Introduction Supragastric belching (SGB) is considered a behavioural disorder. SGB can manifest as a large number of belch episodes during daytime, or can be associated with reflux symptoms or rumination. Supragastric belches can be immediately followed by acid reflux and in some GORD patients, SGB-associated reflux can contribute to up to 1/3 of the total acid exposure (AET) (Koukias, 2015). Current treatments for SGB are cognitive behavioural therapy (CBT) and Baclofen. We hypothesised that reducing SGB might improve QOL and reduce acid GOR. The aim of our study was to assess the effectiveness of CBT on subjective and objective outcomes in patients with pathological SGB.
Method Patients were recruited from the upper GI Physiology Unit after performance of pH-impedance (Sandill Sci, USA). Visual analysis of tracing was performed to identify SGB and patients with more than 13 SGB/day were invited to participate. Patients attended a total of 5 CBT sessions. The CBT protocol was adapted from Katzka et al (2013) and consisted of teaching 1. diaphragmatic breathing, 2. mouth opening/tongue position and 3. recognition of a warning signal/feeling pre-belching. Patients exercised these manoeuvres daily and tried to apply them to prevent belching. Before and after CBT, subjective evaluation included a 4-item visual analogue scale (VAS) regarding severity of belching. Objective evaluation included pH-impedance at baseline and after CBT. Parameters were number of SGB, the acid exposure time, and proportion of AET associated with SGB.
Results 45 patients were recruited since March 2016. So far, 21 patients completed the protocol (age: 44, (21-72), 10 females) of which 17 had a second pH-impedance study. Subjective evaluation : VAS scores decreased after CBT in 20/21 patients [before: 250 (210-310) mm vs. after: 130(80-200) mm, p<0.0001]. 9/21 patients had VAS score improvement >50%. Objective evaluation: Number of SGB decreased significantly after CBT in 15/17 patients [before: 90 (51-228) vs. after 45 (24-149), p=0.0041]. 8/17 patients had reduction of SGB by more than 50%. Ten patients had increased AET pre-treatment, [AET: 8.6 (SEM 0.93). In these patients SGB contributed to 32% of the AET. Overall, AET after CBT was: 6.08 (SEM 0.82), p=0.06). In 5/10 patients with baseline increased AET, we observed after CBT a reduction of number of reflux episodes driven by SGB and AET (by 31.5%).
Conclusion Cognitive behavioural therapy ameliorates supragastric belching. It reduces the number of belches and improves social and daily activities in 50% of patients. Careful analysis of pH-impedance allows identification of a subgroup of GORD patients with acid reflux predominantly driven by SGB. In these patients, CBT can reduce daytime esophageal acid exposure.
Disclosure of Interest E. Glasinovic: None Declared, E. Wynter: None Declared, J. Arguero: None Declared, J. Ooi: None Declared, P. Hajek: None Declared, D. Sifrim Conflict with: Reckitt Benckiser (Hull, UK); Sandhill Scientific (CO, USA)
- cognitive behavioural therapy
- Gastro-oesophageal reflux disease
- supragastric belching