A burp, or eructation, is the body’s natural mechanism for releasing swallowed air from the digestive system. We all unintentionally swallow small amounts of air (aerophagia) while eating and drinking. When a person cannot burp, this excess air becomes trapped, leading to significant physical discomfort and pressure in the chest and abdomen. This inability to vent gas is a recognized medical issue.
How the Body Normally Releases Air
The process of a normal burp is a coordinated reflex involving two muscular valves in the esophagus. Swallowed air accumulates in the stomach, causing the stomach wall to stretch slightly. This stretching triggers a signal that causes the lower esophageal sphincter (LES) to briefly relax, allowing the air to move upward into the esophagus.
Once the air is in the esophagus, it causes the tube to distend, triggering a second reflex. This reflex signals the upper esophageal sphincter (UES), also known as the cricopharyngeus muscle, to relax and open. When both sphincters relax in succession, the gas is expelled through the mouth or nose, which is the burp.
The Primary Medical Explanation: Retrograde Cricopharyngeus Dysfunction
The main medical reason a person cannot burp is a condition called Retrograde Cricopharyngeus Dysfunction (R-CPD), sometimes referred to as “no-burp syndrome.” The disorder is defined by the failure of the cricopharyngeus muscle to relax when air pressures build in the esophagus, preventing air from moving up and out.
The muscle functions normally when swallowing food and liquid (antegrade motion), but it fails to open for the retrograde release of gas. The mechanism of R-CPD is a dysfunctional relaxation of the upper esophageal sphincter despite the esophagus being distended with gas. This means the entire burping reflex is initiated, but the final step of opening the muscular gate is blocked.
This condition has been recognized in medical literature since the late 1980s, but it has only recently gained significant awareness after reports published in 2019 detailing effective treatment. Due to its new recognition, many patients with R-CPD are misdiagnosed with common gastrointestinal issues like Irritable Bowel Syndrome (IBS) or Gastroesophageal Reflux Disease (GERD). The failure of the muscle to open results in the air remaining trapped, causing uncomfortable physical symptoms.
Physical Symptoms of Trapped Gas
The inability to burp causes excess air to accumulate in the esophagus and stomach, creating uncomfortable symptoms. A major complaint is persistent, severe abdominal bloating, which often worsens rapidly after eating or drinking. This pressure can also be felt in the chest and lower neck, described as a tight or full sensation.
The trapped air often causes loud gurgling noises that originate from the chest or throat, which patients sometimes call “croaking.” Since the air cannot exit through the top, it is forced to travel through the entire digestive tract. This results in excessive flatulence as the body’s only remaining way to expel the gas. For some individuals, the pressure also makes vomiting difficult or impossible, leading to a fear of vomiting known as emetophobia.
How Doctors Diagnose and Treat the Issue
Diagnosing Retrograde Cricopharyngeus Dysfunction relies heavily on a detailed patient history due to the specific combination of symptoms. Physicians look for the inability to burp, combined with chronic bloating, gurgling noises, and excessive flatulence. While advanced diagnostic tools like manometry can assess muscle function, R-CPD is primarily a clinical diagnosis.
The standard and most effective treatment for R-CPD is the injection of Botulinum Toxin (Botox) directly into the cricopharyngeus muscle. This procedure is typically performed under general anesthesia. The Botox temporarily paralyzes the muscle, forcing the muscle to relax and remain open for several months.
This temporary relaxation allows the trapped gas to escape and permits the patient to learn how to burp, often resulting in significant symptom relief within a week. Success rates for a single injection are high, with studies showing an 80 to 90 percent success rate in resolving symptoms. For a small number of patients whose symptoms return, a second injection may be necessary or, in rare cases, a cricopharyngeal myotomy, which is a minimally invasive surgical procedure to partially cut the muscle.