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Inability to burp (No-burp syndrome) / R-CPD
Retrograde cricopharyngeus dysfunction (R-CPD)—commonly described as “inability to burp” or “no-burp syndrome”—is a condition in which a person cannot burp because the upper oesophageal sphincter (UOS) (the “valve” at the top of the oesophagus) does not relax appropriately to vent swallowed air. The key muscle within this sphincter is the cricopharyngeus.​
Key facts: Inability to burp (R-CPD)
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Names: inability to burp / no-burp syndrome; retrograde cricopharyngeal dysfunction (R-CPD); inability to belch.
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Cause: the upper oesophageal sphincter (cricopharyngeus) fails to open to vent swallowed air upwards as a burp.
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Symptoms: can’t burp, throat/chest gurgling, painful bloating/pressure (often after meals or fizzy drinks), and excessive flatulence.
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Diagnosis: often recognisable from the classic symptom pattern; where required, the confirmatory test is high-resolution oesophageal manometry.
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Treatment: Botox injection into the cricopharyngeus/upper oesophageal sphincter (often endoscopically under sedation); burping commonly begins within days–weeks in >85-90% of patients.
Why can’t I burp?
Most people swallow small amounts of air when they eat and drink. Normally, that air vents upwards as a burp when the upper oesophageal sphincter (cricopharyngeus muscle) briefly relaxes. If you have inability to burp (“can’t burp”), the most common pattern I see is retrograde cricopharyngeal dysfunction (R-CPD), also called no-burp syndrome.
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In R-CPD, the cricopharyngeus/upper oesophageal sphincter does not relax appropriately for retrograde venting of air, so gas becomes trapped and pressure builds up. This commonly causes throat/chest gurgling, painful bloating or chest pressure (often worse after meals or fizzy drinks), and excessive flatulence. Because it can mimic reflux or anxiety, R-CPD is often missed unless the classic symptom pattern is recognised.
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If your symptoms are longstanding and this pattern sounds familiar, it is worth assessment by a clinician experienced in R-CPD.
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People with R-CPD typically develop a very recognisable pattern of symptoms, including:
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inability to burp (often lifelong)
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loud throat or chest gurgling noises
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painful bloating/pressure, especially after meals or fizzy drinks
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excessive flatulence
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sometimes difficulty vomiting, nausea, or chest discomfort that can mimic reflux
R-CPD is under-recognised, and many patients are initially told they have reflux, anxiety, or “functional” symptoms. With the correct assessment, R-CPD can often be treated effectively—most commonly with botulinum toxin (Botox) injection into the cricopharyngeus/upper oesophageal sphincter.
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Also known as: inability to belch syndrome, retrograde upper oesophageal sphincter dysfunction (R-UES-D).
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How does burping normally occur?
Burping (belching) is a normal reflex that vents swallowed air. In simple terms:
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We all swallow small amounts of air when eating and drinking (aerophagia).
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That air collects in the stomach.
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Some air passes down the bowel and is passed as flatulence, but a proportion returns up into the oesophagus.
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When air distends the oesophagus, nerve sensors trigger relaxation of the upper oesophageal sphincter.
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The air then vents out through the throat and mouth as a burp.
In R-CPD, step 4 fails: the upper oesophageal sphincter does not relax appropriately, so the trapped air cannot vent as a burp.
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What causes someone to be unable to burp (R-CPD)?
We don’t yet know the exact cause of R-CPD. Most evidence suggests it is not a structural blockage and not simply a “weak muscle” problem. Instead, it appears to involve an abnormal or absent burp reflex—the coordinated relaxation of the cricopharyngeus/upper oesophageal sphincter in response to oesophageal gas distension.
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Why does this happen?
Several observations provide clues:
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Swallowing is usually normal. The upper oesophageal sphincter typically opens appropriately during swallowing, suggesting the muscle can function normally in the correct context.
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Treatment effects can outlast the medication. Many patients remain improved well beyond the expected duration of botulinum toxin, which supports the idea of a reflex that can “reset” or be re-established.
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A learned/reflex component is plausible. One explanation is a maladaptive, unconscious reflex pattern—some people may never have learned to burp, or the reflex may become inhibited over time. Treatment may help re-enable the normal venting response.
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How common is inability to burp?
The short answer is: we don’t know the true prevalence. R-CPD has historically been under-recognised, and many people likely remain undiagnosed or are mislabelled with reflux, anxiety, or “functional” symptoms.
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Awareness has increased substantially in recent years, including through online patient communities, which is one reason more patients are now being correctly diagnosed and treated.
What are the symptoms of the inability to belch syndrome (R-CPD)
The defining symptom is inability to burp (often lifelong or longstanding). Many patients recognise a consistent pattern and will say that if they could burp, their other symptoms would largely resolve.
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The most common associated symptoms include:
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throat/chest gurgling noises
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painful bloating or pressure (often worse after meals or fizzy drinks)
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chest discomfort/pressure
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excessive flatulence
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visible abdominal distension
Other symptoms may occur in some patients, including:
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nausea, painful hiccups, excess saliva
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reflux-type symptoms (heartburn/regurgitation)
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shortness of breath
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difficulty vomiting
Some patients also experience emetophobia (fear/anxiety around vomiting), which may coexist with R-CPD.
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How is R-CPD (the inability to burp syndrome) diagnosed?
When the classic symptom profile is present, clinicians with expertise in inability to burp / R-CPD can often make an accurate diagnosis based on history alone.
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When confirmation is needed: high-resolution manometry
When objective confirmation is required, oesophageal high-resolution manometry (pressure recording) can be used to demonstrate the typical physiology. In my practice, I use a validated protocol that measures pressures while the patient consumes a trigger (often a carbonated beverage, such as Coca-Cola), which reliably provokes symptoms in many patients.
Typical findings may include:
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raised intra-oesophageal pressure from gas build-up, and
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failure of normal upper oesophageal sphincterrelaxation during attempted retrograde venting (i.e., no effective burp).
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Do I need other tests?
Other tests (for example, endoscopy, barium swallow, nasendoscopy, or laryngoscopy) are not usually required to diagnose R-CPD itself, but they may be recommended in selected patients to exclude alternative causes of dysphagia, chest symptoms, or upper aerodigestive complaints, depending on age, symptom profile, and red flags.
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Diagnosis of retrograde cricopharyngeus dysfunction by oesophageal high-resolution manometry: Long yellow arrows demonstrate gas rising up from the stomach (St.) into the oesophagus (Oes.), which is normal. However the upper oesophageal sphincter (UOS) pressure remains high, and doesn't relax/open as it should, meaning that gas can't escape. Oesophageal peristalsis (muscle contraction; short green arrows) transiently propels the gas back into the stomach, only for it to immediately rise back into the chest. This cycle occurs repeatedly with no sustained release of trapped gas. These findings were observed after the patient was asked to drink 500mL of soda water, and at the time of these findings was experiencing their typical symptoms of chest discomfort and bloating.
​​Treatment of R-CPD (inability to burp syndrome)
Botox injection into the cricopharyngeus (upper oesophageal sphincter) is the standard first-line treatment for inability to burp (R-CPD).
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The most effective treatment for inability to burp (R-CPD / retrograde cricopharyngeal dysfunction) is botulinum toxin (Botox/BTX) injection into the cricopharyngeus muscle, the key component of the upper oesophageal sphincter (UES). Botox relaxes the muscle, allowing trapped air to vent upwards so that patients can burp, which in turn reduces bloating, chest pressure and gurgling.
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How effective is Botox for R-CPD?
Published case series report high response rates (commonly around 90–95%), although individual results vary and a minority of patients require repeat injections. (I discuss expected benefits and risks in detail during consultation.)
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How is the injection performed?
There are two established approaches:
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ENT/laryngology approach: injection using a rigid laryngoscope, typically under general anaesthesia.
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Endoscopic approach (my technique): injection using standard upper endoscopy (gastroscopy), typically under sedation.
The endoscopic approach avoids the risks of rigid laryngoscopy and, for most patients, allows a simpler anaesthetic pathway and a quicker return to normal activities.
What is the recovery like after treatment of R-CPD (inability to burp syndrome)
After endoscopic Botox injection into the cricopharyngeus/UES, most patients wake within a short period (often within 30–60 minutes). Mild throat soreness is common for 1–2 days; significant pain is uncommon.
What you may notice in the first few weeks
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Temporary swallowing difficulty is common, because the cricopharyngeus is also involved in swallowing. This is usually mild to moderate and improves as the Botox effect settles.
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Diet adjustments often help: softer foods initially, smaller bites, chew thoroughly, and sip fluids with meals.
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Burping typically begins within days to a couple of weeks, though timing varies.
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Some people find that simple manoeuvres (for example, gentle head turning) can make early burping easier while the reflex is establishing.
Possible short-term side effects
In addition to transient swallowing change, some patients notice:
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reflux-type symptoms or regurgitation
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mild voice hoarseness
These are usually temporary and manageable; I provide individualised advice if they occur.​
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FAQ: Inability to burp (R-CPD / no-burp syndrome)
1) What is R-CPD?
R-CPD (retrograde cricopharyngeal dysfunction) is a condition where you cannot burp because the upper oesophageal sphincter (the cricopharyngeus muscle) does not relax properly to let swallowed air vent back up.
2) What are the typical symptoms?
Most patients have inability to burp plus a combination of throat/chest gurgling noises, painful bloating or pressure after meals (especially fizzy drinks), and excessive flatulence. Some also have nausea, painful hiccups, or difficulty vomiting.
3) Is R-CPD the same as reflux (GORD/GERD)?
No. Reflux is acid moving up from the stomach. R-CPD is a mechanical/functional failure of the upper oesophageal sphincter to open for retrograde venting of air. Symptoms can overlap, and some people have both.
4) Can R-CPD be mistaken for anxiety, IBS, or “functional” symptoms?
Yes. Many patients are told symptoms are anxiety-related or IBS because bloating and discomfort are prominent and routine testing may be unrevealing. The key diagnostic clue is the consistent symptom pattern centred on inability to burp.
5) How is R-CPD diagnosed? Do I need a specific test?
R-CPD is usually diagnosed clinically based on the characteristic history, with investigations used selectively to exclude alternative causes. Where required, the current gold-standard for diagnosis is oesophageal manometry.
6) Do I need manometry?
Not everyone does. Manometry is the definitive test for diagnosis of R-CPD. However if the symptoms are classical, experienced specialists can often make an accurate diagnosis based on the symptoms alone.
7) What is the main treatment?
The standard first-line treatment is botulinum toxin (Botox) injection into the cricopharyngeus/upper oesophageal sphincter to allow trapped air to vent upwards. Most patients improve substantially.
8) How quickly does Botox work, and how long does it last?
Burping often starts within days to a couple of weeks. Although Botox itself is temporary, many patients maintain benefit beyond the expected drug duration, likely because the burp reflex “switches on” and becomes learned.
9) What are the most common side effects after treatment?
The most commonly reported short-term effect is temporary swallowing difficulty which might require short-term modification of the diet. Other reported side effects include reflux, regurgitation and voice hoarseness. These are usually manageable and improve as the injection effect settles.
10) What if symptoms come back?
If symptoms recur, a repeat Botox injection is often effective. A small minority of patients with persistent or refractory symptoms may be candidates for other approaches after specialist review.
11) Is surgery ever needed?
Surgery (cricopharyngeal myotomy) is rarely performed for carefully selected refractory cases—typically after inadequate or short-lived response to Botox and after discussion of risks and alternatives.
12) Where can I get treated for R-CPD in Sydney/Australia? Do you see interstate patients?
Yes. I assess and treat inability to burp (R-CPD), including patients travelling from across Australia. The usual pathway is an initial consultation (often suitable via telehealth for interstate patients), followed by a planned endoscopic botulinum toxin injection into the cricopharyngeus/upper oesophageal sphincter when appropriate, and follow-up to assess response and next steps.
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I don’t live in Sydney — can I still see you for R-CPD (inability to burp)?
Yes. A/Professor Sanagapalli regularly assesses and treats patients with inability to burp (R-CPD) from across Australia and overseas. We can often start with a telehealth (video) consultation, allowing you to discuss your symptoms and prior tests from home. If treatment is recommended, we can usually coordinate appointments so that assessment and the planned procedure occur within a single trip to Sydney.
To arrange a telehealth appointment, contact us and simply ask our friendly staff if you would like your initial consultation via telehealth (video).
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Written by: A/Prof Santosh Sanagapalli, MBBS PhD FRACP
Last updated: January 2026
References:
1. Sanagapalli S et al. Prospective Controlled Study of Endoscopic Botulinum Toxin Injection for Retrograde Cricopharyngeus Dysfunction: The Inability to Belch Syndrome. American Journal of Gastroenterology, 2025
2. Bastian R et al. Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment. OTO Open, 2019
3. Lechien JR et al. Etiology, Clinical Presentation, and Management of Retrograde Cricopharyngeus Dysfunction: A Systematic Review. J Otolaryngol Head Neck Surg, 2025
4. Kahrilas PJ. Retrograde upper esophageal sphincter function… and dysfunction. Neurogastroenterol Motil, 2022
5. Sanagapalli S. Moving Towards Standardized Diagnostic Criteria for Retrograde Cricopharyngeus Dysfunction. Clin Gastroenterol Hepatol, 2026 (in press)