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1. BELCHING

Belching (eructation) is the involuntary or voluntary release of gas from the stomach or esophagus. It occurs most frequently after meals, when gastric distention results in transient lower esophageal sphincter (LES) relaxation. Belching is a normal reflex and does not itself denote gastrointestinal dysfunction. Virtually all stomach gas comes from swallowed air. With each swallow, 2–5 mL of air is ingested, and excessive amounts may result in distention, flatulence, and abdominal pain. This may occur with rapid eating, gum chewing, smoking, and the ingestion of carbonated beverages. Evaluation should be restricted to patients with other complaints such as dysphagia, heartburn, early satiety, or vomiting.

Chronic excessive belching is almost always caused by supragastric belching (voluntary diaphragmatic contraction, followed by upper esophageal relaxation with air inflow to the esophagus) or true air swallowing (aerophagia), both of which are behavioral disorders that are more common in patients with anxiety or psychiatric disorders. These patients may benefit from referral to a behavioral or speech therapist.

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Glasinovic  E  et al. Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux. Am J Gastroenterol. 2018 Apr;113(4):539–47.
[PubMed: 29460918]  
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Lang  IM. The physiology of eructation. Dysphagia. 2016 Apr;31(2):121–33.
[PubMed: 26694063]  
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Pauwels  A  et al. A randomized, double-blind, placebo-controlled, cross-over study using baclofen in the treatment of rumination syndrome. Am J Gastroenterol. 2018 (Jan);113(1):97–104.
[PubMed: 29206813]  

2. BLOATING & FLATUS

Bloating is a complaint of increased abdominal pressure that may or may not be accompanied by visible distention. Organic causes of acute bloating with distention, vomiting, and/or pain include ascites, gastrointestinal obstruction (gastric fundoplication, gastric outlet obstruction, small intestine or colon obstruction, and constipation). Complaints of chronic abdominal distention or bloating are common. Some patients swallow excess air (aerophagia, poorly fitting dentures, sleep apnea, and rapid eating) or produce excess gas (excessive FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides, and polyols] ingestion and malabsorption). Others have impaired gas propulsion or expulsion, increased bowel wall tension, enhanced visceral sensitivity, or altered viscerosomatic reflexes leading to abdominal protrusion. Many of these patients have an underlying functional gastrointestinal disorder such as irritable bowel syndrome or functional dyspepsia. Constipation should be treated, and exercise (which accelerates gas propulsion) is recommended. Medications that inhibit gastrointestinal motility should be avoided (opioids and calcium channel blockers).

Healthy adults pass flatus up to 20 times daily and excrete up to 750 mL. Flatus is derived from two sources: swallowed air (primarily nitrogen) and bacterial fermentation of undigested carbohydrate (which produces H2, CO2, and methane). A number of short-chain carbohydrates (FODMAPs) are incompletely absorbed in the small intestine and pass into the colon. These include lactose (dairy products); fructose (fruits, corn syrups, and some sweeteners); polyols (stone-fruits, mushrooms, and some sweeteners); and oligosaccharides (legumes, lentils, cruciferous vegetables, garlic, onion, pasta, ...

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