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Table of Contents
1.1 | R-CPD Webinar
1.2 | The Big 4 Symptoms
1.3 | Other Common Symptoms
6.1 | Dr. Bastian’s Published Articles
6.2 | See Us In The News
6.3 | Community Created Content
6.4 | Additional Entries
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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.
Overview of R-CPD
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.
A panel of expert discussion on Retrograde Cricopharyngeal Dysfunction (RCPD AKA “No Burp Syndrome”) featuring questions and answers from leaders in the field.
R-CPD (no-burp) Webinar
Live R-CPD (no-burp) Webinar hosted by Dr. Bastian on July 26, 2022 at 6 p.m. CST
R-CPD Q&A—Part I
Dr. Bastian answers a list of questions submitted by our R-CPD Webinar attendees.
R-CPD Q&A—Part II
In Part 2 of the R-CPD Q&A, Dr. Bastian answers a list of questions submitted by our R-CPD Webinar attendees.
Symptoms of R-CPD
The Big Four Symptoms Of R-CPD That Provide Virtually 100% Accuracy In Diagnosis
Inability to burp
This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years.
Socially awkward gurgling noises
This is almost always, but not exclusively “lifelong,” though persons may not recognize this as a “problem” or “difference from others” until early childhood or teenage years. These 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.
Bloating & Pressure
Most 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.
Routinely, 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.
Other Common Symptoms
especially after eating larger than normal amounts or drinking carbonated beverages.
when symptoms of bloating are major.
again, more commonly after eating.
Anxiety & social inhibition
This can be MAJOR due to gurgling, flatulence, and discomfort.
Shortness of breath
A person can be so full of air that athletics, or even ability to climb stairs, etc. 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.
Where Do Patients Come From?
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 photo below. 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 flatus.
How to Treat 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.
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.
Abdominal Distention of R-CPD
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.
A Rare “abdominal crisis” Due to R-CPD (inability to burp)
Shortness of Breath Caused by No-Burp (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.
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.
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.
More Interesting Esophageal Findings of R-CPD (Inability to Burp)
R-CPD and Esophageal Dilation
What the Esophagus Can Look Like “Below A Burp”
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
Read more →
March 15, 2019
Partial Cricopharyngeal Myotomy for Treatment of Retrograde Cricopharyngeal Dysfunction Read More →
April 16, 2020
The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction Read More →
June 29, 2020
Efficacy and Safety of Electromyography-Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction Read More →
February 2, 2021
Retrograde Cricopharyngeus Dysfunction: An Orphan Disease? Read More →
See Us In The News
Community Created Content
Check out our entries on R-CPD
Retrograde Cricopharyngeus Dysfunction (R-CPD)
A brief overview of the inability to burp, major symptoms, and treatment options.
Detailed explanation of R-CPD with an in-depth analysis of how to approach treatment options.
The explanation for why some babies can’t burp may be found in the story of adults who had this kind of trouble in their infancy...
The esophagus is typically collapsed around endoscopes inserted into them and air is pumped in through a tiny channel...
Bloating is often accompanied by actual abdominal distention due to excess air in both stomach and intestines.