Key takeaways
- Supragastric belching disorder is rapid, excessive belching that can occur hundreds to thousands of times a day.
- The condition involves air entering and exiting the esophagus, rather than the stomach, which is the more common gastric belching.
- Supragastric belching is a learned response of the vagus nerve; a breathing technique has been developed to retrain the nerve.
For most people, the occasional belch is a normal part of life; in fact, normal gastric belching ranges up to 30 times a day.
But when belching becomes excessive, as it did for Erica Sender, it can profoundly affect one’s work and social relationships, confidence and quality of life.
Sender, a gerontologist and care advocate for older adults, was belching more than 100 times a day.
“It was happening on my way to work, with clients and after lunch,” Sender, 35, recalls. “I was single, and I felt like I couldn’t date. I couldn’t go out to dinner because the belching would get so bad that I would eventually throw up. It really impacted my life.”
For three years, Sender sought relief through her HMO’s gastroenterologist and a speech therapist, undergoing tests to try to diagnose and treat the problem. Nothing helped until she was referred to the Robert G. Kardashian Center for Esophageal Health at UCLA.
There, she met Lisa Bolden, MA, CCC-SLP, a senior speech pathologist, who diagnosed Sender’s condition at their first meeting: supragastric belching disorder; fast and repetitive belching that occurs in some patients hundreds to thousands of times per day.
A learned response
A supragastric belch is distinguished from the more commonly known gastric belch because air rapidly enters and exits the esophagus and never enters or exits the stomach, as it does with gastric belching. Instead, during episodes of supragastric belching, air is inhaled or injected into the esophagus and is expelled through the mouth in one second.
Supragastric belching episodes include belches spaced no more than five seconds apart. Episodes range from a single belch to thousands, lasting for hours. Supragastric belching more than 13 times per 24 hours is considered excessive, says Bolden.
Triggers can include awakening, eating, drinking, hunger and activities such as exercise or sitting in a car, with seating posture affecting pressure on the diaphragm. Episodes are lessened with distraction and don’t occur during talking, singing or sleeping, she adds.
Importantly, Bolden says, supragastric belching is a learned response of the vagus nerve, the longest cranial nerve, which is part of the autonomic nervous system.
The autonomic nervous system controls respiration, heart rate, blood pressure, digestion and sexual arousal. It has three branches: the sympathetic, known as fight, flight or freeze; the parasympathetic, known as calm; and the enteric or digestive. Both the sympathetic and parasympathetic nervous systems influence the enteric nervous system.
Most people with excessive supragastric belching have underlying reflux, hypomotility or other digestive disorders, Bolden explains. A small percentage of people, though, may have an inciting event and no ongoing disorder. The nerve learns the behavior.
Bolden notes that some people supragastric belch at will in a misdirected attempt to alleviate discomfort.
“The preceding sensation or warning signal is uncomfortable,” she adds, and can include an air bubble or pressure in the chest or throat. “Patients are aware that they're belching and they're miserable from it. Excessive belching has a significantly negative impact on quality of life.”
Reteaching the body
Treatment for supragastric belching centers on patient education and specially designed “rescue breathing,” which involves slow, fluent abdominal breathing with an open mouth and tongue resting behind the upper front teeth. This technique is mutually exclusive with supragastric belching and has the added benefit of calming the autonomic nervous system.
The treatment was introduced in 2010 in the Netherlands and was adopted by UCLA Health in 2016. Because the condition involves learned nerve behaviors affecting the vocal folds and breath control, speech pathologists with voice and upper airway training are uniquely positioned to treat these issues.
UCLA Health has developed an innovative technique for rescue breathing that is paced to exhaling for six seconds and inhaling for four seconds, which synchronizes breathing with heart rate to activate the calming parasympathetic nervous system.
Patients begin treatment with a comprehensive evaluation where they provide information on their belching, including current state, onset, the number of belches per day and per episode, triggers, warning sensations, other GI symptoms and expectations for therapy.
Bolden reviews the patient’s medical history, including GI testing, and makes clinical observations about the belching including mode of air influx, first sign of belch, frequency and number of belches per episode. Together, Bolden and her patients complete severity rating scales for patient-centered outcomes. Finally, within the evaluation, Bolden provides education about supragastric belching and teaches the patient rescue breathing.
Finding relief
Sender had her first session with Bolden in October 2024 and remembers being relieved that her condition had a specific treatment that had been successful with other patients.
“Lisa explained the actual physiological process of what’s happening, and that supragastric belching is a learned response” that can be voluntary or involuntary, Sender says. “And that it isn’t your fault; it’s that your body learned to do this, and now it’s automatic. So now we’re going to do things to reteach it.”
Also key, Sender adds, was learning that her feeling she needed to belch to release air was not real.
“Sometimes, when I’m sitting on the couch and the feeling starts, I start doing the breathing, and I realize there’s no reason I need to belch right now,” she says. “Lisa helped me to understand that it wasn’t a necessity, and I could push past it.”
Through working with Bolden, Sender was able to identify her triggers of overeating and eating too quickly, which helped her establish mindful eating habits.
Bolden says that no medication or surgery exists to treat supragastric belching – only this behavioral therapy of education and slow, fluent abdominal breathing has been effective in reducing symptoms.
“Patients who learn the technique and stick with therapy get better,” she says. “The power is within your brain to override this nerve function, and you can learn how to do that.”
Team effort
Bolden emphasizes, “We are a team.” She highlights the importance of UCLA Health’s multidisciplinary approach, integrating care with GI physicians, nurse practitioners, psychologists, registered dietitians and speech pathologists to manage underlying and coexisting conditions.
Patients often undergo diagnostic tests to rule out conditions such as reflux or ulcers. Tests may include an upper endoscopy or an esophageal manometry, likened to an EKG of the esophagus.
A procedure in use for about 15 years, manometry uses a catheter equipped with pressure sensors that is inserted through the nose, giving physicians a clear view of the functioning of the esophagus muscle and the sphincter at the bottom.
“Twenty years ago, we thought all belching was the same,” says Craig Gluckman, MD, a gastroenterologist and associate director of community GI motility and gastroenterology at the Robert G. Kardashian Center. “With manometry, we’re able to tease out gastric belches from supragastric belches,” which results in far fewer misdiagnoses.
In addition, pH testing is often performed to identify acid reflux, which sometimes causes supragastric belching, Dr. Gluckman says.
“It’s my job to look for these treatable conditions,” he adds. “And oftentimes, if we can identify and treat these, then the supragastric belching just gets better on its own.”
The center also screens for eating disorders, hypervigilance and esophageal anxiety, in which a patient is overly focused on physical sensations and potential symptoms in the esophagus.
Regaining her life
Sender attended nine sessions with Bolden – the first was in person and the remaining were virtual. Rescue breathing was challenging at first, she says, because she wasn’t used to breathing from her belly.
It’s been an ongoing practice, but the results have been transformative, she says.
“By the time we finished therapy, my scores on Lisa’s tests from when I started were drastically improved. And I was amazed.”
Since completing treatment, Sender has been able to resume the things she loves, such as going out to eat and drinking carbonated beverages. Her confidence in social settings and her quality of life also improved.
“And now I have a boyfriend, so it’s like I can live my life again,” she says.
