Retrograde Cricopharyngeal Dysfunction (RCPD) ‘No Burp Syndrome’

What is it?

Retrograde Cricopharyngeal Dysfunction (R-CPD) aka ‘no-burp syndrome’ is a condition where the patient is unable burp. Patients cannot burp voluntarily or spontaneously. Patient often complain that this has been the case for many years.

There is often no difficulty in swallowing. This shows there is no fixed tightening of the upper oesophagus as food can pass normally. It points more towards an issue (dysfunction) of the upper oesophageal sphincter (including the cricopharyngeal muscle) not relaxing to allow a burp.

Not being able to pass gas as a burp is not usually dangerous but it can have a big impact on people’s lives. People will often have learnt to avoid certain foods. Others may have adapted their lifestyle to avoid certain social situations. It can cause regular significant discomfort and sometimes social isolation.

What are the symptoms?

The main symptoms I have seen fit with what is reported in the currently literature. These symptoms include bloating, pain, gurgling sounds in the upper oesophagus, avoidance of foods and flatulence [1]. In extreme cases, the pain has become quite severe for a short period. A small proportion of patients also comment that they find it difficult to vomit but this does not seem to be universal.

The gurgling noises in patients’ stomachs and upper oesophagus can also be quite unsettling for people. Patients have been known not to accept certain jobs in quite environments or chosen to work from home.

‘Air-Vomiting’ is another symptom some patients complain of. This involves the patient learning to vomit the air build up. I have been told that this can be quite noisy and as one can imagine, although the relief of letting out the gas is good, the experience as a whole is very unpleasant.

How is it diagnosed?

Currently there is no internationally agreed diagnostic test or criteria. Most patients have already self-diagnosed the condition. It is the physician’s job is to exclude other conditions and possibly help confirm the diagnosis. The history is usually the most important factor in making a correct diagnosis. A thorough examination in clinic will normally not show any obvious abnormality. Sometimes a barium swallow test is arranged. There is some research emerging about the use of highly specific manometry after a carbonated drink and this could potentially be useful in the future as a diagnostic test but it is not standard currently. A dilation and Botox procedure can sometimes be both therapeutic and help confirm diagnosis [2].

Is it common?

It appears that this condition is a lot more common than first realised. Although the incidence has increased a great deal recently it’s more likely this is due to more recognition of the condition than new cases. GPs, healthcare professionals and patients are all becoming more aware of this condition and realising there are some treatment options available. Social media appears to be playing a big part in the recognition of this condition  

What are the treatment options?

In the first instance patients should try to remember or relearn how to burp without any surgical intervention. This may include relaxation, sitting forward slightly and opening one’s mouth. It would be worth doing this in a safe environment where it would be okay to vomit in case that happened. It’s unlikely one would vomit but being in a safe environment is likely to help.

This is a fairly new condition and evidence is emerging on the best way to treat it. However, the theory at the moment is that burping is a natural human function and for one reason or another, this normal relaxation of the upper oesophageal sphincter is not working. Once the patient has relearnt to burp a few times, this should then be able to be continued with some minimal practice and persistence.

For extreme cases, where patients have no other significant or contributing comorbidities and where the condition is seriously affecting their quality of life. Together, we may consider a stretching and Botox procedure to the upper oesophagus. This is undertaken under general anaesthetic in the operating theatre. Although Botox only lasts for a few months the therapeutic benefit seems to last much longer once the patient has learnt / retrained their body in the ability to burp [1].

Could any treatments make it worse?

With most surgical procedures there is always a risk of doing harm or making the patient worse. The potential risk always needs to be weighed up against the potential benefits. Stretching and Botox to the upper oesophageal sphincter is a very safe procedure but patient selection and a thorough consenting process is essential.

Risks include injury to the tongue or teeth (a metal scope through the mouth is used to gain access to the upper oesophagus and muscle). Some patients experience pain and a small amount of bleeding. There is a very small risk of a small hole in the throat called a perforation. Mild swallowing difficult and pain has been reported but this tends resolve spontaneously. There is also the risk of an unfavourable reaction to Botox. Patients could also get no benefit from the procedure. Furthermore, the Botox is temporary, lasting a few months. Symptoms could potentially return. However, the effect tends to be much longer as once you and your body have learnt to burp, usually even once the Botox has worn off, you should be able to continue burping. After the procedure it still requires some work and effort from the patient to learn to burp.

Areas of research?

Retrograde cricopharyngeal dysfunction (R-CPD) (‘No-Burp Syndrome’) is fairly newly recognised syndrome. The evidence at the moment is mainly from fairly small case series of patients but there is a growing consensus that Botox to the cricopharynx is effective [3]. Medicine and surgery have to be evidence based and as doctors and surgeons we are still collecting data on safety and efficacy to ensure the best outcomes. Therefore, as part of any treatment offered you will likely be asked to compete a number of questionnaires before the procedure and at subsequent follow ups. It is very important to collect data on the effectiveness of treatments in addition to long term outcomes.

Bibliography

1.     Bastian RW, Smithson ML. Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeal Dysfunction: Diagnosis and Treatment. OTO Open. 2019 Mar 15;3(1):2473974X19834553. doi: 10.1177/2473974X19834553. PMID: 31236539; PMCID: PMC6572913.

2.     Miller ME, Lina I, Akst LM. Retrograde Cricopharyngeal Dysfunction: A Review. J Clin Med. 2024 Jan 11;13(2):413. doi: 10.3390/jcm13020413. PMID: 38256547; PMCID: PMC10817096.

3.     Malhotra R, Khan H, Zaransky S, Celidonio J, Yan K, Kaye R. Diagnosis and Management of Retrograde Cricopharyngeal Dysfunction: A Systematic Review. OTO Open. 2024 Oct 15;8(4):e70014. doi: 10.1002/oto2.70014. PMID: 39411246; PMCID: PMC11474230.