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 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.

Abdominal Distention of R-CPD: Series of 3 photos

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. 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.”

Bloated Abdomen (2 of 3)
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.

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

(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.