Aerophagia


Diagnostic criteriaa must include all of the following:

1. Excessive air swallowing

2. Abdominal distention due to intraluminal air which increases during the day

3. Repetitive belching and/or increased flatus

4. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition


aCriteria fulfilled for at least 2 months prior to diagnosis



The differential diagnosis of aerophagia is fairly broad and involves other entities which present with abdominal distension. When excessive air swallowing is either not recognized by the medical provider or denied by the parents, the child may be suspected of having gastroparesis or other more generalized motility disorders, such as chronic intestinal pseudo-obstruction. These are conditions which may also present with increasing amount of abdominal distension throughout the day. Bacterial overgrowth, malabsorption (particularly celiac disease and mucosal disaccharidases deficiency), tracheoesophageal fistula, and constipation are other fairly common etiologies of abdominal distension and excessive flatus in children. As patients with aerophagia are usually otherwise healthy with normal growth and development, extensive testing to rule out several other diseases is rarely necessary.

When radiological studies are obtained (Fig. 40.1a, b), there is usually evidence of a dilated stomach and small bowel full of air in the absence of other signs of bowel obstruction. The excessive amount of intraluminal gas is especially obvious when the studies are obtained in the evening, at the apex of the abdominal distension. The esophageal “air sign,” defined as an abnormal air shadow on the proximal esophagus adjacent to the trachea on a full-inflated chest radiograph, has been reported in the majority of children with aerophagia in one study [17] but its specificity for this condition has not been evaluated. Multichannel intraesophageal impedance is able to differentiate air from wet swallows (Fig. 40.2) because air conducts current poorly and thus it has a high impedance, leading to a dramatic increase in baseline. Impedance can be used to diagnose aerophagia by detecting an increased frequency of air swallows and may also be used to diagnose supragastric belching in children [18].

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Fig. 40.1
Plain radiograph (a) and computerized axial tomography (b) of the abdomen showing gaseous distension of the stomach, small and large bowel in two children with aerophagia


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Fig. 40.2
The figure depicts three different types of swallows : (a) air swallow, (b) mixed swallow, (c) wet swallow



Treatment


Management of aerophagia needs to be tailored based on the severity of symptoms generated. Although generally felt to be a benign condition, aerophagia has been associated with development of colonic volvulus [19] and colonic perforation [20]. Most commonly, children with aerophagia are brought to the attention of care providers with complaints of noisy swallow, excessive belching, or abdominal distention. Once a diagnosis of aerophagia has been made, education about what generates the symptoms and effective reassurance that no serious underlying disease is present are the most often employed measures and may represent the most effective intervention [21]. Understanding the mechanisms underlying the excessive air swallows may be very reassuring for the parents and the child. Elimination of gum chewing and carbonated beverages and avoidance of drinking from a straw can be helpful. When the air swallowing is visible and/or audible during the clinic visit, the clinician can help the child and the caretakers become aware of air swallows so that the behavior is minimized. Keeping the mouth wide open after completion of a meal may minimize air swallow, as it is impossible to swallow with an open mouth. When patients with excessive belching are unaware that they are being observed or when they are distracted, the incidence of belching is significantly reduced [22]. These findings underline the importance of psychological factors and provide rationale for behavioral therapy. Hypnosis has been suggested as a mode of therapy in a case report [23]. When primary psychological disorders, especially an anxiety disorder, are present, they should be treated [24]. Different behavioral and mechanical techniques, incorporating biofeedback, have been tried, though only in small trials and rarely with children, to promote self-awareness of swallowing and limit its frequency [25, 26]. Pharmacologic therapy has a limited role in the treatment of children with aerophagia due to the lack of thorough understanding of the pathophysiology of this condition and the potential side effects of the medications that have been tried. Benzodiazepines have been employed on the basis that the emotional state may impact swallowing rates and due to their efficacy in the treatment of myoclonus. There have been two reports in which clonazepam was shown to be effective in children with aerophagia with and without mental retardation [8, 27]. Baclofen is a muscle relaxant used to treat spasticity and movement disorders. It has been shown to improve symptoms of rumination and supragastric belching [28] and may have a role in the treatment of aerophagia. In the most severe cases, nasogastric decompression, a venting gastrostomy or even an esophagogastric separation and abdominal esophagostomy via jejunal interposition may be justified [29].


References



1.

Devanarayana NM, Rajindrajith S. Aerophagia among Sri Lankan schoolchildren: epidemiological patterns and symptom characteristics. J Pediatr Gastroenterol Nutr. 2012;54:516–20.CrossRefPubMed


2.

Devanarayana NM, Jayawickrama N, Gulegoda IC, Rajindrajith S. PP-2 Abnormal personality traits in children with aerophagia. J Pediatr Gastroenterol Nutr. 2015;61:520–1.CrossRef

Aug 29, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Aerophagia
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