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. 2022 May;34(5):e14250.
doi: 10.1111/nmo.14250. Epub 2021 Aug 26.

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

Renske A B Oude Nijhuis  1 , Jurjaan A Snelleman  2 , Jac M Oors  1 , Boudewijn F Kessing  1 , Derrek A Heuveling  2 , Jeroen M Schuitenmaker  1 , Liesbeth Ten Cate  3 , Andreas J P M Smout  1 , Albert J Bredenoord  1
Affiliations

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

Renske A B Oude Nijhuis et al. Neurogastroenterol Motil. 2022 May.

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.

Keywords: UES; belching disorder; high-resolution manometry; impedance; inability to belch; upper esophageal sphincter.

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Conflict of interest statement

RON, JAS, BK, JO, DH, LC, JMS, and AS have no financial or personal competing interests. AB received research funding from Nutricia, Norgine, SST, Thelial and Bayer and received speaker and/or consulting fees from Laborie, EsoCap, Medtronic, Dr. Falk Pharma, Calypso Biotech, Robarts, Reckett Benkiser, Regeneron, AstraZeneca.

Figures

FIGURE 1
FIGURE 1
Gastroesophageal gas reflux event recorded with high‐resolution impedance manometry in a patient with inability to belch. The sequence of events during a gas reflux event was characterized by: (1) retrograde flow of air from the stomach up to the level of the UES; (2) an increase in esophageal pressure to the level of the gastric pressure (common cavity phenomenon) (3) an increased or unchanged UES pressure; (4) failure of UES relaxation with consequently no venting of air across the UES (5) secondary peristalsis transporting the air from the esophagus back to the stomach
FIGURE 2
FIGURE 2
Repetitive gas reflux pattern recorded with high‐resolution impedance manometry in a patient with inability to belch. Retrograde flow of gastric air (white arrows), in absence of subsequent UES relaxation, cleared from the esophageal body by secondary peristalsis and then immediately refluxed back into the esophageal body
FIGURE 3
FIGURE 3
Esophageal air entrapment observed as periods (black rectangles) of continuous high impedance levels recorded with ambulatory pH‐impedance monitoring in a patient with symptoms of inability to belch. The orange rectangular area represents the 2 min window the subject experienced a symptom
FIGURE 4
FIGURE 4
Upper esophageal sphincter basal pressure (A), average UES nadir pressure in reaction to gastroesophageal gas reflux (B), the total number of gastroesophageal gas reflux episodes observed during 15‐min HRIM recording (C) and air presence time calculated during 24‐h ambulatory pH‐impedance monitoring (D) at baseline and post‐treatment. After treatment, the UES basal and nadir pressure decreased significantly, facilitating UES opening and venting of air (p < 0.02). As a result, the number of gastroesophageal gas reflux episodes and air presence time reduced significantly (p < 0.02)
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