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Inability to Belch syndrome

Also termed Retrograde Cricopharyngeus Dysfunction (R-CPD)

An under-recognised condition often associated with debilitating symptoms, but effective endoscopic therapy exists.

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What is retrograde cricopharyngeus dysfunction (R-CPD), or the inability to burp syndrome?

R-CPD is a relatively under-recognised condition, sometimes also known as the ‘inability to burp syndrome’ or ‘inability to belch syndrome’. In R-CPD, patients are unable to burp due to a non-relaxing upper oesophageal sphincter. The cricopharyngeus is the major muscle making up the upper oesophageal sphincter complex.

How does burping normally occur?

The ‘belch reflex’ has been identified to occur by the following steps:

  1. Swallowing of air (aerophagia) is normal – we all swallow air when we eat and drink

  2. Swallowed air reaches the stomach, and some may pass further down to the lower gastrointestinal tract and eventually passed as a ‘fart’ (flatulence)

  3. Much of the swallowed air in the stomach passes back up (refluxes) into the oesophagus

  4. Air refluxed into the oesophagus causes the oesophagus to distend

  5. The distension of the oesophagus is sensed by special nerve endings, which then transmit nerve signals to the upper oesophageal sphincter, directing it to relax and open

  6. The air built up in the oesophagus can then be vented out through the now open upper oesophageal sphincter, throat, and mouth as a burp (belch)

What causes someone to be unable to burp (R-CPD)?

In patients with inability to belch, everything up to step 4 above seems to occur as in other persons. However, the reflex relaxation and opening up of the upper oesophageal sphincter (step 5) doesn't happen. This leads to pressure buildup in the oesophagus, and the symptoms of the condition.

We don’t yet know why exactly this condition develops. However, there are several observations which can give a clue. Firstly, the cricopharyngeus / upper oesophageal sphincter has an important role in swallowing, yet in patients with R-CPD, it appears to open and close normally during swallowing. This implies that R-CPD is not primarily a problem with the muscle/sphincter itself. Secondly, most patients get better after a single course of treatment with nerve paralysis agent (see below), and mostly remain free of symptoms even after the agent wears off (usually within 3-6 months). This suggests that there is an element of learning involved, rather than a fundamental intrinsic problem with either nerve or muscles. It may be that R-CPD represents an unconscious but maladaptive learned behaviour – the patient may have ‘forgotten’ or never 'learned' how to burp, and the treatment we give helps them to relearn.

How common is inability to burp?

The short answer is, we don’t know. As this is not a condition widely recognised by medical specialists, there are almost certainly many people in the community who have this condition but have not been diagnosed. There is a Reddit community with over 20,000 members worldwide.

 

What are the symptoms of the inability to belch syndrome (R-CPD)

The cardinal symptom is difficulty with burping, or a complete inability to burp, which is often longstanding (and usually lifelong). The patient should relate their other symptoms to their burping difficulty, and will often express that they feel that if they were able to burp, all their other symptoms would disappear. Other symptoms include:

  • Chest pain or pressure

  • Gurgling noises arising from the throat or chest

  • Abdominal bloating

  • Visible abdominal distension

  • Excessive flatulence (wind/farting)

Other symptoms that have been described, but may or may not be present, include excess saliva production, painful hiccups, nausea, and heartburn.

How is R-CPD (the inability to burp syndrome) diagnosed?

The inability to belch syndrome can be very easily and definitively diagnosed using oesophageal high-resolution manometry (pressure recording). Ideally, oesophageal manometry should be performed while asking the patient to eat or drink something that will trigger their symptoms (typically, carbonated beverage such as Coca-Cola). The characteristic findings are displayed in the image. Typically, when the patient describes their symptoms, manometry will reveal high pressure in the oesophagus due to gas build-up, and failure of the normal relaxation of the upper oesophageal sphincter – no burping. 

 

Other tests such as barium swallow, endoscopy, nasendoscopy and laryngoscopy are not necessary for the diagnosis, and will not provide any useful diagnostic information in R-CPD.

 

While other surgeons will perform treatment based on the symptoms alone, Dr Sanagapalli ensures a definitive diagnosis is obtained using manometry in all patients where R-CPD is suspected, and before any treatment is contemplated. Patients have usually had symptoms for many years, and the first step is to provide a definitive explanation for their symptoms. Symptoms of R-CPD can overlap with other gastrointestinal disorders, so it is important that the correct treatment is being given for the correct condition. 

Diagnosis of inability to burp or belch (R-CPD retrograde cricopharyngeus dysfunction) by oesophageal high-resolution manometry

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.

I have all the symptoms of R-CPD. Do I need diagnostic tests?

This is an area of disagreement, and many specialists (particularly ENTs/laryngologists) do not perform any diagnostic tests at all. There are several reasons why confirming the diagnosis with oesophageal manometry is important prior to treatment:

  • One of the arguments against diagnostic testing is that until very recently, there was no diagnostic test for R-CPD. Patients were subjected to numerous unnecessary (and almost always normal) diagnostic tests such as endoscopy, barium swallow, pH testing, . This has now changed, and the first description of oesophageal manometry being used to diagnose the condition was published in May 2022 (see image above).

  • Diagnosis via oesophageal manometry is quick and carries no risk

  • Most patients attend after having had significant undiagnosed or misdiagnosed symptoms for many years. Providing a conclusive diagnosis gives patients validation of their symptoms. 

  • Not having an established, conclusive diagnosis prior to therapy presents problems in the small proportion of patients who may have a suboptimal response to initial therapy.

Treatment of R-CPD (inability to burp syndrome)

The most effective therapy is injection of botulinum toxin (BTX) into the cricopharyngeus muscle. The BTX acts on the cricopharyngeus muscle, relaxing it and opening it up. This allows gas to be expelled from the oesophagus as a burp. In several published case series, the efficacy of this therapy in R-CPD is very high (90-95% success rate). 

 

Traditionally, the injection has been performed by laryngologists (voice or ear, nose and throat surgeons) using a rigid laryngoscope under general anaesthesia. However, Dr Sanagapalli has pioneered an injection technique using standard endoscopy. His endoscopic technique is much simpler, safer and can be done under simple sedation, avoiding the need for general anaesthesia. The recovery time following this endoscopic injection technique is much faster.

 

What is the recovery like after treatment of R-CPD (inability to burp syndrome)

After endoscopic injection into the cricopharyngeus, you should wake up within half an hour. Mild discomfort or soreness in the throat is common and may last a day or two. Significant pain is rare. Swallowing difficulty for the first few weeks is to be expected, because the cricopharyngeus muscle also plays a role in swallowing food and liquid. You should stick to soft foods for a few weeks until there is some recovery in swallowing function, and take care to chew carefully and frequently sip on liquid during meals. Burping usually starts within the first few weeks. Some patients find that certain head manouevres (e.g. turning the head to either side) can help in facilitating belching. 

Are there any other, simpler treatments for patients who can't burp?

Various other exercises (especially Shaker exercises) have been advocated as non-medical therapies for R-CPD. You may read more about how to do these exercises on the No Burp subreddit or Facebook groups. These exercises haven’t been studied, and so, the effectiveness is unknown. However, there is no harm in trying them if you wish!

Who manages patients with inability to belch (R-CPD) in Sydney?

Consult an expert in oesophageal diseases who can not only make a definitive diagnosis of your symptoms using oesophageal manometry, but can treat R-CPD using a minimally invasive endoscopic technique. Contact Dr Santosh Sanagapalli to arrange a consultation and assessment today.

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