Supragastric belching and rumination syndrome: diagnosis and management

Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination. Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11]. The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events. Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination. Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11].The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.Purpose of reviewThis review article aims to discuss the clinical presentation and diagnosis of rumination syndrome and supragastric belching, as well as treatment options for both diseases.Functional gastrointestinal disorders such as rumination syndrome and supragastric belching may be effectively treated using biofeedback.A comprehensive approach that includes potential pharmacologic treatments, cognitive behavioral therapy and biofeedback should also be considered for optimal management of supragastric belching and rumination.Papers of particular interest, published within the annual period of review, have been highlighted as:Both rumination syndrome and supragastric belching are considered functional gastrointestinal disorders (FGIDs), a class of diseases encompassing a wide range of conditions, including irritable bowel syndrome, hypersensitive esophagus, functional nausea and vomiting, and functional dyspepsia [1]. Also known as disorders of gut-brain interaction, the recognition of FGIDs as a class of diseases has only emerged in recent decades. FGIDs are defined by the Rome criteria (theromefoundation.org), which describes diagnoses based on clusters of symptoms rather than physiologic or anatomic criteria [2]. Rumination and supragastric belching are grouped within the gastroduodenal domain of FGIDs by the Rome IV criteria.Some clinicians consider supragastric belching and rumination syndrome a behavioral response to abdominal pain or other gastrointestinal discomfort [3]. As the response is performed repeatedly over time, it becomes automatic, with the patient losing voluntary control of the behavior [4]. Some studies suggest an underlying psychological cause given the absence of the behavior when the patient is distracted, asleep, or during speech tasks [4-6]. Regardless of origin, a diagnosis of rumination syndrome and supragastric belching can significantly decrease a patient's quality of life [7,8].This review discusses the clinical presentation and diagnosis of rumination syndrome and supragastric belching and treatment options for both conditions. no caption availablePatients with rumination syndrome present with recurrent, effortless regurgitation of recently ingested gastric contents that is not preceded by nausea [9]. Regurgitated material is then either re-swallowed or spit out. The clinical presentation of rumination syndrome may lead to misdiagnosis of gastroesophageal reflux or gastroparesis before arriving at a diagnosis of rumination syndrome.Rumination events are caused by the contraction of the abdominal muscles, which increases gastric pressure until this pressure overcomes that of the lower esophageal sphincter, resulting in reflux of gastric contents into the esophagus. The upper esophageal sphincter relaxes, and gastric contents flow into the mouth [10]. The underlying mechanism leading to rumination events was elucidated in an electromyography (EMG) study by Barba et al. in which all patients showed a characteristic sudden increase in activity of the intercostal muscles and abdominal wall muscles immediately before rumination events [11]. The diagnosis of rumination syndrome, as defined by Rome IV criteria, is made if a patient exhibits at least 6 months of recurrent regurgitation into the mouth that is not preceded by nausea or retching [2]. While diagnosis can be made on clinical presentation alone, it may be supported by high-resolution esophageal manometry (HRM), which will show gastric strain preceding rumination events (Fig. 1). A study by Kessing et al. compared esophageal HRM in patients with rumination syndrome to that of patients with gastroesophageal reflux and found that patients with rumination syndrome - unlike those with gastroesophageal reflux - had peak gastric pressures exceeding 30mmHg before reflux events [10]. Esophageal pH testing in the evaluation of rumination syndrome is less helpful, as the reflux of rumination syndrome is a consequence rather than a cause of the disease itself [12].High-resolution esophageal manometry showing gastric strain preceding rumination events. Rumination syndrome can be diagnosed when abdominal pressure exceeds 30 mmHg, resulting in reflux events extending to the proximal esophagus.The Rome IV classification system describes supragastric belching as bothersome belching from the esophagus that occurs more than 3 days per week for at least six months (theromefoundation.org). Most gastric belching is physiologic and serves as a venting mechanism to relieve gaseous pressure from the stomach [13]. Supragastric belching differs from gastric belching in that air is forced into the esophagus and expelled via abdominal straining. Two mechanisms of supragastric belching have been identified. Air may be pushed into the esophagus via pharyngeal contraction or sucked into the esophagus through a decrease in intrathoracic pressure [14,15]. After the entry of air into the esophagus, the engagement of the abdominal musculature creates an increase in intra-abdominal and intrathoracic pressure, causing the air to be expelled from the esophagus as a belch.A 2004 study by Bredenoord et al. demonstrated the difference between gastric and supragastric belching using impedance and manometry in otherwise healthy patients who complained of excess belching [15]. Patients with excess belching swallowed the same amount of air and had similar gastric bubble size on radiographic imaging as control subjects. Supragastric belching was only observed in patients with excess belching, and manometry did not show lower esophageal sphincter relaxation during supragastric belches suggesting that supragastric belching does not involve air entry into the stomach. Furthermore, Kessing et al. identified increased esophagogastric junction pressure during supragastric belching onset with a simultaneous downward contraction of the diaphragm [16].Given these distinct mechanical features, manometry with impedance-pH monitoring are helpful diagnostic tools for detecting supragastric belching. Impedance tracings can distinguish the directionality of gas flow through the esophagus [17]. Likewise, supragastric belching is monometrically represented by pharyngeal contraction and/or a decrease in esophageal body pressure immediately followed by a rapid increase in abdominal and esophageal pressure in the absence of lower esophageal sphincter (LES) relaxation (Fig. 2) [15].High-resolution esophageal manometry demonstrating supragastric belching. Note that the lower esophageal sphincter does not open during these belching events.