Anxiety correlates with excessive air swallowing and PPI refractoriness in patients with concomitant symptoms of GERD and functional dyspepsia.

BACKGROUND: Anxiety may exacerbate GERD and FD symptoms perception and reduce quality of life. As many as 50% of patients with GERD symptoms have incomplete relief with PPI therapy, and psychological factors may influence PPI responsiveness. AIM: The potential relationship between anxiety, excessive air swallowing, and PPI responsiveness was evaluated. METHODS: GERD patients with concomitant FD were prospectively evaluated. Validated structured questionnaires were used to evaluate anxiety, GERD, and FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard dose PPI therapy. RESULTS: One hundred sixty-one patients were included. Frequency of non-responders in patients with moderate/severe anxiety was significantly higher compared to patients with mild anxiety (62.7% vs. 37.3%, p < 0.01). Patients with moderate/severe anxiety displayed a significantly higher mean FD symptoms score value compared to patients with mild anxiety. A significantly higher mean number of air swallows were observed in patients with moderate/severe anxiety. At ROC analysis, air swallows and mixed reflux episodes were significantly associated with the presence of PPI refractoriness (AUC: 0.725, 95% CI: 0.645-0.805 and 0.768, 0.692-0.843). According to univariate analysis, an abnormal number of air swallows, mixed reflux episodes and presence of moderate/severe anxiety was significantly associated with PPI refractoriness. CONCLUSION: Our results, if confirmed in in a larger, prospective clinical and therapeutic study, demonstrate the usefulness of an up-front evaluation with anxiety questionnaire and esophageal testing in patients with a broad spectrum of upper gastrointestinal symptoms who fail to respond to PPI treatment, supporting the option of alternative treatment modalities.

Relevance of Excessive Air Swallowing in GERD Patients With Concomitant Functional Dyspepsia and Poor Response to PPI Therapy.

GOALS: The present study was aimed at evaluating the possible role of air swallowing in the association between gastroesophageal reflux disease (GERD) symptoms and concomitant functional dyspepsia (FD) and their role in GERD symptom persistence despite proton pump inhibitor (PPI) therapy. BACKGROUND: It has been shown that individuals with excessive air swallowing experience FD. It has been also demonstrated that a consistent group of GERD patients not responding to PPI therapy swallow more air during mealtime and also have more mixed refluxes. MATERIALS AND METHODS: Multichannel intraluminal impedance-pH tracings from consecutive patients were retrospectively evaluated. A validated structured questionnaire was used to evaluate GERD and concomitant FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard-dose PPI therapy. RESULTS: A total of 35 patients with conclusive GERD, 35 patients with reflux hypersensitivity, and 35 with functional heartburn were studied. A direct relationship was observed between the number of air swallows and of mixed refluxes ( R =0.64). At receiver operating characteristic curve analysis, air swallows and mixed refluxes were significantly associated to the presence of FD and PPI refractoriness. An air swallow cutoff of 107 episodes/24 hours was identified to discriminate patients with and without FD (sensitivity: 87%, specificity: 82.8%). A mixed reflux cutoff of 34 episodes/24 hours was identified to discriminate PPI responders from nonresponders (sensitivity: 84.8%, specificity: 69%). At multivariate analysis, an abnormal number of air swallows and of mixed refluxes were significantly associated to FD and PPI refractoriness. CONCLUSION: Our study highlights the relevant role of excessive air swallowing in eliciting both dyspepsia and refractoriness of typical GERD symptoms to PPI therapy.

Aerophagia in adolescents is associated with exposure to adverse life events and psychological maladjustment.

BACKGROUND: Aerophagia is a common childhood functional gastrointestinal disorder. We studied the association between adverse life events (ALEs), psychological maladjustment, somatization, and aerophagia (AP) in adolescents. We also assessed the impact of AP on their health-related quality of life (HRQoL). METHODS: A cross-sectional survey was conducted on 2500 subjects of 13-18 years in 8 randomly selected schools in Sri Lanka. Translated, validated, and self-administered questionnaires were used to collect data. Aerophagia was diagnosed using Rome III criteria. KEY RESULTS: A total of 2453 questionnaires were analyzed (males 1200 [48.9%], mean age 14.8 years, SD 1.6 years). Of them, 371 adolescents had AP (15.1%). Aerophagia was associated with exposure to physical abuse (20.4% vs. 12.7% in controls, P < .0001), emotional abuse (20.3% vs. 8.2% in controls, P < .0001), and other ALEs (22% vs. 10.2% in controls, P < .001). One hundred and ninety (51.2%) adolescents with AP and 775 (37.2%) controls had a personality score above the international cutoff value of 105, indicating psychological maladjustment (odds ratio 1.77, 95% confidence interval 1.42-2.21, P < .0001). Those with AP had higher somatization (16.4 vs. 8.9) and lower overall HRQoL scores (77.0 vs. 85.1, P < .0001). HRQoL scores of adolescents with AP were lower in all domains, namely, physical (80.6 vs. 86.9), emotional (69.1 vs. 80.3), social (83.8 vs. 90.5), and school (72.6 vs. 82.5) functioning (P < .0001). CONCLUSIONS AND INFERENCES: Aerophagia was associated with exposure to ALEs and psychological maladjustment. Affected teenagers suffer from more somatic symptoms and has a poor HRQoL.

Gas swallow during meals in patients with excessive belching.

BACKGROUND: Swallowed gas is an important source of abdominal gas, and aerophagia is often believed as a putative cause of gas-related abdominal symptoms. However, altered gas-swallow during meals has not been demonstrated. Our aim was to characterize the number of gas swallows during meals in patients complaining of excessive belching and gaseousness and a control group without abdominal symptoms during a 24-h period. METHODS: A 24-h pH-impedance monitoring was performed in 10 patients with excessive belching, and 11 patients without digestive symptoms or reflux in the pH-impedance study. During the study, patients followed their daily routine and customary meals, without any specific limitation. In each patient the number and content of swallows and belches were analyzed. KEY RESULTS: Total meal periods were similar in controls (75±26 min) and patients (79±21 min; P=.339), but the number of gaseous swallows was greater in patients (114±13 swallows) than controls (71±8 swallows; P=.007), due to a greater frequency of gaseous swallows during meals (15±2 swallows/10 min vs 10±1 swallows/10 min, respectively; P=.008). During the 24-h study period, 66±13 belches were recorded in patients, but only 13±3 belches in controls (P<.001), mainly gastric belches (80±4% and 92±2% of belches, patients, and controls, respectively) which showed a good correlation with the number of gaseous swallows performed during meals (r=.756; P=.011). CONCLUSION AND INFERENCES: Gas is frequently swallowed during meals. Patients complaining of excessive belching have a different swallow pattern during meals, with an increased ingestion of gas that correlates with increased gastric belching events.

Hipo. Actitud en otorrinolaringología en pacientes que consultan. Aproximación diagnóstica y terapéutica / Hiccups. Attitude in otorhinolaryngology towards consulting patients. A diagnostic and therapeutic approach

Introducción. Las crisis de hipo suelen ser autolimitadas y benignas, pero los episodios prolongados alteran la calidad de vida y requieren asistencia, ya que existen causas identificables que el otorrinolaringólogo debe conocer para su diagnóstico y tratamiento. Su manifestación última es un ruido glótico espasmódico con alteraciones cervicales características. Pacientes y métodos. Desde 1979 se revisaron todos los casos que consultaron por hipo persistente o recidivante, anotando cronobiología, patología concomitante, resultados de las exploraciones, tratamiento y respuestas al mismo. Resultados. Se asistieron 37 pacientes con una edad media de 45,5±13,5 años, de los cuales 30 eran varones; 23 pacientes (el 62%) presentaron hipo persistente. En 24 casos (el 65%) se evidenció una causa potencialmente asociable: enfermedades del esófago en 14 —la mayoría reflujo gastroesofágico— y en 8 se apreció o descubrió patología oncológica concomitante. Solo 3 casos fueron intervenidos como resultado de los hallazgos efectuados. Los protocolos de tratamiento incluyeron metoclopramida en 18 sujetos, clorpromazina en 17 y baclofeno en 13, pero también carbamazepina o haloperidol. Se empleó neuroestimulación del nervio frénico en 6 pacientes. El hipo desapareció en 32 casos. De los 22 sujetos en los que se pudo efectuar seguimiento, se constató recidiva en 5 —precisando por ello nuevas terapias— y 11 fallecieron. Conclusiones. El hipo crónico implica un reto multidisciplinar con potencial afectación en cabeza y cuello, una sistemática diagnóstica de descarte, frecuente patología de base esofágica y una incidencia de neoplasia maligna alta. Los agentes procinéticos y neurolépticos con efecto antidopaminérgico y anticolinérgico suponen la base del tratamiento (AU)

Introduction. Hiccup crises are generally benign and self-limiting, but longer episodes affect quality of life and must be treated. There are recognisable causes that otorhinolaryngologists must know and be aware for diagnosis and therapeutic alternatives. The main expression is a spasmodic glottic noise with characteristic neck alterations. Patients and methods. This was a retrospective study from 1979 with patients suffering persistent or recurrent hiccups. Chronobiology, comorbidity, findings from explorations, therapies and outcomes were noted. Thirty-seven patients were studied (mean age, 45.5±13.5 years; 30 males), with persistent hiccups in 23 (62%). Results. A potential associated aetiology was observed in 24 cases (65%): oesophageal disorders —mainly gastroesophageal reflux— were detected in 14 cases and concomitant oncological disease was found in 8. Only 3 cases were admitted for surgery due to these findings. Therapeutic strategies with metoclopramide were used in 18 subjects, chlorpromazine in 17 and baclofen in 13, while carbamazepine or haloperidol were used in a minority. Phrenic nerve stimulation was employed in 6 patients. Hiccups disappeared in 32 cases. Out of 22 cases for which follow-up was possible, the hiccups recurred in 5 subjects (the subjects requiring new therapies) and 11 patients died. Conclusions. Chronic hiccup represents a multidisciplinary challenge that includes potential head and neck affection, a diagnostic schedule for ruling out causes, frequent base oesophageal alterations and high incidence of malignant neoplasm. Prokinetic and neuroleptic agents with antidopaminergic and anticholinergic effects are the pillars of its treatment (AU)

Gas and Bloating-Controlling Emissions: A Case-Based Review for the Primary Care Provider.

The evaluation of the patient with gas and bloating can be complex and the treatment extremely challenging. In this article, a simplified approach to the history and relevant physical examination is presented and applied in a case-oriented manner, suitable for application in the primary care setting.

Help from habit reversal for supragastric belching.

Supragastric belching differs from common gastric belching. It can be detected by 24-hour intra-esophageal impedance monitoring. Belching is seldom the only symptom: reflux symptom is present in 95% and dysphagia in 65% of the patients. In supragastric belching, the air does not come from the stomach but instead from the esophagus. Belching is caused by the patient him/herself swallowing air into the esophagus. This voluntary but unconscious symptom is treated by therapy in which explaining the mechanism of belching for the patient and learning of correct diaphragmatic breathing technique play a central role. Habit reversal is utilized for teaching the patient to react correctly to preemptive symptoms.

[Pathologic aerophagia: a rare cause of chronic abdominal distension]. / Aerofagia patológica: uma causa rara de distensão abdominal crônica.

OBJECTIVE: To describe an adolescent with pathologic aerophagia, a rare condition caused by excessive and inappropriate swallowing of air and to review its treatment and differential diagnoses. CASE DESCRIPTION: An 11 year-old mentally impaired blind girl presenting serious behavior problems and severe developmental delay with abdominal distension from the last 8 months. Her past history included a Nissen fundoplication. Abdominal CT and abdominal radiographs showed diffuse gas distension of the small bowel and colon. Hirschsprung's disease was excluded. The distention was minimal at the moment the child awoke and maximal at evening, and persisted after control of constipation. Audible repetitive and frequent movements of air swallowing were observed. The diagnosis of pathologic aerophagia associated to obsessive compulsive disorder and developmental delay was made, but pharmacological treatment was unsuccessful. The patient was submitted to an endoscopic gastrostomy, permanently opened and elevated relative to the stomach. The distention was resolved, while maintaining oral nutrition COMMENTS: Pathologic aerophagia is a rare self-limiting condition in normal children exposed to high levels of stress and may be a persisting problem in children with psychiatric or neurologic disease. In this last group, the disease may cause serious complications. Pharmacological and behavioral treatments are ill-defined. Severe cases may demand surgical strategies, mainly decompressive gastrostomy.

Aerophagia increases the risk of ventilator-associated pneumonia in critically-ill patients.

BACKGROUND: Gastric residual volume in ventilated critically ill may complicate gut function. Over the years studies suggested to tolerate progressively higher residuals. The relationship between such volumes and the development of ventilator-associated pneumonia (VAP) is still under debate. No reports deal with the relevant anecdotal finding of air in the stomach. Aim of the present study is to test the role of air in the development of VAPs. METHODS: Prospective observational trial in consecutive patients with a predicted length of ICU stay >3 days. The first 8 days of stay were studied. Sedation was targeted to have awake/cooperative patients. Early enteral nutrition was attempted. Gastric content was measured every 4 hours by 60 mL-syringe suction. Upper digestive intolerance (UDI) was defined as >2 consecutive findings of liquid >200 mL, aerophagia was defined as >2 consecutive findings of air >150 mL. RESULTS: Three hundred sixty-four patients enrolled, 43 developed VAP (11.8%). Patients were sedated with enteral (76% total time), intravenous (6%) or both (28%) drugs. Conscious sedation was achieved in 54% of the observations. 326 patients began enteral nutrition during the first 24 hours (1000 kcal median calorie intake). 10% developed UDI, 15% had aerophagia. No association was found between VAP and UDI (P=0.78), while significant association was found between VAP and aerophagia (OR=2.88, P<0.01). A sensitivity analysis, excluding patients admitted with respiratory infection, confirmed the results. CONCLUSION: High volumes of air in the stomach significantly increased the risk of developing VAP, while gastric residual volumes were not associated with the incidence of pneumonia.

Characteristics of belching, swallowing, and gastroesophageal reflux in belching patients based on Rome III criteria.

BACKGROUND AND AIMS: Belching is a common disorder with undetermined pathogenesis. With the combined multichannel intraluminal impedance pH monitoring, two different models of belching have been defined: gastric belching (GB) and supragastric belching (SB). The aim of this study was to assess whether SB was associated with air swallowing as compared with GB or healthy volunteers based on Rome III criteria. METHODS: Consecutive patients who presented with troublesome repetitive belching were recruited. Both upper endoscopy and multichannel intraluminal impedance pH monitoring were performed. Patients were divided into two groups: SB and GB groups according to the percentage of the predominant belching types. Twenty volunteers were enrolled as healthy controls. The number of air swallowing, regular swallowing, and gastroesophageal reflux profile was compared among the three groups. RESULTS: Thirty-seven patients were included in the study: 25 in the SB group and 12 in GB group. SB patients presented more belching events than GB patients (P < 0.05). There were no significant differences among the SB, GB patients, and healthy volunteers concerning the episodes of air swallowing and regular swallowing (P > 0.05). No significant difference was found among the three groups in regard with the reflux parameters (P > 0.05). The number of gas-containing reflux episodes were 33.0 (20.0, 48.0), 39.5 (29.5, 47.5), and 30.5 (27.0, 41.8) among SB, GB, and healthy volunteers (P = 0.383), respectively. CONCLUSIONS: SB patients presented with more belching events compared with GB patients. However, air swallowing and reflux profile were similar among the SB, GB patients, and normal controls.

Simple office-based behavioral approach to patients with chronic belching.

Chronic belching can be a difficult and socially disabling symptom often attributed to reflux with poor response to therapy. In patients where aerophagia is identified as a clear cause, treatment with baclofen may not be tolerated, and biofeedback therapy is time-intensive and may still not be effective. In this pilot study, an office-based easy-to-perform method based on sustained glottal opening was used in five patients with chronic belching, in whom reflux and other causes had been excluded. Treatment consisted of having the patient breathe slowly and diaphragmatically with his or her mouth open during supine, then sitting periods to prevent belching. When this was successful, patients were then counseled on continuing this breathing with mouth slightly ajar as an outpatient using this persistently. Wide mouth opening was used for rescue therapy of belching attacks. All five patients responded to the office-based therapy with complete cessation of belching during the visit. At 1-month follow up, four patients remained asymptomatic. One patient was asymptomatic but for two breakthrough attacks easily managed with the protocol. A simple office-based procedure based on complete glottal opening can be curative for a subset of patients with chronic eructation secondary to repetitive air swallowing.

Aerophagia in a toddler with gastric pull-up: an unusual combination precipitating severe respiratory distress.

Aerophagia is a common disorder in adults as well as children, which often goes unnoticed. In toddlers, it may lead to acute gastric dilatation, which, if severe enough, may lead to respiratory distress. We hereby report case of a child who had successfully undergone gastric pull-up approximately 18 months before and presented with gradually progressing dyspnea due to aerophagia from excessive crying. Expedient diagnosis from history, examination and x-ray study, and simple treatment by passage of feeding tube and gastric decompression relieved the distress and helped us overcome the acute crisis. Literature search revealed few cases of aerophagia after dissociative anesthesia. Management of aerophagia in children is discussed, and the importance of proper clinical diagnosis to prevent unnecessary interventions in an emergency scenario is highlighted.

Aerophagia among Sri Lankan schoolchildren: epidemiological patterns and symptom characteristics.

OBJECTIVE: Aerophagia is a functional gastrointestinal disorder characterised by repetitive air swallowing, abdominal distension, belching, and flatulence. In severe cases, it can lead to pneumoperitonium, volvulus of the colon, and intestinal perforation. Little is known about the epidemiology and clinical profile of affected children. The main objective of the present study was to assess the epidemiology of aerophagia in 10- to 16-year-olds in Sri Lanka. METHODS: A school-based cross-sectional survey was conducted in 8 randomly selected schools in 4 randomly selected provinces in Sri Lanka. Data were collected using a pretested, self-administered questionnaire, which was distributed in an examination setting and collected on the same day. Trained research assistants were present during completion of the questionnaire, for any required clarification. Aerophagia was diagnosed using the Rome III criteria. RESULTS: In the present study, aerophagia was seen in 163 (7.5%) of the 2163 children evaluated. The prevalence was higher in older children (10.5% in 15-year-olds) and no sex difference was observed (boys 8.2% vs girls 6.8%, P>0.05). Intestinal-related (abdominal pain, nausea, and anorexia) and extraintestinal symptoms (headache, limb pain, sleeping difficulty, photophobia, and lightheadedness) were more prevalent among affected children (P<0.05). A higher percentage of affected children were found to be exposed to stressful events when compared with controls (P<0.05). CONCLUSIONS: The present study highlights the high prevalence of aerophagia among Sri Lankan children and adolescents. This condition is more common in those exposed to emotional stress. Intestinal-related symptoms and extraintestinal somatic symptoms are frequently seen in affected children.

Signo y síndrome de Chilaiditi: entidades a tener en cuenta / Chilaiditi's sign and syndrome: conditions to be aware of

El signo de Chilaiditi fue descrito en 1910 por el radiólogo vienés Dimitrius Chilaiditi y consiste en la interposición de intestino entre el hígado y el hemidiafragma derecho. En la mayor parte de los casos se trata del ángulo hepático del colon. Se trata de un hallazgo radiológico, generalmente casual, sin que provoque en el paciente sintomatología alguna. Se define como síndrome de Chilaiditi a la asociación del signo radiológico con manifestaciones clínicas, que usualmente serán digestivas. Es importante que el médico sepa reconocer la imagen radiológica y realizar un correcto diagnóstico diferencial, así como conocer los síntomas que puede provocar el síndrome (AU)

Chilaiditi's sign was described in 1910 due to the radiology by Dimitrius Chilaiditi and consists of the overlapping of the intestine between the liver and the right diaphragm. In the majority of cases it involves the hepatic angle of the colon. It is a, generally, casual radiological finding without there being any patient symptomatology. Chilaiditi's syndrome is defined as the combination of the sign with other clinical manifestations, which are usually gastrointestinal. It is important that the physician knows how to recognise the radiological image and make the correct differential diagnosis, as well as knowing the symptoms that may trigger the syndrome (AU)

[Forty-four years of advances in pathogenesis, diagnosis and treatment of flatulence syndrome]. / 44 años de avances en etiopatogenia, diagnóstico y tratamiento del síndrome flatulencia.

In the present paper, the author reminds investigations performed, since forty-four years ago, to clarify the etiopathogenesis and to improve the diagnosis and treatment of the flatulence syndrome.

[Gastrointestinal syndromes (3): flatulence (1)]. / Grandes síndromes gastrointestinales (3): flatulencia (1).

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

[Autopsy case of abdominal compartment syndrome in a patient with schizophrenia].

A 61-year-old man who had taken several kinds of psychotropic agents for schizophrenia from eighteen was admitted due to acute abdomen. In spite of any treatment he died after arrival. The autopsy revealed marked dilation of gastrointestinal tracts without necrosis through stomach to rectum and pathological examination disclosed hypoganglionosis of whole gastrointestinal wall. We thought that he died of abdominal compartment syndrome as a result of acute on chronic secondary pseudo-obstruction of gastrointestinal tracts due to acquired hypoganglionosis, megacolon, and aerophagia.

[Bowel gases]. / A bélgázok jelentosége.

Abdominal bloating is one of the most common symptoms in patients with different gastrointestinal disorders. The majority of patients usually attribute this complaint to increased intestinal gas volume. Recent experimental studies using the gas challenge test help us to better understand the gas dynamics and tolerance in humans. Although there are some clinical conditions that are clearly related to impaired gas dynamics, the role of gases in functional gastrointestinal disorders especially in irritable bowel syndrome is much more complicated. Impaired gas handling, abnormal reflexes and visceral hypersensitivity seem to be the main factors resulting in abdominal bloating in this group of patients. Further clinical studies are needed to clarify the pathophysiologic mechanisms of intestinal gas and this may contribute to the evaluation of optimal therapy.