Case study 1: Mix of Real Gastric and Supragastric Belching

A 20-year-old lady presented with heartburn, belching and persistent hiccups.  High resolution manometry and 24-hour pH/impedance reflux monitoring were carried out.

High Resolution Manometry

HRM results were as follows:

  • The upper oesophageal sphincter was normotensive and showed complete relaxation on wet-swallows.
  • The oesophagus showed normal peristalsis.        
  • The lower oesophageal sphincter was normotensive and showed complete relaxation on wet-swallows.
  • There was no evidence of a hiatus hernia.

These results based on the Chicago Classification showed that the patient exhibited normal oesophageal motility.

24-hour pH-Impedance Reflux Monitoring Off PPI

The pH-impedance reflux monitoring gave the following results:

  • Proximal oesophagus: total of three episodes; normal <31 (impedance).
  • Distal oesophagus: total: 2.8%, normal <4.2%; upright: 0.2%, normal <6.3%; supine: 5.2%, normal <1.2%; DeMeester score: 13.9, normal <14.72; number of reflux events (impedance): total 29, normal <73 (off PPI).
  • Reflux symptom correlations: belching 79 episodes, SI & SAP not analysed; positive SI >50%, positive SAP >95%.


  1. The patient was experiencing pathological acid/non-acid reflux when off PPIs during the night.
  2. There was a positive reflux symptom association for belching which indicated that the majority of reflux events were indeed triggered by a belch episode.
  3. Although nocturnal reflux was not directly triggered by belching, it occurred within a few minutes after the patient had a little food/drink at around 1.30am.
  4. 79 belching episodes were reported and was a mix of real gastric and supragastric belching.

Next Steps

For the true gastric belching, a hydrogen and methane breath test may be considered to exclude small intestinal bacterial overgrowth (SIBO).  The patient may benefit from oesophageal biofeedback therapy.

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