PUEDES TENER

R-CPD

La incapacidad para eructar o «eructar» (también conocida como disfunción cricofaríngea retrógrada o R-CPD para abreviar) ocurre cuando el esfínter esofágico superior (músculo cricofaríngeo) pierde su capacidad de relajarse para liberar la «burbuja» de aire.

Descripción general de R-CPD

Reproducir video acerca de Can't burp

Las personas que no pueden liberar aire hacia arriba son miserables. Pueden sentir la «burbuja» asentada en la parte media y baja del cuello sin ningún lugar a donde ir. O experimentan gorgoteos cuando el aire sube por el esófago y descubren que la vía de escape está bloqueada por un esfínter que no se relaja. Es como si el músculo del esófago se agitara y apretara continuamente sin éxito. Los síntomas comunes incluyen la incapacidad para eructar, ruidos de gorgoteo, presión e hinchazón en el pecho/abdomen, y flatulencia.

Síntomas de R-CPD

Los cuatro grandes síntomas de R-CPD que brindan prácticamente un 100 % de precisión en el diagnóstico

Incapacidad para eructar

Esto es casi siempre, pero no exclusivamente, “de por vida”, aunque es posible que las personas no lo reconozcan como un “problema” o una “diferencia con los demás” hasta la primera infancia o la adolescencia.

Reproducir vídeo
R-CPD frog icon

Ruidos de gorgoteo socialmente incómodos

Esto es casi siempre, pero no exclusivamente, “de por vida”, aunque es posible que las personas no lo reconozcan como un “problema” o una “diferencia con los demás” hasta la primera infancia o la adolescencia. Estos ruidos pueden ser en su mayoría silenciosos e «internos», pero con mayor frecuencia son lo suficientemente fuertes como para ser vergonzosos. La apertura de la boca los hace más ruidosos. Casi todos dicen que se les escucha fácilmente a varios metros de distancia; no pocas veces “hasta la puerta”. Engendran ansiedad social en la mayoría de las personas con R-CPD, lo que hace que algunas eviten comer o beber horas antes de las ocasiones sociales e incluso durante ellas. La carbonatación los empeora mucho y debe evitarse a toda costa. Algunas descripciones de pacientes más coloridas:

  • Sinfonía de gorgoteos
  • Ranas croando
  • Tablas del suelo que crujen
  • Sonidos de dinosaurios
  • Ballena estrangulada.
R-CPD Bloating icon

Hinchazón y Presión

La localización más frecuente es el abdomen central alto. La distensión es común, especialmente más tarde en el día. Usando el embarazo como una analogía incluso en los hombres, el grado habitual de distensión se describe como «3 o 4 meses». “Seis meses” no es raro, y un joven delgado estaba “a término”. Casi tan a menudo como el malestar abdominal, los pacientes describen presión en el pecho y, para algunos, ese es el peor síntoma. Algunos tienen presión en la parte baja del cuello. Si bien “presión” es el descriptor frecuente, algunos experimentan dolor agudo ocasional en el abdomen, la espalda o entre los omóplatos. Algunos tienen que acostarse después de comer para encontrar algo de alivio.

R-CPD Flatulence leaf blower icon

Flatulencia

Rutinariamente, esto se describe como «importante» o incluso «ridículo». La flatulencia aumenta a medida que avanza el día y muchos la experimentan durante la noche. Cuando están cerca de otros, algunos escanean su entorno en todo momento en busca de un lugar al que puedan ir brevemente para expulsar gases. Comprensiblemente, las ramificaciones sociales de este problema también pueden ser importantes.

Reproducir vídeo

Otros síntomas comunes

Náuseas

especialmente después de comer cantidades más grandes de lo normal o beber bebidas carbonatadas.

hipersalivación

cuando los síntomas de hinchazón son mayores.

Hipo Doloroso​

de nuevo, más comúnmente después de comer.

Reproducir vídeo

Incapacidad para vomitar

Algunos simplemente no pueden vomitar; más a menudo es posible, pero sólo después de arcadas extenuantes. Los vómitos (espontáneos o autoinducidos) siempre comienzan con un ruido muy fuerte y una gran liberación de aire en un fenómeno que llamamos “vómitos de aire”. La emetofobia puede ser importante.

Ansiedad e inhibición social

Esto puede ser IMPORTANTE debido al gorgoteo, la flatulencia y la incomodidad.

Dificultad para respirar

Una persona puede estar tan llena de aire que el atletismo, o incluso la capacidad para subir escaleras, etc., se vean afectadas.

constipación

(Aún en evaluación): no siempre se puede responder a la flatulencia, y el resultado es que el colon descendente parece dilatarse, lo que hace que los músculos estirados en su pared sean menos efectivos para mover el contenido del colon.

¿De dónde vienen las pacientes?

0
No-burpers turned burpers!

¿Qué Causa la R-CPD?

La incapacidad para eructar o eructar ocurre cuando el esfínter esofágico superior (músculo cricofaríngeo) no puede relajarse para liberar la «burbuja» de aire. El esfínter es una válvula muscular que rodea el extremo superior del esófago justo debajo del extremo inferior del conducto de la garganta. Si mira de frente el cuello de una persona, está justo debajo de la “nuez de Adán/Eva”, directamente detrás del cartílago cricoides.

Si desea ver esto en un modelo, mire la foto a continuación. Ese músculo del esfínter se relaja durante aproximadamente un segundo cada vez que tragamos saliva, comida o bebida. Todo el resto del tiempo se contrata. Siempre que una persona eructa, el mismo esfínter necesita soltarse durante una fracción de segundo para que el exceso de aire escape hacia arriba. En otras palabras, así como es necesario que el esfínter se “suelte” para admitir alimentos y bebidas hacia abajo en el acto normal de la deglución, también es necesario que el esfínter pueda “soltarse” para dejar salir el aire hacia arriba para eructar.

Las personas que no pueden liberar aire hacia arriba son miserables. Pueden sentir la «burbuja» asentada en la parte media y baja del cuello sin ningún lugar adonde ir. O experimentan gorgoteos cuando el aire sube por el esófago y es bloqueado por un esfínter que no se relaja. Es como si el músculo del esófago se agitara y apretara continuamente sin éxito. La persona quiere y necesita eructar, pero no puede. A veces esto puede incluso ser doloroso. Estas personas a menudo experimentan distensión abdominal ya que el aire debe atravesar los intestinos antes de ser finalmente liberado en forma de flatos.

¿Cómo tratar la R-CPD?

Inyección de Botox en Bastian Voice Institute

Para las personas que experimentan este problema hasta el punto de la incomodidad y la reducción de la calidad de vida, aquí hay un enfoque: primero, un estudio videofluoroscópico de deglución, quizás con gránulos efervescentes. Esto establece que el esfínter funciona normalmente en una dirección de deglución hacia adelante (anterógrada), pero no en una dirección de eructo o regurgitación inversa (retrógrada). Junto con los síntomas descritos anteriormente, esto establece el diagnóstico de disfunción cricofaríngea retrógrada solamente (falta de relajación).

En segundo lugar, una prueba de tratamiento que involucra la colocación de Botox en el músculo del esfínter que funciona mal. El efecto deseado del Botox en el músculo es debilitarlo durante al menos varios meses. La persona tiene así muchas semanas para comprobar que el problema se soluciona o al menos se minimiza. La inyección de Botox podría potencialmente realizarse en un consultorio, pero recomendamos la primera vez (al menos) colocarla durante una breve anestesia general en un quirófano ambulatorio. Eso es porque la primera vez, es importante responder a la pregunta de manera definitiva, es decir, que el problema es la incapacidad del esfínter para relajarse cuando se le presenta una burbuja de aire desde abajo.

Al menos durante unos meses, los pacientes deberían experimentar un alivio espectacular de sus síntomas. Y, la experiencia temprana sugiere que puede ser que esta sola inyección de Botox permita que el sistema se «reinicie» y que la persona nunca pierda su capacidad de eructar. Por supuesto, si el problema reaparece, la persona podría optar por seguir tratamientos adicionales con Botox o, en un caso realmente grave, incluso podría optar por someterse a una miotomía cricofaríngea con láser endoscópica.

Reproducir vídeo

Ensayos Fotográficos (en inglés)

Abdominal Distention of R-CPD

Visual Portfolio, Posts & Image Gallery para WordPress

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.

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.

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.

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.

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.

Visual Portfolio, Posts & Image Gallery para WordPress

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.

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.

Mild distension (2 of 6)

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

Mild distension (2 of 6)

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

Front view (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 (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.

Another view (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.

Another view (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).

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.

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.

A Rare “abdominal crisis” Due to R-CPD (inability to burp)

Visual Portfolio, Posts & Image Gallery para WordPress

X-Ray of Abdominal Bloating (1 of 2)

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. 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.

X-Ray of Abdominal Bloating (1 of 2)

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. 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.

X-Ray of Abdominal Bloating (2 of 2)

X-Ray without markings
Reproducir video acerca de R-CPD in X-ray Pictures: Misery vs. Crisis from Inability to Burp

Shortness of Breath Caused by No-Burp (R-CPD)

Las personas que no pueden eructar y tienen el síndrome R-CPD completo a menudo dicen que cuando la hinchazón y la distensión son particularmente malas, y especialmente cuando tienen una sensación de presión en el pecho, también tienen una sensación de falta de aire. Dirán, por ejemplo, “Soy un [cantante, o corredor, o ciclista o _____], pero mi habilidad está muy disminuida por R-CPD. Si estoy compitiendo o actuando, no puedo comer ni beber durante las 6 horas anteriores”. Algunos incluso dicen que no pueden completar un bostezo cuando los síntomas son particularmente graves. Las radiografías a continuación explican cómo la incapacidad para eructar puede causar dificultad para respirar.

Visual Portfolio, Posts & Image Gallery para WordPress

X-ray of trapped air (1 of 2)

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

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)

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.

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.”

Esophageal Findings

Visual Portfolio, Posts & Image Gallery para WordPress

Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

Visual Portfolio, Posts & Image Gallery para WordPress

Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

R-CPD and Esophageal Dilation

Visual Portfolio, Posts & Image Gallery para WordPress

Posterior pharyngeal wall (1 of 3)

Here, in the panoramic view of the "bottom of the throat," between posterior pharyngeal wall (marked PPW) and arytenoid eminences (A). The airway is indicated by the short arrow, and the dotted line shows the waiting "entrance" to the upper esophagus just above the CPM. The "entrance" opens for a second to permit passage of food or liquid through the sphincter and into the upper esophagus. The * is for reference with photo 2.

Posterior pharyngeal wall (1 of 3)

Here, in the panoramic view of the "bottom of the throat," between posterior pharyngeal wall (marked PPW) and arytenoid eminences (A). The airway is indicated by the short arrow, and the dotted line shows the waiting "entrance" to the upper esophagus just above the CPM. The "entrance" opens for a second to permit passage of food or liquid through the sphincter and into the upper esophagus. The * is for reference with photo 2.

Is it R-CPD? (2 of 3)

At the entrance to the esophagus, at closer range. Notice that the mucosa is redundant, a common but not universal finding in R-CPD.

Is it R-CPD? (2 of 3)

At the entrance to the esophagus, at closer range. Notice that the mucosa is redundant, a common but not universal finding in R-CPD.

Stretched esophagus indicates R-CPD (3 of 3)

Now the view is within the upper esophagus. It almost appears that the lumen is dilated, especially in a lateral direction (arrows). Purely speculatively, one wonders if constant forcing of air upwards again a barrier ( the non-relaxing cricopharynxgeus muscle, aka upper esophageal sphincter), dilates the esophagus over time. Certainly, many with R-CPD experience not only gurgling, but also chest pressure and even pain that may be from "stretching" of the esophagus.

Stretched esophagus indicates R-CPD (3 of 3)

Now the view is within the upper esophagus. It almost appears that the lumen is dilated, especially in a lateral direction (arrows). Purely speculatively, one wonders if constant forcing of air upwards again a barrier ( the non-relaxing cricopharynxgeus muscle, aka upper esophageal sphincter), dilates the esophagus over time. Certainly, many with R-CPD experience not only gurgling, but also chest pressure and even pain that may be from "stretching" of the esophagus.

What the Esophagus Can Look Like “Below A Burp”

Visual Portfolio, Posts & Image Gallery para WordPress

Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Recursos Adicionales

Véanos en Las Noticias
Contenido Creado por la Comunidad
Subscribe
Notify of

0 Comments
Inline Feedbacks
View all comments