A Journal of Observational Laryngology

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Can’t Burp? Here Are the Symptoms of R-CPD

Robert W. Bastian M.D.

There is a group of people whose inability to burp causes severe daily distress. They are left without a solution (or even explanation) in spite of many doctor visits. Recently a major cause of inability to burp, retrograde cricopharyngeus dysfunction (R-CPD) has been codified for diagnosis and treatment.*

*A constellation of key symptoms powerfully “makes” the initial diagnosis. Patients can often “make” the tentative diagnosis by matching themselves to this clear syndrome of R-CPD.

THE BIG FOUR SYMPTOMS OF R-CPD THAT PROVIDE VIRTUALLY 100% ACCURACY IN DIAGNOSIS

  1. 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.
  2. Socially awkward gurgling noises. 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
  3. 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.
  4. Flatulence. 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.

COMMON BUT LESS UNIVERSAL R-CPD SYMPTOMS OR EFFECTS

  1. Nausea, especially after eating larger than normal amounts or drinking carbonated beverages.
  2. Painful hiccups, again more commonly after eating.
  3. Shortness of breath. A person can be so full of air that athletics, or even ability to climb stairs, etc. are impaired.
  4. Hypersalivation when symptoms of bloating are major.
  5. 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.
  6. Anxiety and social inhibition. This can be MAJOR due to gurgling, flatulence, and discomfort.
  7. (Still under evaluation): The question is whether the descending colon dilates over time if flatulence cannot be responded to, so that muscular effectiveness is diminished.

Check out our list of resources containing peer-reviewed articles, patient stories and more!

 

Abdominal Distention of R-CPD: Series of 3 photos

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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.

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.

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.

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).

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 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. 

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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.”

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

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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

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

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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

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.

Dramatic Lateral Dilation of the Upper Esophagus: Series of 3 photos

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(1 of 3)

This photo is at the level of (estimated) C6 of the spine (at S). This person has known cervical arthritis, accounting for the prominence. Opposite the spine is the trachea (T). Note the remarkable lateral dilation (arrows) in this picture obtained with with no insufflated air using a 3.6mm ENF-VQ scope. It is the patient’s own air keeping the esophagus open for viewing.

(2 of 3)

At a moment when air from below further dilates the upper esophagus, the tracheal outline is particularly well-seen (T) opposite the spine (S). The “width” of the trachea indicated further emphasizes the degree of lateral dilation, which is necessary because spine and trachea resist anteroposterior dilation.

(3 of 3)

Just for interest, at mid-esophagus, the familiar aortic “shelf” is seen. Again, this esophagus is being viewed with a 3.6 mm scope with only the patient own (un-burped) air allowing this view.

What the Esophagus Can Look Like “Below A Burp”: Series of 3 photos

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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.

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.

 

Where have patients traveled from?

 

R-CPD patients BVI treated across the USA

World Map of RCPD Patients

6 thoughts on “Can’t Burp? Here Are the Symptoms of R-CPD

  1. This IS real. I have had this my entire life. My mother always said that of her 6 children I am the only one who never spit up as a baby. Early in my career as a speech pathologist I was involved in dysphagia research with GI. The GI was looking for patients with these exact symptoms to study – I knew I fit the group, but did not want to be one of the subjects so kept this to myself. When I have the stomach flu, and when I was pregnant, I was able to eventually vomit, but the pressure was so great that “projectile” does not describe what occurred. It was very painful, loud and distressing. I believe that learning about foods that can contribute to IBS can help with the bloating, pressure and flatulence. I used the low FODMOP diet to determine foods that I am more sensitive to. By eliminating them, I have reduced these symptoms, although it’s certainly not perfect. I have never liked carbonated drinks because of the inability to burp, although I think I can tolerate this a little better as I have gotten older…maybe things are stretching or less rigid/tight than when I was younger. I still cannot burp volitionally or in response to air in the upper GI tract.

  2. Can someone please, please tell me where we can find help with this in the Jacksonville FL area? My husband has been trying for months and months and no-one seems to be able to figure out what is wrong. He has had at least 3 upper and lower GI procedures done, MRI and CAT scans and they just keep pushing him off. He is miserable ever time he eats which in turns make the entire family that way. I am desperate to find him help.

  3. I have suffered with these exact symptoms all my life and have simply been told it’s IBS and GERD or other. I have never been able to burp, I’ve always had gargling like a frog in the throat and my bloating is excessive. I describe it as me looking 6 months pregnant. Again this I have suffered with all my life too. I have other symptoms, pain, pressure, inability to vomit unless extremely ill and when I have it would be painful and violent and nausea. I couldn’t believe how much I could relate to this condition. I am now trying to find someone who can diagnose in the U.K. preferably West Country. Why these conditions aren’t more widely studied is unknown but I’m determined to get a diagnosis and spread the word.

  4. I’ve had emetaphobia all my life. Most likely because my stomach ALWAYS feels sick.
    I can barely go out in public now , at age 44. Things have only gotten worse.
    I can count the amount of times I’ve burped in my whole left on one hand.
    My stomach gets incredibly sick. I also have a hiatal hernia and wonder if that adds to how severe this is…
    I make those loud awful gurgly noises and those make me feel even worse.
    The only relief I get can be hours later when the gas has moved down and out of my stomach . Or when I vomit/if I can.
    I have to wear flatulence filtering underwear it’s so bad.
    I can barely eat and ONLY feel good if I HAVNT eaten in a long time.
    When I vomit I do make that incredibly LOUD long belch .. and it truly is like I’m vomiting air until the air is all gone..
    The only way I can feel better is laying flat on my back. But I have three kids and can’t run to lay flat on my back everytime I need to (that’s a lot of time.)
    I find myself in the back seat of our mini van a lot more over the past few years coz I can lay down and have more privacy there… the kids are fine with it they get the front seat lol
    I get sick often out in public.. or feel like I’m going to vomit.. I rarely go out anymore.. I’ve been stuck in public bathrooms so much.. for hours.. even a banks bathroom for over 2 hours being sick…
    the bloating is ridiculous.. I have been pregnant 3 times and this bloating looks exactly like a pregnancy would. And it feels the same too. Like I can’t get a full breath of air in.. it’s awful.

    I think I’ve been going through hormonal changes over the past few years which has caused me to become even more ill .. and my stomach is like a volcano ready to explode at all times.. I’m miserable…….

  5. I am a Japanese medical student, at age 24.
    I have never burped in my entire life. I feel discomfort in my chest and abdomen with hiccups after drinking carbonated drinks.
    After I have eaten a lot, or have been stressed and have taken a lot of air, I make a froggy sound in my throat. I guess it’s not the same as burping, that sound never makes me feel any better. In a quiet room, such as during exams, I am always worried that others will hear this sound.
    I have already had an upper gastrointestinal endoscopy and have been diagnosed with GERD and Barrett’s esophagus.
    I would also like to see a specialist for treatment, but R-CPD is probably not even known in Japan. I could not find any doctors or hospitals that mentioned R-CPD in my country. I would like to help the people who are in the same trouble.

  6. after looking into this this I feel the exact same. i have never had something explain how i feel so well. i have always gotten looked at like im insane.

    doctor in chicago has come out with a fix for some temporary fix for others

    but it is not covered my health insurance.

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