow was found in almost half (47%) of acid reflux episodes. When present together, however, liquid preceded gas on 44% of occasions. Overall, gas reflux occurred as the initial event in only 25% of acid reflux episodes. CONCLUSIONS: These findings suggest that in upright normal subjects, although belching can precipitate acid reflux, most acid reflux occurs as a primary event.

Adolescent↗

Preservation of postural control of transient lower oesophageal sphincter relaxations in patients with reflux oesophagitis.

INTRODUCTION: In normal subjects, transient lower oesophageal sphincter relaxations (TLOSRs) and gas reflux during belching are suppressed in the supine position. Supine reflux, however, is a feature of reflux disease. AIMS: To investigate whether postural suppression of TLOSRs and gas reflux is impaired in patients with reflux disease. PATIENTS: Ten patients with erosive oesophagitis. METHODS: Oesophageal manometry was performed during gastric distension with 750 ml carbon dioxide. Measurements were made for 10 minutes before and after distension in both sitting and supine positions. RESULTS: In the sitting position gastric distension substantially increased the rate of gas reflux (median (interquartile range)), as evidenced by increases in oesophageal common cavities from 1 (0-1)/10 min to 7 (5-10)/10 min and TLOSRs from 1 (1-1.5)/10 min to 6 (2.5-8)/10 min. However, this effect was suppressed in the supine position in all but one patient (TLOSRs 0 (0)/10 min to 1 (0-4.5)/10 min, common cavities 0 (0)/10 min to 0.5 (0-2)/10 min). CONCLUSIONS: Postural suppression of TLOSRs and gas reflux is generally preserved in reflux disease.

Adult↗

From comic relief to real understanding; how intestinal gas causes symptoms.

Gas content and transit appear to conspire with the motor and sensory responses of the gut to produce gas related symptoms, both in normal individuals and especially in patients with irritable bowel syndrome (IBS). In relation to gas in IBS, two questions need to be addressed: do IBS patients produce more gas and what are the relationships between intestinal gas and symptoms? The balance of evidence seems to indicate that distension is a real phenomenon in IBS and that such distension accurately reflects gas content. More problematic is extrapolation of the observations relating symptoms to gas transit and retention.

Eructation↗

Tachyarrhythmias triggered by swallowing and belching.

Three cases with supraventricular tachyarrhythmias related to oesophageal transit are reported. A 61 year old man had episodes of atrial tachycardia on each swallow of food but not liquid; this has been reported only rarely. A 55 year old man had atrial fibrillation initiated by drinking ice cold beverages; this has not been described previously although atrial tachycardia triggered by drinking ice cold beverages has been described once. A 68 year old man had supraventricular tachycardia initiated by belching; this has not been described previously. These cases illustrate the diversity of atrial tachyarrhythmias that can be precipitated by oesophageal stimulation and suggest that what is regarded as a very rare phenomenon may be found more commonly when sought.

Aged↗

Flatulence.

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Carbon Dioxide↗