New insights into aerophagia, belching and gastro-oesophageal reflux

Abstract

Gastro-oesophageal reflux is a physiological phenomenon and occurs in every healthy subject approximately 40 times every day. Twenty percent of the general western population experiences reflux symptoms such as heartburn, regurgitation, and retrosternal pain at least once a week. Gastro-oesophageal reflux disease (GORD) is a condition in which symptoms or complications are brought about by reflux of gastric contents into the oesophagus. Ambulatory 24h pH-impedance monitoring can be performed in order to assess a relationship between reflux symptoms and reflux episodes. This measurement can be helpful in patients who fail to respond satisfactorily to proton pump inhibitors (PPIs), and in whom the diagnosis GORD is uncertain. In this thesis we have shown that an ambulatory 24h pH-impedance measurement in patients who do not respond satisfactorily to PPI therapy should preferably be performed after the cessation of PPIs. This results in the best discrimination between patients who truly have GORD and those who do not. In addition, we describe a study into different pH-electrodes (antimony, ISFET and glass pH electrodes) that can be used to measure intra-oesophageal pH. It appears that ISFET-electrodes are not influenced by temperature and components of buffer solutions, and theoretically result in the most reliable measurements. The analysis of impedance tracings requires expertise and is time consuming. We have shown that computer analysis can be helpful, but is less reliable than manual analysis. GORD patients often report an increase of their reflux symptoms during stressful situations. In this thesis we assessed the influence of acute psychological stress on oesophageal acid perception and conclude that neither in healthy volunteers nor in GORD patients, acute psychological stress induced by an IQ test increased oesophageal acid perception. Besides typical reflux symptoms GORD patients often complain of excessive belching. It is known that GORD patients swallow air more frequently than healthy subjects. We have shown that this is likely the result of the experience of reflux symptoms. In theory, swallowing may reduce the uncomfortable oesophageal sensation. Besides normal belching (an air-escape from the stomach), we have shown that supragastric belching occurs in patients with reflux symptoms as well. This typical belching pattern has previously been shown in patients with excessive belching as primary and presenting symptom and concerns probably a behavioral disorder. In approximately 50% of the patients with reflux symptoms supragastric belches were identified. More interestingly, 50% of these supragastric belches were related to reflux episodes, suggesting that supragastric belching elicits reflux in some cases and is the patient’s response to an unpleasant esophageal sensation in others. In this thesis we describe a group of patients who have large amount of intestinal gas on plain abdominal radiographs. We have shown, using ambulatory 24h pH-impedance monitoring, that these patients have high incidences of air swallows and gastric belches. Therefore, this study presents objective parameters confirming the existence of a phenomenon of excessive air swallowing or aerophagia using esophageal impedance monitoring. The last chapter of this thesis concerns a study into the effect of speech therapy on the symptoms of patients with excessive supragastric belching. In more than 50% of the patients, speech therapy resulted in significant improvement of the severity of symptoms. Therefore, we conclude that speech therapy performed by a well-informed speech therapist leads to a significant symptom reduction in patients with excessive supragastric belching.