Unveiling Excessive Supragastric Belching in Conclusive GERD: Clinical Insights and Predictors

Highlight

1. Excessive supragastric belching (SGB) is identified in approximately 18.5% of patients with conclusive gastro-oesophageal reflux disease (GERD) confirmed by pH-impedance monitoring.
2. One quarter of acid exposure time (AET) in affected patients is attributable to SGB-related acid reflux episodes.
3. Higher total reflux episodes (TRE) and increased proximal reflux episodes independently predict the excessive SGB GERD phenotype.
4. Predominance of perceptive symptoms such as heartburn and chest pain and higher distal acid exposure are negative predictors of excessive SGB-related GERD.

Study Background

Gastro-oesophageal reflux disease is a prevalent disorder characterized by pathological reflux of gastric contents causing troublesome symptoms and/or complications. Supragastric belching (SGB) is a behavioral reflux event wherein air is rapidly sucked into the esophagus and expelled without reaching the stomach. While SGB can precipitate reflux episodes, its clinical relevance and contribution to pathological reflux burden remain inadequately defined. Identifying excessive SGB is important because it may alter symptom perception, influence treatment response, and impact management strategies in GERD patients.

Study Design

This international multicentre cross-sectional study included 580 patients from 11 tertiary care centers across Europe, North America, Latin America, and Asia. Inclusion criteria required conclusive GERD defined as acid exposure time (AET) exceeding 6% on pH-impedance monitoring performed off acid-suppressive therapy. Manual identification of supragastric belching episodes was performed, with excessive SGB defined as 13 or more SGB episodes per 24 hours. SGB-related acid reflux was quantified by the duration of esophageal pH below 4 following an SGB event. Both univariate and multivariate logistic regression analyses examined clinical and manometric predictors of excessive SGB-related GERD. Key endpoints included total acid exposure time, total reflux episodes, symptom correlation, and regional reflux metrics.

Key Findings

Among the 580 GERD patients studied (mean age 56.1 years, 62% female), 107 (18.5%) exhibited excessive supragastric belching. The prevalence was consistent across geographic regions (p=0.97). The excessive SGB subset showed distinct physiologic and clinical profiles:

• Acid Exposure: Although total acid exposure time was lower in the excessive SGB group (p=0.01), approximately 24.6% of their total acid exposure was directly attributable to acid reflux induced by SGB events.
• Reflux Episodes: These patients had a significantly higher number of total reflux episodes (TRE) (p=0.0006), with more frequent proximal reflux events, especially those temporally related to SGB.
• Symptoms: The number of symptom episodes associated with SGB-related reflux was significantly elevated (p<0.0001), suggesting greater symptom burden correlated with SGB events.

Multivariable logistic regression identified higher total reflux episodes (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.004–1.014, p=0.0004) as an independent positive predictor of excessive SGB. Conversely, predominant typical perceptive symptoms (heartburn or chest pain) were negative predictors (OR 0.36, 95% CI 0.155–0.854, p=0.002) as was higher distal acid exposure time (OR 0.96, 95% CI 0.920–0.998, p=0.042). Receiver operating characteristics curve analyses further demonstrated that more than 115 total reflux episodes and more than 56 proximal reflux episodes predicted excessive SGB with over 90% specificity.

Expert Commentary

This well-powered multicentre study offers important insights into the underrecognized excessive SGB-related GERD phenotype. The finding that nearly one-fifth of conclusive GERD patients exhibit excessive SGB highlights the need for routine assessment of belching behavior during impedance pH monitoring to avoid misinterpretation of reflux burden. The elevated symptom association with SGB-related reflux episodes may explain refractory symptoms in some GERD patients despite PPI therapy. Recognizing this phenotype has meaningful clinical implications, as behavioral interventions aimed at reducing SGB might complement conventional acid suppression for symptom control.

Limitations include the cross-sectional design precluding assessment of longitudinal symptom outcomes and treatment response. Also, manual identification of SGB requires expertise and may limit widespread application. Further studies should explore the interplay of SGB with esophageal hypersensitivity and psychological factors.

Conclusion

Excessive supragastric belching contributes substantially to acid exposure and symptom generation in a significant subset (up to 20%) of patients with conclusive GERD. Higher total and proximal reflux episode counts are robust clinical predictors for identification of this phenotype, whereas typical perceptive symptoms and distal acid exposure inversely predict its presence. Targeted evaluation for excessive SGB during advanced pH-impedance testing should be considered in refractory or atypical GERD cases to guide personalized management strategies focused on both reflux control and behavioral modification.

Funding and ClinicalTrials.gov

The original study was conducted across 11 international tertiary centers, supported by institutional research funds; no specific grant or trial registration was stated in the source publication.

References

• Chan WW, et al. Excessive supragastric belching can be identified in up to one-fifth of patients with conclusive gastro-oesophageal reflux disease. Gut. 2026 Sep 7. PMID: 42705698.
• Gyawali CP, et al. Modern diagnosis of GERD: ISDE consensus statement. Am J Gastroenterol. 2020;115(11):1466-1479.
• Bredenoord AJ, Weusten BL, Smout AJ. Distal esophageal acid exposure and proximal reflux episodes in GERD. Neurogastroenterol Motil. 2013;25(12):1088-1096.