Search

A 15-year-old man presented with an acute history of facial swelling following a bout of forceful eructation after eating. Subcutaneous emphysema was noted on examination of his left face and neck. He was initially managed with intravenous antibiotics for suspected facial infection. A chest radiograph performed on day 3 of admission identified subcutaneous emphysema of the upper thorax and neck. CT with oral contrast confirmed extensive subcutaneous emphysema of neck, thorax and upper abdomen, with associated pneumomediastinum. The site of air leak was not identified. He subsequently underwent upper gastrointestinal endoscopy and this was normal. Despite the delay in diagnosis, he remained haemodynamically stable, and repeated radiography showed improvement reflecting the benign course of this condition as described in existing literature. There are no previous published reports of spontaneous pneumomediastinum following eructation; therefore, high clinical suspicion should be maintained in this presentation.

Background/aims Belching is the act of expelling gas from the stomach or esophagus noisily through the oral cavity. Although it is a physiological phenomenon, belching may also be a symptom of upper gastrointestinal diseases such as reflux esophagitis and functional dyspepsia (FD). A detailed epidemiology of belching has not yet been reported. The aim of this study is to examine the prevalence and clinical characteristics of clinically significant belching (CSB) in adults. Methods We analyzed 1998 subjects who visited the hospital for annual health checkups. Belching was evaluated by a simple question "Do you burp a lot?" and scored as 0 (never), 1 (occasionally), 2 (sometimes), 3 (often), or 4 (always). Subjects with CSB were defined as having scores ≥ 3. We also collected the clinical parameters, endoscopic findings, and data according to the Athens Insomnia Scale, Rome IV questionnaire, and Hospital Anxiety and Depression Scale (HADS). Results Of the 1998 subjects, 121 (6.1%) had CSB. Subjects with CSB had FD more commonly than reflux esophagitis, but presence of heartburn was high (10.7% vs 3.1%). In addition, the HADS and Athens Insomnia Scale scores in subjects with CSB were significantly higher than those in subjects without CSB. Presence of heartburn (OR, 2.07; 95% CI, 1.05-4.09), presence of FD (OR, 2.12; 95% CI, 1.33-3.36), anxiety/depression (OR, 2.29; 95% CI 1.51-3.45), and sleep disturbances (OR, 1.73; 95% CI, 1.14-2.61) were significantly associated with CSB. Conclusion The detailed epidemiology of belching in the general adult population was clarified.

The hand-held laser methane detector (LMD) technique has been suggested as an alternative method for measuring methane (CH4) emissions from enteric fermentation of ruminants in the field. This study aimed to establish a standard procedure for using LMD to assess CH4 production in cattle and evaluate the efficacy of the protocol to detect differences in CH4 emissions from cattle fed with diets of different forage-to-concentrate (FC) ratios. Experiment 1 was conducted with four Hanwoo steers (584 ± 57.4 kg body weight [BW]) individually housed in metabolic cages. The LMD was installed on a tripod aimed at the animal's nostril, and the CH4 concentration in the exhaled gas was measured for 6 min every hour for 2 consecutive days. For the data processing, the CH4 concentration peaks were identified by the automatic multi-scale peak detection algorithm. The peaks were then separated into those from respiration and eructation by fitting combinations of two of the four distribution functions (normal, log-normal, gamma, and Weibull) using the mixdist R package. In addition, the most appropriate time and number of consecutive measurements to represent the daily average CH4 concentration were determined. In experiment 2, 30 Hanwoo growing steers (343 ± 24.6 kg BW), blocked by BW, were randomly divided into three groups. Three different diets were provided to each group: high FC ratio (35:65) with low-energy concentrate (HFC-LEC), high FC ratio with high-energy concentrate (HFC-HEC), and low FC ratio (25:75) with high-energy concentrate (LFC-HEC). After 10 d of feeding the diets, the CH4 concentrations for all steers were measured and analyzed in duplicate according to the protocol established in experiment 1. In experiment 1, the mean correlation coefficient between the CH4 concentration from respiration and eructation was highest when a combination of two normal distributions was assumed (r = 0.79). The most appropriate measurement times were as follows: 2 h and 1 h before, and 1 h and 2 h after morning feeding. Compared with LFC-HEC, HFC-LEC showed 49% and 57% higher CH4 concentrations in exhaled gas from respiration and eructation (P0.01). In conclusion, the LMD method can be applied to evaluate differences in CH4 emissions in cattle using the protocol established in this study.The hand-held laser methane detector (LMD) technique has been suggested as a potential method for measuring methane (CH4) emissions from enteric fermentation of ruminants in the field. This study aimed to establish a standard procedure for using LMD to assess CH4 production in cattle and evaluate the efficacy of the protocol to detect differences in CH4 emissions from cattle fed with diets of different forage-to-concentrate (FC) ratios which is known to affect CH4 emissions. Experiment 1 was conducted to establish a protocol for measuring and analyzing the CH4 emissions from cattle using LMD. In experiment 2, 30 Hanwoo growing steers were divided into three groups and fed with a diet of high FC ratio (35:65) with low-energy concentrate (HFC-LEC), high FC ratio (35:65) with high-energy concentrate (HFC-HEC), or low FC ratio (25:75) with high-energy concentrate (LFC-HEC). The CH4 concentrations for all steers were measured in duplicate according to the protocol established in experiment 1. HFC-LEC showed 49% and 57% higher CH4 concentrations in exhaled gas from respiration and eructation, respectively (P0.01), than LFC-HEC. In conclusion, the LMD method can be applied to evaluate differences in CH4 emissions in cattle using the protocol established in this study.

Background/Aims Belching disorder (BD) is clinically distinct from gastroesophageal reflux disease (GERD) with belching. Supragastric belching (SGB) is closely associated with reflux episodes. This study investigates belch characteristics in association with reflux, compared between patients with BD and those who had GERD with belching. Methods Impedance pH monitoring data from 10 patients with BD and 10 patients with GERD who exhibited belching were retrospectively analyzed. Belches were considered “isolated“ or “reflux-related” and acidic/non-acidic. Belch characteristics were compared between patients with BD and those with GERD. Results Symptomatic belches were more frequent in patients with BD than in patients with GERD (median, 160.5 vs 56.0, P < 0.05). SGB was the most common type in both groups; common subtypes comprised “isolated“ in patients with BD and “isolated during the reflux period” in patients with GERD. Reflux-related SGB was more common in patients with GERD than in BD (78.3% vs 45.2%, P < 0.005). Both “preceding belching” including the reflux period and acidic SGB were more common in patients with GERD than in BD (31.8% vs 8.6% and 38.1% vs 8.9%, both P < 0.05). Supragastric belch number positively correlated with all reflux episodes in patients with GERD (adjusted R2 = 0.572, P = 0.007). Conclusions BD is characterized by more belching, compared to GERD. SGB is more frequently associated with reflux in GERD than in BD; acidity may be related to GERD. In BD, SGB is typically non-acidic and unrelated to reflux. Distinct SGB characteristics may reflect different pathogenic mechanisms of reflux and associated symptoms.

Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It becomes pathologic if it is excessive and becomes bothersome. According to Rome IV diagnostic criteria, there is a belching disorder when one experiences bothersome belching (severe enough to impact on usual activities) more than 3 days a week. Esophageal impedance can differentiate between gastric and supragastric belching. The aim of this review was to provide data on pathogenesis and diagnosis of supragastric belching and study its relationship with gastroesophageal reflux disease and psychological factors. Treatment options for supragastric belching are also presented.

Background Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK. Methods We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries. Results Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09–7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0–4.9)] compared to the UK [35% (0–54.1)] (P = 0.071). Conclusions The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized.

Background Functional dyspepsia (FD), belching disorders (BD) and functional heartburn (FH) are the three most common upper functional gastrointestinal disorders (FGID) in IBS patients. FD is known to exert deleterious effects on health-related quality of life (HRQoL) and the psychological status of IBS patients; however, the impact of overlapping BD and FH on anxiety, depression and HRQoL of IBS patients remains unknown. This cross-sectional study was conducted to investigate the impact of overlapping FD, BD and FH on anxiety, depression and HRQoL in patients with IBS. Methods This study enrolled 319 consecutive outpatients with IBS from 2 tertiary hospitals in Beijing and Shijiazhuang of China. IBS, FD, BD and FH were diagnosed using the Rome III Criteria. Hospital Anxiety and Depression Scale and a 36-item Short-Form Health Survey (SF-36) were used to assess the psychological distress and HRQoL of patients respectively. Results Among the 319 patients with IBS, the IBS subtypes were diarrhoea (67%), constipation (16%), unsubtyped (12%) and mixed (5%). These IBS patients were further classified into IBS + FD, IBS + BD/FH (BD and/or FH), IBS + FD + BD/FH, or IBS only according to the patients’ overlapping upper GI symptoms. IBS+FD patients reported higher levels of anxiety than IBS+BD/FH and elevated depression scores than IBS only patients (P Conclusions Among the diarrhoea-prevalent IBS patients, those with concomitant FD experienced more psychological distress and demonstrated poorer physical HRQoL. Overlapping FD + BD/FH is a significant predictor of worse mental and physical HRQoL for IBS patients. The impact of concomitant BD and FH on the psychological status and HRQoL of IBS patients was limited. These findings implied that the overlapping upper FGIDs in IBS might be treated distinctively when developing comprehensive management strategies for IBS treatment.

BACKGROUND/AIMS Irritable bowel syndrome (IBS) is an important health problem that presents serious social burdens and high costs. Our study investigated the efficacy of synbiotic (Bifidobacterium lactis B94 with inulin), probiotic (B. lactis B94), and prebiotic (inulin) treatment for IBS in a pediatric age group. MATERIAL AND METHODS This study was randomized, double-blind, controlled, and prospective in design and included 71 children between the ages of 4 and 16 years who were diagnosed with IBS according to the Rome III criteria. The first group received synbiotic treatment [5×109 colony forming units (CFU) of B. lactis B94 and 900 mg inulin]; the second group received probiotic treatment (5×109 CFU B. lactis B94), and the third group received prebiotic treatment (900 mg inulin) twice daily for 4 weeks. RESULTS Probiotic treatment improved belching-abdominal fullness (p

Chronic gastrointestinal disorders are disruptive to patients physically and psychologically, and benefit from multidisciplinary care, including targeted psychological interventions. This case study details a case of a 42-year-old Caucasian female with idiopathic eructation, who was identified as having psychological contributors to her 3-year history of GI symptoms. Following extensive medical testing, she was diagnosed with excessive, likely supragastric belching and referred for psychological care. She noted initial reticence to psychological approaches but was offered psychoeducation and CBT interventions targeting eructation disorder and anxiety. Although the patient paused treatment after only a single session of psychological contact (including assessment and brief intervention), her GI symptoms effectively resolved with application of anxiolytic breathing, psychoeducation, and other cognitive behavioral techniques, suggesting rapid efficacy of CBT interventions, when diligently applied.

Upper esophageal sphincter (UES) function has been extensively studied in the context of swallowing and antegrade bolus transit, but relatively little attention has been paid to its retrograde function to facilitate belching. Indeed, prior to 2019, there were only three case reports in the world literature of individuals with a physiologically demonstrated inability to belch due to failure of the UES to relax after gas venting from the stomach and ensuing low-pressure esophageal distention. In this minireview, that disorder is termed retrograde UES dysfunction (R-UESD). The associated symptom complex includes some combination of chest pain, gurgling noises in the chest, bloating, nausea, hiccups, and flatulence. The obscurity of R-UESD has recently been challenged by two large series published in the ENT literature of circumstantially demonstrated R-UESD that was resolved by botulinum toxin (BT) injection to the cricopharyngeus. The field has now further advanced with the publication in this issue of the Journal by Oude Nijhuis et al. of 8 cases of R-UESD demonstrated by high-resolution impedance manometry (HRIM) with a provocative challenge of carbonated water. These individuals were also treated with BT and at 3-month follow-up had both an encouraging symptomatic response and HRIM demonstrated resolution of R-UESD.

Background The relationship between bothersome symptoms and gastric pressure or CO2 injection volumes in drug-resistant functional dyspepsia (FD) patients remains unknown; therefore, this relationship was examined in drug-resistant FD and non-FD patients. Methods Thirty drug-resistant FD patients and 30 non-FD patients were recruited. Gastric pressure was assessed using an external pressure transducer, and the CO2 injection volume was measured using an endoscopic CO2-supplied device and flow meter. The following variables were examined: gastric pressure at baseline and gastric pressure and the CO2 injection volume when patients initially felt abdominal tension and bothersome symptoms following the CO2 injection. The relationship between belching and bothersome symptoms was also investigated. Results No significant differences were observed in basal gastric pressure between the groups. Initial and bothersome symptoms in the upper abdomen in drug-resistant FD patients developed at a significantly lower gastric pressure and significantly smaller CO2 injection volume than in non-FD patients. The frequency of belching was significantly lower in the drug-resistant FD group than in the non-FD group. Conclusion Bothersome symptoms in drug-resistant FD patients develop at a lower gastric pressure and smaller CO2 injection volume than in non-FD patients. These patients also had difficulties with belching.

Background and aims: Gastric bypass surgery effectively treats obesity; however, its association with belching, which occurs in other bariatric surgeries, remains unclear. Hence, we aimed to evaluate belching occurrence after gastric bypass surgery. Methods: We enrolled 12 healthy volunteers and 17 patients (12 and 5 underwent Roux-en-Y gastric bypass and mini-gastric bypass surgeries 24 (18–54) months prior, respectively). Gastrointestinal symptoms were assessed. Gastroscopy was performed, followed by the 24-hour pH-impedance analysis. Results: Age and sex were not statistically different between the two groups (P > 0.05). Patients had a significantly higher mean DeMeester score than the healthy controls (9.11 ± 19.40 vs. 6.04 ± 5.60, P = 0.048), but the pathologic acid reflux (DeMeester score > 14) rate was similar in both groups (11.8% vs. 8.3%). Regarding the impedance, symptom-association probability was positive in 11.8% of patients. The patients also had higher alkaline reflux rates (6% vs. 0%); additionally, 50% of them experienced belching based on the questionnaire, and 25% had esophagitis based on gastroscopy. Furthermore, patients had a significantly higher number of gas reflux (123.24 ± 80 vs. 37.2 ± 21.5, P = 0.001) and supragastric/ gastric belches (182 ± 64/228 ± 66.69 vs. 25.08 ± 15.20/12.17 ± 17.65, P = 0.001). Supragastric belching was more frequent than gastric belching in the controls, whereas gastric belching was more frequent in the patients. Conclusion: Belching increases after gastric bypass surgery in a long-term period. Gastric belching was more frequent than supragastric belching in these patients.

Increased SGB is currently more often recognized not only in patients with belching as a main symptom, but also in patients with reflux like symptoms that are refractory to PPI treatment or patients with reflux hypersensitivity. Detection of increased SGB during analysis of impedance-pHmetry can help to better understand the pathophysiology of symptoms in individual patients and to provide more focused and specific treatment. At the moment, the most efficient treatments for increased SGB are CBT and Speech therapies, pharmacological treatment being less effective and prone to mild secondary effects. In this issue of Neurogastroenterology and Motility, Punkinnen et al demonstrate, in controlled clinical trial, that behavioral therapy was superior to follow-up without intervention in patients with SGB. We present a critical review of the different treatment modalities currently available for patients with pathological SGB.

PURPOSE Belching is a common condition that frequently overlaps with other functional gastrointestinal disorders. While not associated with any increase in mortality, it is associated with impaired health-related quality of life. Management is challenging, as there are no pharmacologic therapies specifically targeted towards this disorder. This review covers pathogenesis, prevalence, and treatments for this condition, with specific emphasis on the evolving role of behavioral treatments in management. KEY FINDINGS The diagnosis of gastric and supragastric belching can usually be made clinically, without the need for invasive testing. If necessary, multichannel intraluminal impedance and pH testing can provide a more definitive diagnosis and can also be used to estimate the frequency of gastric and supragastric belching episodes, which each have a distinct appearance on impedance tracing. Belching disorders are commonly associated with gastroesophageal reflux disease and functional disorders of the gastrointestinal tract. Supragastric belching is also associated with behavioral disorders like anxiety and obsessive-compulsive disorder. Speech therapy, cognitive-behavioral therapy, and diaphragmatic breathing are all interventions that have recently shown promise in the management of this challenging disorder.

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

The timing of sodium bicarbonate (NaHCO3) supplementation has been suggested to be most optimal when coincided with a personal time that bicarbonate (HCO3–) or pH peaks in the blood following ingestion. However, the ergogenic mechanisms supporting this ingestion strategy are strongly contested. It is therefore plausible that NaHCO3 may be ergogenic by causing beneficial shifts in the strong ion difference (SID), though the time course of this blood acid base balance variable is yet to be investigated. Twelve highly trained, adolescent swimmers (age: 15.9 ± 1.0 years, body mass: 65.3 ± 9.6 kg) consumed their typical pre-competition nutrition 1–3 hours before ingesting 0.3 g∙kg BM-1 NaHCO3 in gelatine capsules. Capillary blood samples were then taken during seated rest on nine occasions (0, 60, 75, 90, 105, 120, 135, 150, 165 min post-ingestion) to identify the time course changes in HCO3–, pH, and the SID. No significant differences were found in the time to peak of each blood measure (HCO3–: 130 ± 35 min, pH: 120 ± 38 min, SID: 98 ± 37 min; p = 0.08); however, a large effect size was calculated between time to peak HCO3– and the SID (g = 0.88). Considering that a difference between time to peak blood HCO3– and the SID was identified in adolescents, future research should compare the ergogenic effects of these two individualized NaHCO3 ingestion strategies compared to a traditional, standardized approach.

Excessive belching is frequently reported in adult patients with gastro-oesophageal reflux disease (GORD) and dyspepsia. Although postprandial gastric belching (GB) is considered a physiological mechanism for gastric venting, supra-gastric belching (SGB) is considered a distinct behavioural disorder. We aimed to define the prevalence of different types of belching and its association with reflux disease in paediatric patients.We retrospectively analysed reflux monitoring studies from 287 patients (median age: 7.0 years; interquartile range 3.0-11.3 years) with a suspicion of GORD. Based on oesophageal acid exposure time (AET) patients were divided in 3 groups: (a) physiological AET, (b) borderline AET and (c) pathological AET. MII-pH studies were manually edited and reflux disease parameters were measured together with quantification of GB and SGB.Two hundred one children (70.0%) had physiological AET (median: 0.8; interquartile range 0.3-1.6), 52 (18.1%) had borderline AET (median: 4.2; interquartile range 3.4-5.3) and 34 (11.9%) had pathologic AET (median: 10.7; interquartile range 9.1-14.2). Gastric belching was observed in all studies. Gastric belching related reflux was more frequently observed in patients with borderline and pathological AET (p0.001). This was more common in older children. SGB were observed in only 7 (2.4%) children (age range: 8-17years) in our population and all patients had Physiological AET. Only 3 (1%) patients had pathological number of SGB (13/24 h).Gastric belching related reflux is observed in children with increased AET. SGB is very rare in the paediatric population.

Background Aerophagia is a common functional gastrointestinal disorder among children. The disease leads to symptoms related to air in the intestine leading to burping, abdominal distension, and excessive flatus. We aimed to perform a systematic review and a meta-analysis to assess the epidemiology of aerophagia in children. Methods We conducted a thorough electronic databases (MEDLINE, EMBASE, PsycINFO and Web of Science) search for all epidemiological surveys conducted in children on aerophagia. All selected studies were assessed for their scientific quality and the extracted data were pooled to create a pooled prevalence of aerophagia. Results The initial search identified 76 titles. After screening and in depth reviewing, 19 studies representing data from 21 countries with 40129 children and adolescents were included in the meta-analysis. All studies have used standard Rome definitions to diagnose aerophagia. The pooled prevalence of aerophagia was 3.66% (95% Confidence interval 2.44–5.12). There was significant heterogeneity between studies [I2 98.06% with 95% Confidence interval 97.70–98.37). There was no gender difference in prevalence of aerophagia in children. The pooled prevalence of aerophagia was highest in Asia (5.13%) compared to other geographical regions. Conclusion In this systematic review and meta-analysis, we found aerophagia has a significant prevalence across the world.

Background Behavioral therapy (BT) has been proven effective in the treatment of supragastric belching (SGB) in open studies. The aim was to compare BT to follow-up without intervention in patients with SGB in a randomized study. Methods Forty-two patients were randomized to receive 5 sessions of BT, comprising diaphragmatic breathing exercises, or to follow-up without intervention. Patients were evaluated at 6 months, at which point the control group was also offered BT and evaluated after another 6 months. The frequency and intensity of belching and mental well-being were evaluated with a visual analog scale (VAS). Depression, anxiety, and health-related quality of life (HRQoL) were evaluated with four questionnaires: BDI, BAI, 15D, and RAND-36. Key results The frequency and intensity of SGB were significantly lower in the therapy group (n = 19) than in the control group (n = 18) at the 6-month control (p < 0.001). When all patients (n = 36) were evaluated 6 months after BT, in addition to relief in the frequency and intensity of belching (p < 0.001), mental well-being had also improved (p < 0.05). Of all 36 patients, 27(75%) responded to BT. Depression scores were lower after therapy (p < 0.05). Only minor changes occurred in anxiety and HRQoL. Conclusions and Inferences Behavioral therapy is superior to follow-up without intervention in patients with SGB in reducing belching and depression; it also improves mental well-being but has only a modest effect on anxiety and HRQoL.

BACKGROUND Supragastric belching (SGB) and rumination are behavioral disorders associated with proton pump inhibitor (PPI) non-response and can be diagnosed using multichannel intraluminal impedance-pH (MII-pH) and post-prandial high-resolution impedance manometry (PPHRIM). This pilot study compared diagnostic yield and inter-rater agreement for SGB and rumination using MII-pH and PPHRIM. METHODS Three esophageal physiologists performed blinded interpretations of MII-pH and PPHRIM in 22 PPI non-responders. Raters selected from 4 diagnostic impressions (normal, GERD, behavioral disorders, GERD+behavioral disorders) without clinical context. Primary outcomes were diagnostic impressions compared against clinical gold standard impression, between raters, and between test modalities. Following a 28-month wash-out period, raters re-interpreted MII-pH with clinical context and under consensus definition of diagnostic criteria. KEY RESULTS Compared to gold standard, rater accuracy for presence of behavioral disorders ranged from 45 to 77% on MII-pH and 45-59% on PPHRIM. On MII-pH, inter-rater agreement was fair for diagnosis (ĸ0.32, p

Case series This is retrospective case series involving 72 patients who presented with symptoms associated with inability to burp. The following symptoms was described by almost all the patients; retrosternal pain after eating or drinking, bloating feeling in the stomach, gurgling noise in the throat, excessive flatulence. These symptoms are worse with fizzy/carbonated drinks and beer. A full clinical history and examination plus endoscopic and in some cases barium a swallow radiological investigation was done. Procedure The surgery was performed under a general anaesthesia for all cases. Suspension pharyngoscopy in supine position using a Weerda diverticuloscope to identify the cricopharyngeal bar muscle. High dose of botulinum toxin A (botox) 100 iu was injected into the cricopharynxgeus muscle under a general anaesthesia. Results A total of 72 patients were diagnosed and undergone surgery between November 2016 and December 2020. There were 50 male and 22 female patients. Their average age was 30 (range 18–68 years old). All patients were able to burp again within first 4 weeks of the injection. This persisted even after the Botox worn off beyond the 3 months in 96% of cases. The average follow-up was 24 months post injection with longest follow-up 48 months (range 1–48 months). Conclusion The author reported a new condition of inability to burp due to failure of the cricopharyngeal sphincter to relax spontaneously and outcome of treatment using botulinum toxin A injection into the cricopharyngeus muscle. It is expected that the paralysing action of botulinum toxin injection last approximately 3 months. However, this group of patients seem to be cured even after the effect of the botox is worn off. The author therefore postulated that there might me some neural dysfunction that inhibits the brain to send signals to the cricopharyngeal sphincter to initiate burping. Once burping is re-established with the help of botox injection, spontaneous burping seems to occur and sustained even after the botox is worn off.

Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term “refractory GERD” has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term “refractory GERD symptoms” only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.

A 52-year-old woman had a 6-month history of frequent belching;however, esophagogastroduodenoscopy revealed no abnormal findings. She presented to our department with belching refractory to several medications. Abdominal radiography revealed no massive gas in the stomach and intestine. She had frequent belching during the medical interview but no belching during speaking. Findings from high-resolution esophageal manometry and esophageal impedance pH monitoring confirmed supragastric belching. Thus, she was diagnosed as having excessive supragastric belching, which improved with cognitive behavioral therapy.

U ovom radu opisan je problem izlučivanja prevelike količine metana u okoliš. Izlučivanje se događa pod utjecajem mikrobiološke populacije buraga. Metan se stvara u fermentacijskim procesima koja su ostvariva u anaerobnim okolnostima buraga preživača. Metan se nečujnom pojavom eruktacije izlučuje u okoliš i time zagađuje atmosferu povećavajući staklenički efekt. U radu su opisane anatomsko – fiziološke odlike probavnog sustava preživača i hranidbene potrebe goveda za određenim krmivima, kao i mogućnost dodataka prehrani kako bi se smanjila količina metana u buragu., This document describes the problem about too much excretion methane into the environment. Excretion occurs under the influence of microbiological populations of the rumen. Methane is formed in fermentation processes that are achievable in the anaerobic circumstances of ruminant rumen. Methane is excreted in the environment by the silent occurrence of eructation and pollutes the atmosphere over time, increasing the greenhouse effect. This document also describes the anatomical - physiological characteristics of the digestive system of ruminants and the nutritional needs of cattle for certain feeds, as well as the possibility of adding food to reduce the amount of methane in the rumen.

Background Gas-related abdominal symptoms are common in patients with functional gut disorders, but the responses to cope with the large volumes of gas that enter daily into the stomach have not been studied in detail. Our aim was to evaluate transit and tolerance of gastric gas in patients with functional gastrointestinal disorders. Methods In eight healthy volunteers and 24 patients with functional gut disorders (eight functional dyspepsia, eight belching disorder, and eight functional bloating) 1500 ml of a gas mixture were infused into the stomach at 25 ml/min. Belching, rectal gas evacuation, and abdominal perception were continuously recorded for 90 minutes. Key results Healthy subjects expelled the infused gas per rectum (1614 ± 73 ml), with a small rise in epigastric perception (score increment 1.0 ± 0.4) and virtually no belching (1 ± 1 belches). Patients with functional dyspepsia had a hypersensitive response to gastric gas, with a significant rise in epigastric perception (score increment 2.5 ± 0.6; P = .045), a transient delay in rectal gas evacuation and similar belching as healthy controls. Patients with belching disorders responded to gastric gas with continuous belches (33 ± 13 belches; P = .002), low epigastric perception, and a small reduction in rectal gas evacuation. Patients with functional bloating exhibited a slow transit response, with reduced rectal gas evacuation (1017 ± 145 ml; P = .002) and abdominal symptoms (score increment 2.5 ± 0.7), but without compensatory belching. Conclusions and inferences Different pathophysiological mechanisms underlay specific adaptive responses to gastric gas in patients with different functional gut disorders. Therapeutic interventions for gas-related abdominal symptoms should be addressed towards these specific pathophysiological disturbances.

The aim of the present study was to derive individual methane (CH4) emissions in ewes separated in CH4 respiration and eructation traits. The generated longitudinal CH4 data structure was used to estimate phenotypic and genetic relationships between ewe CH4 records and energy efficiency indicator traits from same ewes as well as from their lambs (intergenerational perspective). In this regard, we recorded CH4 emissions via mobile laser methane detector (LMD) technique, body weight (EBW), backfat thickness (BFT) and body condition score (BCS) from 330 ewes (253 Merinoland (ML), 77 Rhön sheep (RH)) and their 629 lambs (478 ML, 151 RH). The interval between repeated measurements (for ewe traits and lamb body weight (LBW)) was 3 weeks during lactation. For methane concentration (µL L−1) determinations in the exhaled air, we considered short time measurements (3 min). Afterwards, CH4 emissions were portioned into a respiration and eructation fraction, based on a double normal distribution. Data preparation enabled the following CH4 trait definitions: mean CH4 concentration during respiration and eructation (CH4r+e), mean CH4 concentration during respiration (CH4r), mean CH4 concentration during eructation (CH4e), sum of CH4 concentrations per minute during respiration (CH4rsum), sum of CH4 concentrations per minute during eructation (CH4esum), maximal CH4 concentration during respiration (CH4rmax), maximal CH4 concentration during eructation (CH4emax), and eructation events per minute (CH4event). Large levels of ewe CH4 emissions representing energy losses were significantly associated with lower LBW (P<0.05), lower EBW (P<0.01) and lower BFT (P<0.05). For genetic parameter estimations, we applied single- and multiple-trait animal models. Heritabilities and additive genetic variances for CH4 traits were small, i.e., heritabilities in the range from CH4r+e, CH4r, CH4rmax, CH4esum) to 0.03 (CH4rsum). We estimated negative genetic correlations between CH4 traits and EBW in the range from −0.44 (CH4r+e) to −0.05 (CH4rsum). Most of the CH4 traits were genetically negatively correlated with BCS (−0.81 for CH4esum) and with BFT (−0.72 for CH4emax), indicating same genetic mechanisms for CH4 output and energy efficiency indicators. Addressing the intergenerational aspect, genetic correlations between CH4 emissions from ewes and LBW ranged between −0.35 (CH4r+e) and 0.01 (CH4rsum, CH4rmax), indicating that breeding on reduced CH4 emissions (especially eructation traits) contribute to genetic improvements in lamb weaning performance.

Reflux hypersensitivity (RH), a functional esophageal disorder, is detected in 14%-20% of patients who present with typical esophageal symptoms. As many as 40% of patients with RH do not respond to treatment with pain modulators or proton pump inhibitors (PPIs); behavior disorders might contribute to lack of treatment efficacy. We aimed to assess the prevalence of behavioral disorders and their effects on typical reflux symptoms in patients with RH.We performed a retrospective study of 542 patients with PPI-refractory esophageal symptoms (heartburn, regurgitation, or chest pain) or with symptoms that responded to PPI therapy, evaluated for anti-reflux surgery from January 2016 through August 2019 at a single center in London, United Kingdom. We collected data on symptoms, motility, and impedance-pH monitoring and assigned patients to categories of RH (n = 116), functional heartburn (n = 126), or non-erosive reflux disease (n = 300).Of the 116 patients with a diagnosis of RH, 59 had only hypersensitivity, whereas 57 patients (49.2%) had either excessive supragastric belching (SGB, 39.7%), based on 24-hour impedance-pH monitoring, or rumination (9.5%), based on postprandial manometry combined with impedance. The prevalence of SGB and rumination in patients with RH was significantly higher than in patients with functional heartburn (22%; P.001). Patients with RH and rumination were significantly younger (P = .005) and had the largest number of non-acid reflux episodes (P = .023). In patients with RH with SGB, SGB episodes were associated with 40.6% of marked reflux symptoms (heartburn, regurgitation, or chest pain), based on impedance-pH monitoring. In patients with RH and rumination, 40% of reflux-related symptoms (mostly regurgitation) were due to possible rumination episodes.Almost half of patients with a diagnosis of RH have behavior disorders, including excessive SGB or rumination. Episodes of SGB or rumination are associated with typical reflux symptoms. Segregation of patients with diagnosis of RH into those with vs without behavioral disorders might have important therapeutic implications.

In the absence of well-informed science, people intuitively associate breath odors with the digestive system. Perhaps, the stomach odors that arise transiently during eructation (burping) lead many to assume that breath odor may originate in the stomach. Looking into old medical texts on this topic (Howe 1898; Shifman et al. 2002), in which indigestion, constipation, and dyspepsia are considered prime causes of breath odors, further illustrates this point. Even nowadays, patients complaining of breath odors to their physicians or dentists are often referred to the gastroenterologist (Delanghe et al. 1996).

The Australian Department of Climate Change and Energy Efficiency announced that a camel produces methane equivalent to one ton of carbon dioxide a year, making the animal one of the country’s biggest greenhouse gases emitters. In order to stop pollution, a plan was proposed to shoot the camels from a helicopter or round them up and send them to the slaughterhouse. As scientists working on camel physiology and human beings dealing with animal welfare and protection, we developed a trial to measure camel methane emissions and compared them to dairy cattle receiving the same amount of feed. Seven Holstein cows (average weight 350 kg) and seven she-camels (average weight 330 kg) were used in this study. All animals were not pregnant and are in the latest stage of lactation with very limited milk production. Animals were housed in boxes and fed individually the same ration composed of 3 kg of barley and 2 kg of lucerne hay daily at 9 a.m. After eating, methane emissions measurements were carried out for 2 hours on several periods per day by using a face mask open circuit system. The results showed that the camel eliminated most of the methane by eructation with an average of 18 (eructations) emission cycles per hour. In cattle, the number of emission cycles averaged 54 eructations per hour. Methane emission from the camel was estimated to average 67 liters per day corresponding to 15.2 liters per kg of dry matter intake while dairy cattle methane emissions was estimated to average 194 liters per day corresponding to 42.2 liters per kg of dry matter intake. The present study showed clearly that dairy cattle produced three times more methane than camel when the two species received the same diet. Some digestive and metabolic particularities of each species may explain the difference. Other solutions to reduce the greenhouse gases should be proposed other than the eradication of the camel population of Australia.

Both rumination syndrome and supra-gastric belching (SGB) have limited treatment options. We demonstrated (open-label) that baclofen reduces pressure flow events in these patients. We aimed to study the effect of baclofen in a placebo-controlled, double-blind, cross-over study in patients with clinically suspected rumination and/or SGB.Twenty tertiary-care patients (mean age 42 years (range 18-61), 13f) with clinically suspected rumination and/or SGB were randomized to receive baclofen (10 mg, t.i.d) or placebo for 2 weeks with cross-over to the alternative intervention after a 1 week wash-out period. At the end of each treatment period, patients underwent a solid-state high-resolution impedance manometry measurement, during which they registered symptoms. Patients received a solid meal and recordings continued for 1 h. They scored overall treatment evaluation (OTE) on a -3 to +3 scale.Both the number of regurgitation event markers and rumination episodes were significantly decreased after baclofen (6 (0-19) vs. 4 (0-14), P=0.04; 13 (8-22) vs. 8 (3-11), P=0.004). The number of SGB episodes was similar in both groups. Lower esophageal sphincter (LES) pressure was significantly higher and the number of transient LES relaxations was significantly lower after baclofen (17.8 (12.7-22.7) vs. 13.1 (7.2-16.9) mm Hg, P=0.0002; 4(1-8) vs. 7(3-12), P=0.17). The number of reflux events decreased in the baclofen condition (4 (1-9) vs. 3 (0-6), P=0.03). Straining episodes were similar in both arms, but the rumination/straining ratio was significantly lower in the baclofen arm (0.06 (0-0.32) vs. 0.33 (0-0.51), P=0.0012). OTE was superior after baclofen compared to placebo (P=0.03).Baclofen is an effective treatment option for patients with rumination syndrome, probably through its effect on LES pressure.

Supragastric belching is the most important factor in the etiology of excessive belching complaints. Supragastric belching is a belching disorder with a behavioral origin. The standard diagnosis is made by monitoring the esophageal impedance. Supragastric belching has been shown to be associated with globus, as well as reflux symptoms in proton pump inhibitor non-responders in gastroesophageal reflux disease; however, the pathophysiology of supragastric belching in patients with gastroesophageal reflux disease or functional dyspepsia has not been clarified. Patient education with behavioral therapy is the treatment of choice in isolated supragastric belching. On the other hand, the best management of supragastric belching associated with globus, gastroesophageal reflux disease, and dyspepsia remains to be studied.

This study was designed to investigate the frequency of gastroesophageal reflux disease (GERD) in children with functional constipation (FC). It was structured to assess the improvement level in reflux symptoms by measuring the acid reflux in these patients after they had received FC treatment.Ninety-four children who suffered from constipation were evaluated prospectively. Data forms were completed to assess the GERD symptoms in all the cases. Twenty-four-hour pH meter monitoring was performed in 55 of the patients with GERD symptoms. The cases with abnormal acid reflux were treated by conventional therapy for FC. These cases were re-evaluated for GERD symptoms and weekly defecation frequency, and 24-h pH meter monitoring was performed at the end of a 3-month period.An abnormal level of acid reflux was determined in 23 of the 55 cases. After the constipation treatment, a significant improvement was achieved in the acid reflux index and GERD symptoms, whereas the weekly defecation frequency increased.GERD is a frequent problem in children with FC. Treatment of the constipation can improve the reflux symptoms and abnormal acid reflux in these cases. Physicians should bear in mind the co-occurrence of these two prevalent problems for better disease management.

BACKGROUND Supragastric belching (SGB) has a significant behavioural component. We recently used cognitive behavioural therapy (CBT) to treat SGB. We demonstrated that CBT significantly reduces symptoms and improves quality of life in 50% of patients who had completed treatment. AIMS To investigate factors associated with successful CBT for SGB and to assess symptoms 6-12 months after completion of CBT METHODS: Records of 39 patients who had completed the CBT protocol were analysed. Per cent pre- to post-treatment change in symptoms was assessed using a visual analogue scale (VAS) score. We evaluated the association between 'pre-treatment' factors and 'during-treatment' factors, and symptomatic outcomes. Symptoms were also assessed 6-12 months after treatment. RESULTS From 'pre-treatment factors', a lower number of SGBs (P

Gas, bloating, and belching are associated with a variety of conditions but are most commonly caused by functional gastrointestinal disorders. These disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress. An organized approach to the evaluation of symptoms fosters trusting therapeutic relationships. Patients can be reliably diagnosed without exhaustive testing and can be classified as having gastric bloating, small bowel bloating, bloating with constipation, or belching disorders. Functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation are the most common causes of these disorders. For presumed functional dyspepsia, noninvasive testing for Helicobacter pylori and eradication of confirmed infection (i.e., test and treat) are more cost-effective than endoscopy. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease. Patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation. Empiric therapy is a reasonable initial approach to functional gastrointestinal disorders, including acid suppression with proton pump inhibitors for functional dyspepsia, antispasmodics for irritable bowel syndrome, and osmotic laxatives and increased fiber for chronic idiopathic constipation. Nonceliac sensitivities to gluten and other food components are increasingly recognized, but highly restrictive exclusion diets have insufficient evidence to support their routine use except in confirmed celiac disease.

Background This study was conducted to analyze the association between digestive symptoms and sleep disturbance, and to determine if any digestive symptoms are related to sleep disturbance. Methods This was a cross-sectional study of 5792 subjects surveyed in a community-based cohort. Subjects provided information regarding the quality of sleep as assessed by the Pittsburgh Sleep Quality Index (PSQI), as well as digestive symptoms as assessed by the Gastrointestinal Symptom Rating Scale (GSRS). Logistic regressions were used to examine factors associated with sleep quality. Results The mean PSQI global score of the no sleep disturbances group (n = 4948) was 3.92 (SD = 2.14), while that of the sleep disturbance group (n = 844) was 11.18 (SD = 2.17). The association between digestive symptoms and sleep disturbance was evaluated by logistic regression after adjusting for cofounding factors. The results revealed that sleep disturbances were associated with digestive symptoms (aOR = 1.29, 95% CI = 1.22–1.36), especially abdominal pains (aOR = 1.63, 95% CI = 1.19–2.25), acid regurgitation (aOR = 1.48, 95% CI = 1.17–1.86), abdominal distension (aOR = 1.80, 95% CI = 1.42–2.28), and eructation (aOR = 1.59, 95% CI = 1.24–2.03). Conclusions Digestive symptoms and sleep disturbances seem to be associated. These results will help medical professionals to effectively diagnose and manage patients with sleep disturbance. Furthermore, subsequent studies using comprehensive longitudinal data should be conducted to confirm the results of the present study.

Bloating is a common gastrointestinal complaint which is difficult to treat.This study investigated the efficacy and compliance of a formulation called KAASER comprised of Trachyspermum ammi (L.) Sprague seed, Zingiber officinale Roscoe. rhizome and Piper nigrum L. berry in the treatment of functional bloating.A total of 106 patients with functional bloating, between 20 and 50 years of age, participated in this double-blind randomized controlled trial. Patients were divided into 3 parallel groups that received 500 mg of placebo, dimethicone or KAASER, three times a day for 2 weeks.The frequency and severity of bloating were primary outcomes, while the frequencies of eructation, defecation, borborygmus and early satiation were secondary outcomes. All parameters were evaluated at the beginning (week 0), and also weeks 2, 4 and 10 of the study, through self-report checklists with a scoring system.Among the 84 patients who completed the study, the frequency and severity of bloating (P 0.001), the frequencies of eructation, defecation and borborygmus (P = 0.03) were significantly improved in the group receiving KAASER (36 patients) compared with the dimethicone (35 patients) and placebo (35 patients) groups, during the 3 phases of follow-up. These significant differences persisted through the 2 and 8 weeks of follow-ups after cessation of medication (week 4 and 10). In early satiation, no significant differences were observed among the 3 groups.The results showed that KAASER can be effectively used to treat patients suffering from bloating. Bloating, eructation, defecation and borborygmus in the KAASER group remained significantly improved after 2 and 8 weeks of cessation of medication, making this mechanism an interesting area for further investigation.Registration trial IRCT2015100324327N on Iranian Registry of Clinical Trials.

Rationale: Primary gastric inflammatory myofibroblastic tumor is extremely rare. Only a few cases were reported in the domestic and foreign medical literature with corresponding imaging findings of this disease even more rarely reported. Patient concerns: We present one case of a 52-year-old female patient with upper abdominal pain, acid reflux, and belching for 2 months. Diagnoses and Interventions: Electron ultrasound gastroscopy (EUS) revealed elevation of gastric antrum mucosa. A whole abdominal and pelvic multi-slice spiral computed tomography (CT) detected a round nodule in the gastric antrum with considerably delayed enhancement, with initial suspicion of gastrointestinal stromal tumors (GISTS). Then a laparoscopic assisted distal gastrectomy was performed. Finally, the postoperative pathology confirmed the diagnosis of primary gastric IMT. Outcomes: After 6 months of follow-up, the patient was still alive without any evidence of metastasis or recurrence. Lessons: Familiarizing with the CT features of this rare tumor may raise radiologists’ awareness of the disease and potentially could avoid misdiagnosis.

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.

Item does not contain fulltext BACKGROUND: Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pomp inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD). Besides preventing reflux of gastric fluid and solid content, LARS may also impair the ability of the stomach to vent intragastric air (i.e. gastric belching) and induce gas-related complications, such as bloating and/or hyperflatulence. Furthermore, it was previously hypothesized that LARS induces a behavioral type of belching, not originating from the stomach, called supragastric belching. The aim of this study was to objectively evaluate the impact of LARS on gastric (GB) and supragastric belching (SGB) in children with GERD. METHODS: We performed a prospective, Dutch multicenter cohort study including 25 patients (12 males, median age 6 (range 2-18) years) with PPI-resistant GERD who were scheduled for LARS. Twenty-four-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after fundoplication. Impedance pH tracings were analyzed for reflux episodes and GBs and SGBs. KEY RESULTS: LARS reduced acid exposure time from 8.5% (6.0-16.2%) to 0.8% (0.2-2.8%), p < 0.001. The number of GBs also significantly decreased after LARS (59 [43-77] VS 5 [2-12], p < 0.001). The number of air swallows remained unchanged after LARS. SGBs were infrequent before LARS with no change in the number of SGB observed after the procedure. Postoperative belching symptoms were associated with GBs, not with SGBs. CONCLUSION & INFERENCES: LARS significantly reduces the number of GBs in children with GERD, whereas the number of air swallows remains unchanged. Postoperative symptomatic belching is associated with GBs, but not with SGBs. These findings suggest that LARS does not induce the occurrence of SGBs in children, but longer follow-up is required.

Resumo: Timpanismo ruminal consiste na distensão acentuada do rúmen e retículo, devido a incapacidade do animal em expulsar gases produzidos durante o processo fisiológico da fermentação. O timpanismo pode ser ocasionado de forma primária, por formação de espuma estável, ou secundária, devido a anormalidades funcionais e/ou físicas que interferem na eructação. Nesse trabalho, são descritos os aspectos epidemiológicos, clínicos e anatomopatológicos da ocorrência de timpanismo secundário em bovinos, decorrente da obstrução esofágica aguda por limões sicilianos. Cinco bovinos, de um lote de 210, foram afetados. Os bovinos eram suplementados com resíduo de tangerina (Citrus reticulata) no cocho e na última carga desse subproduto, havia limões sicilianos inteiros misturados ao resíduo. Os cinco animais afetados eram da raça Aberdeen Angus e tinham entre 12-24 meses de idade. Todos apresentaram sinais clínicos caracterizados principalmente por mucosas cianóticas, grave timpanismo, desconforto abdominal, acentuada dispneia e taquicardia, atonia ruminal, desidratação, decúbito e morte. O curso clínico variou entre 24 a 48 horas. Na necropsia, os cinco bovinos apresentavam grave obstrução esofágica por limões nas porções: cranial (logo após a laringe [1/5]), porção medial (entrada do tórax [1/5]) e final (próximo ao cárdia [3/5]). Nas áreas de oclusão, observou-se extensa necrose e ulceração da mucosa esofágica. O conteúdo ruminal dos bovinos estava seco e misturado com limões inteiros. No esôfago de dois animais havia linha de timpanismo. As lesões histológicas eram visualizadas principalmente no esôfago, na região da obstrução, onde se evidenciaram alterações degenerativas, necróticas e ulcerativas acentuadas no revestimento epitelial. Abstract: Ruminal bloat (acute timpany) in ruminants is a marked rumen-reticular distension which results from more gas being produced during the physiologic process of fermentation than is eliminated by eructation. This condition may present itself as either primary timpany due to the formation of stable foam or secondary timpany resulting from functional and/or physical disturbances compromising eructation. This paper describes the epidemiological, clinical, and anatomopathological aspects of acute timpany in cattle secondary to esophageal obstruction by sicilian lemons. Five out of a herd of 210 cattle were affected. Cattle were supplemented with tangerine (Citrus reticulata) residues in a trough. In the last batch of this feed there were whole sicilian lemons mixed with the tangerine residue. The five affected cattle were 12-24 month-old Aberdeen-Angus. All of the five presented clinical signs characterized mainly by cyanotic mucous membranes, severe timpany, abdominal discomfort, marked dyspnea and tachycardia, ruminal atony, dehydration, recumbence and death. Clinical course lasted from 24 to 48 hours. Necropsy findings in the five affected cattle were similar and included complete esophageal obstruction by lemons in the cranial esophagus (immediately cranial to the larynx [1/5]) medial esophagus (at the thoracic inlet [1/5]) and caudal esophagus (close to the cardia [3/5]). At the occluded sites the esophageal mucosa was necrotic and ulcerated. Ruminal content was dried and admixed with whole lemons. In the esophagus o two affected bovine a bloat line was observed. Histological lesions were observed mainly in the esophagus at the sites of obstruction and consisted of marked degenerative, necrotic and ulcerative changes in the esophageal mucosal epithelium.

Contains fulltext : 172797.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is considered to be an effective procedure for patients with morbid obesity. Belching is frequently reported after this procedure, but it has not been well studied in the bariatric population. This study aims to assess the changes in belching before and after sleeve gastrectomy, as measured with impedance monitoring. METHODS: In a prospective study, patients underwent 24-h pH-impedance monitoring before and 3 months after LSG. Using this technique, belches can be identified. Preoperative and postoperative upper gastrointestinal symptoms were assessed using the Reflux Disease Questionnaire (RDQ). RESULTS: Fifteen patients (1 M/14 F, mean age 42.2 +/- 11.0 years, mean weight 134.5 +/- 21.1 kg, mean BMI 46.4 +/- 6.0 kg/m(2)) participated in this study. Belching occurred significantly more often after LSG, with an increase in symptom score from 2.9 +/- 2.6 before to 5.3 +/- 3.5 3 months after LSG (p = 0.04). The total number of gastric belches increased from 29.7 +/- 11.7 before to 59.5 +/- 38.3/24 h 3 months after LSG (p = 0.03). The total number of supragastric belches did not change after LSG. The number of swallows decreased from 746.9 +/- 302.4 before to 555.7 +/- 172.5 3 months after the procedure (p = 0.03). The number of air swallows tended to decrease (p = 0.08). Esophageal acid exposure increased significantly, from 3.7 +/- 2.9 % before to 12.6 +/- 10.5 % after LSG (p = 0.01). CONCLUSION: Subjectively (as reported by patients) and objectively (as measured by impedance monitoring), an increase in gastric belches is seen after LSG, while the number of (air) swallows tends to decrease after the procedure and the incidence of supragastric belches remains constant. The altered anatomy as well as increased gastroesophageal reflux after LSG may play a role in the increase of belching.

Objectives This study aimed to examine the validity of the modified Reflux Symptom Questionnaire-electronic Diary (mRESQ-eD) through patient input and psychometric testing of the questionnaire to support use in clinical trials in patients with persistent gastroesophageal reflux disease (GERD) and in accordance with Food and Drug Administration guidance on patient-reported outcome instruments. Methods Cognitive interviews were conducted with patients (n = 30) to evaluate the interpretability and content validity of draft mRESQ-eD items. Patient data from a phase 2b clinical study (ClinicalTrials.gov identifier: NCT02637557) on persistent GERD served to aid in the construction of weekly scores for heartburn severity, regurgitation severity, and total GERD severity. These scores' psychometric properties were also evaluated. Results Minor modifications were made to the draft mRESQ-eD based on patient feedback to improve interpretability and clarity of the instrument. Psychometric analysis suggested that an 8-item version of the mRESQ-eD was best suited to the clinical data. The internal consistency was found to be high (Coefficient ω = 0.95). Retest reliability and convergent validity were strong for a heartburn weekly severity score, regurgitation weekly severity score, and total GERD severity score. Discussion The final 8-item mRESQ-eD is a reliable and valid instrument with good psychometric properties for use in clinical trials in patients with persistent GERD. The mRESQ-eD may be considered for inclusion in clinical trials for persistent GERD and potentially positioned, in consultation with Food and Drug Administration, as endpoints to characterize treatment benefit.

A 17-year-old girl was referred to our hospital with an inability to belch, while experiencing chest gurgling noises, and severe abdominal bloating. She reported having these symptoms all her life. A timed barium esophagogram revealed a moderate amount of bubbles in the esophagus and gastric fundus, which significantly increased after the examination. High resolution manometry revealed that the basal upper esophageal sphincter pressure increased with a rise in the cervical esophageal pressure. A pathological inability to belch is rare; at present, no specific name exists to describe the disorder. Further research is needed in this unexplored field.

Background: In routine medical examination, the hypopharyngeal-esophageal area (HER) is difficult to assess due to its position and anatomical complexity. The purpose of this study was to evaluate the feasibility of a volitional eructation maneuver during transnasal flexible laryngoscopy and its influence on the visibility of the HER. Methods: Twenty healthy volunteers underwent flexible laryngoscopy. Once the larynx was freely visible during laryngoscopy, the subjects were asked to trigger a “burp.” The volitional belching during the study was assisted by drinking a carbonated cold drink. The triggered relaxation of the upper esophageal sphincter along with the widening of the hypopharynx region was recorded and subsequently analyzed frame by frame. Results: Out of 20 volunteers, 16 (80%) were able to volitionally induce an eructation. Significant widening of the hypopharynx region up to the relaxant upper esophageal sphincter could be recorded. The structures were clearly visible in the offline analysis. In 13 (81%) of the 16 subjects who could induce an eructation, the upper esophageal sphincter was partially visible or free for full inspection. Conclusion: The eructation method as a simple physiological function can be used as a complementary method during flexible transnasal endoscopy to enhance visibility of the entire hypopharynx region as well as the upper esophageal sphincter.