Inability to belch or “burp” (Also known as Retrograde Cricopharyngeus Dysfunction, or R-CPD for short) occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air.
What is R-CPD (Inability to burp, no-burp)?
People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. Common symptoms include the inability to belch, gurgling noises, chest/abdominal pressure and bloating, and flatulence.
The Top 4 Symptoms of R-CPD
Inability to burp
This is almost always, but not exclusively “lifelong,” often excluding infancy, since many with R-CPD did burp as infants. Most no-burpers can’t remember being conventionally able to burp and can also point to a time when they became aware of this as a “problem” or “difference from others” in childhood or teen years.
Some with R-CPD do burp occasionally but they are micro, random, not harnessable, and they don’t provide relief of the following symptoms.
Socially awkward gurgling noisesThese noises can be mostly quiet and “internal,” but more often are loud enough to be embarrassing. Mouth opening makes them louder. Almost everyone says they are easily heard several feet away; not infrequently “all the way to the door.” They engender social anxiety in most persons with R-CPD, causing some to avoid eating or drinking for hours before social occasions and even during them. Carbonation makes them much worse and is to be avoided at all costs. Some more colorful patient descriptions:
- Symphony of gurgles
- Croaking frogs
- Creaking floorboards
- Dinosaur sounds
- Strangled whale
- The Exorcist
Audio examples of gurgling
Bloating & PressureMost common location is high central abdomen. Distention is common, especially later in the day. Using pregnancy as an analogy even in men, the usual degree of distention is described as “3 or 4 months.” “Six months” is not rare, and one slender young man was “full term.” Almost as often as abdominal distress, patients describe chest pressure, and for some that is the worst symptom. Some have pressure in the low neck. While “pressure” is the frequent descriptor, some experience occasional sharp pain in abdomen, back, or between shoulder blades. Some have to lie down after eating to find some relief.
Common Questions about R-CPD
Dr. Bastian responds to a list of questions submitted through YouTube, Facebook, and Instagram.
FlatulenceRoutinely, this is described as “major,” or even “ridiculous.” Flatulence increases as the day progresses, and many experience it into the night. When around others, some scan their surroundings at all times for a place they can go briefly to pass gas. Understandably, the social ramifications of this problem can also be major.
Less Common Symptoms of R-CPD
Nauseaespecially after eating larger than normal amounts or drinking carbonated beverages.
Hypersalivationwhen symptoms of bloating are major.
Painful Hiccupsagain, more commonly after eating.
Anxiety & social inhibition
This can be MAJOR due to gurgling, flatulence, and discomfort.
Shortness of breathA person can be so full of air that athletics—or even the ability to climb stairs—are impaired.
(Still under evaluation): Flatulence can’t always be responded to, and the result is descending colon appears to dilate, making stretched muscles in its wall less effective in moving colon contents along.
Inability to Vomit
A few simply cannot vomit; more often it is possible but only after strenuous retching. Vomiting (spontaneous or self-induced) always begins with a very loud noise and major release of air in a phenomenon we call “air vomiting.” Emetophobia can be major.
What Causes R-CPD?
Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple,” directly behind the cricoid cartilage.
If you care to see this on a model, look at the photos to the right. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching.
People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus and is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. The person so wants and needs to burp, but can’t. Sometimes this can even be painful. Such people often experience abdominal bloating as the air must make its way through the intestines before finally being released as flatulence.
Treatment for R-CPD
Botox Injection at Bastian Voice Institute
For people who experience this problem to the point of discomfort and reduced quality of life, here is one approach: First, a videofluoroscopic swallow study, perhaps with effervescent granules. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this establishes the diagnosis of retrograde-only cricopharyngeus dysfunction (non-relaxation).
Second, a treatment trial involving placement of Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized. The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem.
Lifting the CPM for a R-CPD Injection
These are intra-operative photos of one of nearly 1500 persons treated for R-CPD as of September 2023. This sequence shows several things: The dilated, “always open” esophagus distal (below) the muscle; how to identify the cricopharyngeus muscle; and one way of injecting it.
What to Expect Post Botox Procedure?
Review Dr. Bastian’s published Journal entry for a complete explanation, but in a nutshell:
- There will be no relief of R-CPD symptoms for 1—5 days.
- Only when micro-burps begin do patients start to notice the beginning of symptom relief. So do not try carbonation for lunch on the day of the injection!
- Initial Botox side effects can be “weird” for a few days to weeks.
- If you can manipulate your gurgles prior to Botox treatment, to make them softer or louder, use that technique to see if you can hurry burps along or make them bigger.
For a few months at least, patients should experience dramatic relief of their symptoms. And, early experience suggests that it may be that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to belch. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or in a truly severe case, might even elect to undergo endoscopic laser cricopharyngeus myotomy.
Complications Compared to Expected Effects in Treatment of R-CPD
In this video, Dr. Bastian distinguishes the difference between early EFFECTS that are expected, and COMPLICATIONS patients have experienced in a caseload of approximately 870 people. This informal discussion will likely reassure persons considering this treatment for the severe daily misery caused by R-CPD.
What Is the Best Botox Dose for R-CPD? 100 units? 50? 200?
Newly diagnosed R-CPD patients often ask: “What is the best dose for the initial injection of Botox?” Dr. Bastian provides an answer that includes context and nuance from his group’s experience with over 1200 patients injected to date.
Do Shaker Exercises Work in Treating R-CPD?
In this video, Dr. Bastian explains his thinking about “Shaker Exercises” as a means of learning to burp in persons with R-CPD (no-burp). A recent Reddit thread was created in response to his July 2022 Webinar comments on this subject, and it appeared to him that he had not conveyed his thinking clearly enough. Here is his more detailed and nuanced discussion…
Where Our R-CPD Patients Come From
Photo Essays from our R-CPD Patients
Abdominal Distention of R-CPD
The Daily Inflation-Deflation Cycle for R-CPD
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.
Abdominal Distention Caused by R-CPD
This sixty-something man has endured the misery of R-CPD all of his life. His symptoms of inability to burp, gurgling, bloating, flatulence (and more) are dramatically relieved after botulinum toxin into his cricopharyngeus muscle (upper esophageal sphincter). Here, we see the before and after difference in his abdominal distension as well.
A Rare “abdominal crisis” Due to R-CPD (inability to burp)
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.
Shortness of Breath Caused by No-Burp
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.
Esophageal Stretching by Unburpable Air in R-CPD
This young man has had the classic syndrome of R-CPD lifelong. His esophageal findings at the end of a videoendoscopic swallow study are classic. The esophagus is mostly a collapsed muscular tube in young people, yet his esophagus is widely open on a continuous basis due swallowed air that he cannot burp up.
More Interesting Esophageal Findings of R-CPD (Inability to Burp)
R-CPD and Esophageal Dilation
What the Esophagus Can Look Like “Below A Burp”
Additional R-CPD Resources
Dr. Bastian’s Published Articles
Dr. Bastian’s Initial Article about R-CPD
Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment
March 15, 2019
Partial Cricopharyngeal Myotomy for Treatment of Retrograde Cricopharyngeal Dysfunction
April 16, 2020
The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction
June 29, 2020
Efficacy and Safety of Electromyography-Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction
February 2, 2021
Retrograde Cricopharyngeus Dysfunction: An Orphan Disease?
More R-CPD Videos
A live R-CPD (no-burp) Webinar hosted by Dr. Bastian on July 26, 2022 at 6 p.m. CST
Dr. Bastian answers a list of questions submitted by our R-CPD Webinar attendees.
In Part 2 of the R-CPD Q&A, Dr. Bastian answers more questions submitted by our webinar attendees.
A panel of expert discussion on R-CPD (aka “No-Burp Syndrome”) featuring questions and answers from leaders in the field.
What Surprises No-burpers about People who Can BurpHere are a few things that surprise people who can’t burp, about people who can! (This is especially for those with R-CPD aka no-burp).
RCPD Workup – Do You Need Testing for a Diagnosis?
What is necessary to diagnose R-CPD? What is sufficient? Do we need to spend thousands of dollars for x-rays, manometry, upper GI scopes, gastric emptying studies?
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Robert W. Bastian, M.D. — Published: July 1, 2021 The big picture Babies who cannot burp are in terrible misery. So are their parents. While the child struggles with daily colic, spitting up, sometimes projectile vomiting, and gassiness, the parents
Robert W. Bastian, M.D. — Published: January 26, 2023 Background of R-CPD R-CPD causes 4 primary symptoms: inability to belch, gurgling noises, bloating, and flatulence. Less universal symptoms include painful hiccups, nausea after large meals, shortness of breath when very
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