Abdominal Distention (Crisis) of R-CPD Including Before and After Botox Injection

One of the primary symptoms of R-CPD (inability to burp) is bloating. Bloating is often accompanied by actual abdominal distention due to excess air in both stomach and intestines. Since the person is unable to burp, air must now pass through the entire GI tract and be dispelled as flatulence.

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

A Rare “abdominal crisis” Due to R-CPD

This young man had an abdominal crisis related to R-CPD. He has had lifelong symptoms of classic R-CPD: inability to burp, gurgling, bloating, and flatulence. During a time of particular discomfort, he unfortunately took a “remedy” that was carbonated. Here you see a massive stomach air bubble. A lot of his intestines are air-filled and pressed up and to his right (left of photo, at arrow). The internal pressure within his abdomen also shut off his ability to pass gas.

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X-Ray of Abdominal Bloating (1 of 2)

Note arrow pointing to lack of gas in the descending colon/rectum. NG decompression of his stomach allowed him to resume passing gas, returning him to his baseline “daily misery” of R-CPD.

Original X-Ray (2 of 2)

X-Ray without markings

Abdominal Distention Caused by R-CPD

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Bloating and abdominal distention before botox injection for inability to burp (1 of 2)

Late-day abdominal distension caused by inability to burp. The discomfort of R-CPD may cause hypersalivation and extra reflexive swallowing, which only adds to the air in his GI tract. He is athletic; the distension represents air in stomach and intestines that could not be burped—not excess weight.

Resolved, one month after botox, with burping restored (2 of 2)

Within the first month after botulinum toxin injection, he no longer feels bloated and his stomach does not distend at the end of the day. Body weight is the same in both photos.

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Front view (2 of 6)

Also early in the day, a front view, showing again mild distention.

Greater Distention (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Front view of bloating stomach (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

Shortness of Breath Caused by R-CPD

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath.

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

The Daily Inflation-Deflation Cycle for R-CPD

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Deflated Abdomen (1 of 4)

Lateral (side) view of abdomen of a person with R-CPD in the morning, before eating or drinking anything. Flatulence late evening and through the night has “deflated” the abdomen.

Bloated lateral view (2 of 4)

Side view of the same person, in the afternoon: bloating and abdominal distention by air has occurred. Compare with photo 1.

Deflated abdomen (3 of 4)

Frontal view again in the morning with abdomen “deflated.”

R-CPD distention (4 of 4)

Frontal view in the afternoon, showing distention by air. Compare with photo 2.

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R-CPD in X-ray Pictures: Misery vs. Crisis from Inability to Burp
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R-CPD in X-ray Images | Misery vs. Crisis from Inability to Burp

Why do persons with R-CPD experience such daily misery? These X-ray images provide the explanation, as well as the rare “abdominal crisis” in this group is also explained.

In a new video format, Dr. Bastian will discuss various photo essays found across Laryngopedia, and provide in-depth descriptions on their origins and what is going on behind the scenes during the time of capture.