\n<\/p>\n
Kendra Pierre-Louis: For Scientific American\u2019s Science Quickly, I\u2019m Kendra Pierre-Louis, in for Rachel Feltman.<\/p>\n
You\u2019ve probably been in this situation: you just had a big lunch or a tall carbonated drink, and out of nowhere a burp rises in your throat unbidden.<\/p>\n
[CLIP: A person burps loudly.]<\/p>\n
If you’re enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.<\/p>\n
Pierre-Louis: It\u2019s so magnificent you can taste it. If you are someone\u2019s annoying brother, you\u2019ve probably summoned a burp and unleashed it on your sibling\u2019s face at least once.<\/p>\n
But Paras Dhama can\u2019t relate to any of that.<\/p>\n
Paras Dhama: Because [Laughs] I can\u2019t burp. And for as long as I can remember, I could never burp.<\/p>\n
Pierre-Louis: It may sound silly, but it leads to all kinds of discomfort.<\/p>\n
Dhama: So my whole chest and stomach, it becomes heavy\u2014it feels like some air is stuck inside. And it becomes so uncomfortable that one time I was driving on a highway, I had to stop my car, get outside, try to vomit on the side of the road in order to get that air out. I just can\u2019t sit or walk or do anything.<\/p>\n
Pierre-Louis: This inability to burp\u2014he thought it was a personal failing, like how some people can\u2019t whistle. But what he\u2019s experiencing is actually due to a medical condition that doctors have only recently begun to understand. To learn more we spoke to Robert Bastian, an otolaryngologist and expert in treating this unusual inability to burp.<\/p>\n
Hello. Thanks for taking the time to chat with us today.<\/p>\n
Robert Bastian: My pleasure.<\/p>\n
Pierre-Louis: So we\u2019re here to talk to you\u2014I think in your paper you describe it as retrograde cricopharyngeus dysfunction. Did I say that anywhere near close to accuracy? [Laughs.]<\/p>\n
Bastian: Pretty close. That\u2019s very good. Retrograde cricopharyngeus dysfunction [RCPD].<\/p>\n
Pierre-Louis: Can you describe what that is in plain English?<\/p>\n
Bastian: Sure. If we think of it mechanistically, there is a sphincter, which is a circular muscle. The iris of the eye, it pinches down in response to light. Well, there is a circular muscle, or a sphincter, right at the top of the esophagus, the bottom of the throat\u2014so in most people it\u2019s in the mid- to low neck, behind the lower part of the voice box\u2014and that circular sphincter lives in a state of constant contraction. Counterintuitively, when it\u2019s kind of at rest it\u2019s contracted. All the sphincters of the GI tract sort of stay contracted, except at the moment they\u2019re in use, and then they relax.<\/p>\n
So in this case the upper esophageal sphincter relaxes in the antegrade, the forward direction, to allow us to swallow, and then it clamps shut on the back side of the liquid or the food. But it also must relax in the retrograde direction to let us burp or vomit. And so people with retrograde cricopharyngeus dysfunction have normal antegrade function\u2014they swallow; none of them really have any trouble swallowing\u2014but they can\u2019t burp, and some of them can\u2019t vomit. And so you can imagine the distress that that can cause, horrible difficulty.<\/p>\n
Pierre-Louis: Yeah, I think kind of intuitively people understand how it might be a problem that you can\u2019t vomit. Many of us have had stomach bugs, and, like, you know, it\u2019s better out than in. But the burping side, I think, was really not intuitive to many of us because we sort of do that unconsciously, I think, and so why is it useful to burp?<\/p>\n
Bastian: Well, every human swallow includes a little component of air because the saliva bubbles. If you spit, you\u2019ll see that it\u2019s kind of foamy. Well, each of those little, tiny bubbles, when it gets to the stomach they begin to coalesce, so they don\u2019t stay as foam. They kind of\u2014over time that builds up what\u2019s called a gastric air bubble; it\u2019s normal in everyone to have that little air bubble. But if that bubble gets to be a certain size, then it needs to be vented as burping.<\/p>\n
So if you can\u2019t do that and now you feel uncomfortable because you\u2019ve sensed the need to burp, but you can\u2019t\u2014typically, I think what happens is people begin to swallow extra, and they just build up more and more air, to a degree, in some, that is ridiculous; I mean, they just blow themselves up with air. And all of the downstream air that hasn\u2019t been released upwards, it has nowhere to go except, eventually, as flatulence. But in the meantime, on the trip from the place where it should have been burped all the way down to flatulence, all of that in-between area is distressed by this excess air.<\/p>\n
Pierre-Louis: It\u2019s, I think, so fascinating that some people can\u2019t do this because, like, we expect babies to burp, you know, and we know that if babies can\u2019t burp, they get a little bit irritated, and, you know, you have to work [Laughs] to get that gas out.<\/p>\n
Bastian: Mm-hmm.<\/p>\n
Pierre-Louis: And something I\u2019ve been thinking about is: after I drink something like soda, you know, I burp a lot\u2014like, you know, I\u2019ll do that, like, classic belch\u2014but most of the time I feel like we\u2019re kind of unconsciously burping. It\u2019s not, like, a loud release of gas; it\u2019s just something kind of in the background. How does someone know that they can\u2019t burp versus maybe they\u2019re more of a, like, a tiny burper, I guess [Laughs] is what I would call it?<\/p>\n
Bastian: Well, the majority of human burps are silent. Probably in the last week you were around 20 or 30 or 40 burps within five feet, and you knew nothing about it. If you ask people how much they burp, they will tend to minimize the number per day, simply because they stop paying any attention.<\/p>\n
So people who can\u2019t burp, how do they know? They know because of the discomfort. They feel the rise of the air, and they say it needs to come out, but they can\u2019t get it out. Some of them have little micro burps on a very occasional basis, once or twice a week or even a few times per year, but they\u2019re unexpected. They\u2019re unharnessable. They\u2019re non-relieving. But then there are other people who absolutely never burp\u2014they cannot remember a single time in their entire lives.<\/p>\n
Pierre-Louis: Is there, like, a test for burping? I know that\u2019s a weird sentence. [Laughs.]<\/p>\n
Bastian: Well, yes, the single test that would prove that a person can\u2019t burp is called manometry. But if you do standard manometry, as it\u2019s done routinely thousands of times around the world, it will not make the diagnosis.<\/p>\n
So the real answer to your question is: no, there is no test needed. What you need is to establish what we call the syndrome \u2019cause there\u2019s a constellation of symptoms that make the diagnosis in a very firm way. And so basically you ask the patient, and the symptoms that they give you are highly, highly diagnostic: \u201cI can\u2019t burp.\u201d Probably 90 percent say, \u201cI make gurgling noises.\u201d They can be quiet and internal …<\/p>\n
Pierre-Louis: Mm-hmm.<\/p>\n
Bastian: But more often they\u2019re heard somewhere between a couple of feet away and across a large room. Bloating, and bloating is mostly thought of as an abdominal term, a feeling of pressure in the abdomen, which is the most universal, but often in the chest and even in the low neck. So can\u2019t burp, gurgling, bloating, flatulence\u2014world-class, gold-medal, unbelievable kind of flatulence.<\/p>\n
Now, those are the big four, but there are quite a few less universal but still very common: painful hiccups. There\u2019s a hypersalivation issue. When they begin to feel uncomfortable they say, they\u2014their mouths water; that\u2019s quite common. There is a feeling of shortness of breath. There is nausea after eating; that\u2019s a common one. Emetophobia, fear of vomiting, is very, very common. And constipation, even, is one.<\/p>\n
So when you talk to patients, and you get enough of those symptoms together, and you combine it with the primary issue\u2014\u201cI can\u2019t burp\u201d\u2014and your diagnostic accuracy is practically 100 percent.<\/p>\n
Pierre-Louis: And this is a relatively new diagnosis, right?<\/p>\n
Bastian: Yes, well, the index patient for me was in 2015, and the caseload trickled in at first. And so I thought to myself, \u201cFor goodness\u2019 sakes, this\u2014somebody knows about this. I better look it up.\u201d So I looked up the English literature; I could find no description. I found individual case reports. For example, one was: combination of can\u2019t burp and chest pain. But it didn\u2019t describe the whole syndrome. Nobody had put it together, and there was no treatment.<\/p>\n
And so I was privileged to be the one to codify\u2014by codify, I mean drawing it all together and creating the complete picture, rather than stabbing at \u201ccan\u2019t burp\u201d and adding one additional symptom. The full-orbed description of RCPD came from me and was first published in 2019, so really, RCPD became known to the medical community. That\u2019s when the stake was put in the ground.<\/p>\n
Pierre-Louis: And do we know if people are born this way, or does this condition, like, develop over time?<\/p>\n
Bastian: When you talk to people with RCPD there are many who don\u2019t have information about their infancy. But of the group that knows, that is able to get any information, we\u2019ve learned that approximately one out of three had notable inability to burp as infants; two outta three did burp. Out of the two outta three who did burp there were some who had colic and were gassy and things like that, so there may have been some insufficient burpers. But definitely, there is a group that can\u2019t burp as babies as well.<\/p>\n
And in that one third there\u2019s a subset where it was an ordeal for the parents, where they said, \u201cWe were taking them to the doctor. We were changing up the formula. We were up all night. He was crying.\u201d One parent said, \u201cYes, we would measure what we fed her, and we\u2019d cover ourselves with a towel and stand by with a bowl \u2019cause it, like clockwork, about 20 minutes later she would throw up a huge amount, and we needed to know, \u2018Was she keeping anything?\u2019 So we measured what went in, and we measured what came out into the bowl.\u201d And we\u2019ve had a number say, \u201cIf this child had been our first child, she would\u2019ve been our only child. We would\u2019ve said, \u2018Absolutely cannot do that again.\u2019\u201d But that\u2019s a subset.<\/p>\n
So when we say the trouble is \u201clifelong\u201d\u2014that\u2019s the word we apply\u2014what we mean by that is the patient\u2019s memory, where the patient says, \u201cI don\u2019t remember ever burping,\u201d then we say that\u2019s lifelong.<\/p>\n
Pierre-Louis: That makes sense. How does someone get treated for this?<\/p>\n
Bastian: Well, the way we do it here is very simple: we meet the patient and validate the diagnosis, and then we go straight to Botox.<\/p>\n
We go over to a nearby day surgery center. The patient spends about two and a half hours there. And what happens is: while they are completely asleep\u2014so it\u2019s a full general anesthesia, but it\u2019s a very brief one\u2014we go through the mouth, kind of like a sword-swallowing approach, with a hollow, lighted tube. And you can go down into the upper esophagus. You can find the ridge; it\u2019s like a band. And then you use a tiny needle, and you inject that muscle in two or three places. And then the patient wakes up. They don\u2019t need pain medicine, except rarely. It\u2019s just a little scratchy sore throat. They leave. And then within a few days they begin to burp. That\u2019s one method.<\/p>\n
The second method is the EMG-guided. So in that method we do a little bit of numbing. Then we attach some little electrodes, like EKG pads, and then we use a hollow\u2014a Teflon-coated needle and come in from the side and\/or from the front; there are two basic approaches to the muscle. And so the patient is sitting in a chair like this with a headrest, and I inject from the side, and then they go home.<\/p>\n
Pierre-Louis: And what does the Botox do, exactly?<\/p>\n
Bastian: Botox, it causes a chemical paralysis of muscle. When muscle is innervated the nerve endings come in, and they have to be planted into the fibers of the muscle. And it\u2019s that junction\u2014it\u2019s called the neuromuscular junction\u2014Botox goes into that neuromuscular junction, and now that spark of electricity can\u2019t jump across from the nerve to the muscle, so the muscle goes limp. So it\u2019s a chemical denervation that is temporary, lasting three to five months. So now this sphincter muscle, which has refused to relax in the retrograde direction\u2014it clamps; it won\u2019t let go\u2014now it\u2019s become limp, and so the burp can get out and vomiting can happen or whatever.<\/p>\n
During the time that the muscle is limped from the Botox the patient then experiences maybe 1,000 burps\u2014micro burps, big burps, in-between burps\u2014and they commune with those burps. They get very mindful about the series of sensations. And they look for what I call the gesture, or the fidget. If you are a burper, you know that just at the moment that you burp you do something to let it go, and that\u2019s what patients have to learn. And so sometimes it\u2019s a head turn; sometimes it\u2019s a chin tuck. But the common one, the one that I\u2019m looking for, is\u2014it\u2019s a lowering the larynx, so the burp is arriving, they feel it arriving, and they kind of [Lowers voice], you know, like, when you talk like Yogi Bear …<\/p>\n
Pierre-Louis: Yeah. [Laughs.]<\/p>\n
Bastian: You sound like that, or when you\u2019re yawning [Imitates a yawn] …<\/p>\n
Pierre-Louis: Mm-hmm.<\/p>\n
Bastian: You know, your voice does that kind of a thing when you\u2019re yawning. It\u2019s that sort of a movement.<\/p>\n
And then the idea is we have pure Botox burps, and then Botox is fading, so it\u2019s a training wheels kind of idea.<\/p>\n
Pierre-Louis: Oh, that\u2019s interesting. So in theory they don\u2019t need to continue doing it. It\u2019s sort of training the muscle on how to burp.<\/p>\n
Bastian: That\u2019s correct.<\/p>\n
Pierre-Louis: And I guess the last question that I have is, like, patients who have\u2014who, like, undergo the Botox or gain the ability to burp, how do they, like, react?<\/p>\n
Bastian: I was fascinated by the number of people who came up with the word \u201clife-changing.\u201d People say things like, \u201cI simply can\u2019t believe that this is what other people are like.\u201d Or they\u2019ll say, \u201cI knew this was bad, but I didn\u2019t realize how bad it was until I got rid of it, and it\u2019s, like, unbelievable.\u201d They\u2019re very ecstatic about the improvement in their quality of life.<\/p>\n
RCPD untreated, the way I describe it is severe daily misery. I have patients\u2014I had one who said to me, \u201cDoctor, if I eat lunch\u2014it\u2019s summer or winter\u2014I have to go out to my car, put the seat back because I can\u2019t tolerate the discomfort, the pain in my stomach. I can\u2019t tolerate it,\u201d stuff like that. Miserable discomfort of this disorder.<\/p>\n
Pierre-Louis: And such a pretty straightforward treatment.<\/p>\n
Bastian: Yes.<\/p>\n
Pierre-Louis: That\u2019s all for today. Tune in on Friday, when we’ll dive into potential changes in how we define and diagnose mental health conditions.<\/p>\n
But before you go we\u2019d like to ask you for help for a future episode\u2014it\u2019s about kissing. Tell us about your most memorable kiss. What made it special? How did it feel? Record a voice memo on your phone or computer, and send it over to ScienceQuickly@sciam.com. Be sure to include your name and where you\u2019re from.<\/p>\n
Science Quickly is produced by me, Kendra Pierre-Louis, along with Fonda Mwangi, Sushmita Pathak and Jeff DelViscio. This episode was edited by Alex Sugiura. Shayna Posses and Aaron Shattuck fact-check our show. Our theme music was composed by Dominic Smith. Subscribe to Scientific American for more up-to-date and in-depth science news.<\/p>\n
For Scientific American, this is Kendra Pierre-Louis. Have a great rest of your week!<\/p>\n","protected":false},"excerpt":{"rendered":"
Kendra Pierre-Louis: For Scientific American\u2019s Science Quickly, I\u2019m Kendra Pierre-Louis, in for Rachel Feltman. You\u2019ve probably been in this situation: you just had a big lunch or a tall carbonated drink, and out of nowhere a burp rises in your throat unbidden. [CLIP: A person burps loudly.] On supporting science journalism If you’re enjoying this<\/p>\n","protected":false},"author":1,"featured_media":43822,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[58],"tags":[11230,22857,510,22856,364,6312],"class_list":{"0":"post-43821","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-science","8":"tag-botox","9":"tag-burp","10":"tag-daily","11":"tag-miserywhy","12":"tag-people","13":"tag-rescue"},"_links":{"self":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/43821","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=43821"}],"version-history":[{"count":0,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/43821\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/media\/43822"}],"wp:attachment":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=43821"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=43821"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=43821"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}