Hello, I'm Dr. Robert Bastian of Laryngopedia and Bastian Voice Institute. You're probably
watching because you can't burp and you experience severe daily misery because of it.
R-CPD, or retrograde cryptopharyngeus dysfunction, is a major cause, and in fact, as of the time of
this recording–December 2020-I've treated nearly 400 people with this truly terrible condition. In
case it can help you, here's a summary with a focus on symptoms. But first, just a reminder that the
disorder is based in the upper esophageal sphincter. It's located–here's the airway,
and here's the esophagus, and it's located about here–where my finger is–on the esophagus.
And that sphincter muscle is a circular muscle like this, and it opens a split second every time
you swallow saliva, food, or liquid. It opens and lets it through, and then it clamps shut.
But it refuses to let go when you need to burp or vomit. So, in the reverse direction,
retrograde direction, it won't let go. Well, in 2020, the diagnosis is hard to come by other than from
your peers on social media, though I think that will change over the next few years as more
doctors become familiar with R-CPD–and there are at least two clear articles in the peer-reviewed
medical literature provided below. But I believe all that will really ever be needed for a
really really strong preliminary diagnosis is that you match with a set of symptoms.
In medical parlance we call it a syndromic diagnosis. And I would argue that the single test
needed is botox injection into that uncooperative muscle right here. Put botox into that muscle.
It validates the preliminary diagnosis and it also treats the condition. And fortunately for 4
out of 4 people, a single injection fixes it permanently. It's like training wheels for belching.
So if you're wondering if you have R-CPD, here's the complete list of symptoms compiled in one place.
First, there are the big four. These four provide virtually 100% accuracy and diagnosis.
And, if you match these four things, the next step is a botox injection. Number one is the
inability to burp. Almost always lifelong, though persons may not have recognized this
as a problem or a difference from others until early childhood or teenage years. Maybe one in
four or so there's a history even in infancy, but not always. Number two is socially awkward gurgling noises.
These noises can be mostly quiet and internal, but usually, they're loud enough to be heard several
feet away, and, not infrequently, people say all the way to the door of the room. They cause social
anxiety in most persons with R-CPD, causing some of them to avoid eating or drinking for hours before
social occasions. And even during them, they go out with friends but they won't eat. And carbonation
makes the noises worse and is to be avoided at all costs. And everyone with R-CPD already knows that.
Some more colorful patient descriptions of this sound; one person said it's a symphony of gurgles,
croaking frogs–that's a very common one–creaking floorboards, dinosaur sounds, that kind of thing.
Number 3 is bloating/pressure. Three levels, there's really abdomen, chest and neck. The commonest is
the high central abdomen here. Distension is also very common, especially later in the day
the stomach gets very hard and it even protrudes a little bit. We use pregnancy as an analogy–even in
men–and the commonest descriptor is "I'm three or four months pregnant by the end of the day,
by the next morning I'm flat again." I've had not few say six months, and I have one young man
who was, I think he was, full term. He was really very very distended. And some have not that much.
Now, almost as often as abdominal distress, patients describe chest
pressure, and for some that's actually the worst symptom–the pressure in the chest.
They even occasionally go to the emergency room. It's that bad. Some have pressure in the low neck
as well. While pressure is the commonest descriptor, bloating, pressure–like I'm going to blow up–some
experience occasional sharp pain in the abdomen, the back, between the shoulder blades and so forth.
And not at all uncommon is for people to say "I have to lie down after eating to find some relief."
Other people gag themselves and air vomit. They go to the bathroom or into another room and they
put their fingers down their throat and gag, and there's this very loud sound and out comes this
huge amount of air, and they're relieved at least for a time. Fourth of the big four is flatulence.
Routinely, people say it's "crazy flatulence", "it's ridiculous", "it's major", "I could win any competition."
Flatulence increases as the day progresses, and many experience it into the night
as well, and many have said to me that when they're around other people, they are sort
of scanning their surroundings all the time to figure out where they can go briefly to
relieve the pressure. And understandably, the social ramifications of this problem can also be major.
Now common but less universal symptoms or effects–i'll just list them: Nausea–especially after
eating larger than normal amounts, or drinking carbonated beverages–again a no-no for everybody.
Two is painful hiccups, more commonly after eating. Shortness of breath; people say they feel so full
of air that they just can't breathe. A friend says "let's go out for a run" and they say "I can't.
I can't breathe I'm just so full." Hypersalivation, especially feeling a little nauseated and bloated,
the mouth kind of waters and it makes them swallow more, and then they're swallowing more air. It's
just miserable. Inability to vomit or difficulty vomiting; there are a few who say "I simply can't
vomit, even with severe food poisoning I can't. I wretch and gag and even I can't vomit." Others say,
"I can vomit, but I have to, to heave for quite a while it has to be really aggressive before it
will actually happen." And then there are of course some who say no vomiting is not a problem and in
fact they do it. They induce it several times a day in order to do that air vomiting thing.
Now, you can imagine that with this vomiting issue, the fear of vomiting or emetophobia
can be major. It's very common in people with R-CPD. Now, five isn't really a symptom but
it's an effect on people: anxiety and social inhibition. You're in good company if that
applies to you. It can be major due, due to the gurgling, the flatulence and the discomfort.
People say, "I'm invited out and I say no," or "I'm invited out and I have to think about it," and "Okay,
what if I get so uncomfortable? What if I have to leave early?" It's just quite awful for social life
And still under evaluation is constipation. My question is whether the descending colon dilates
over time, because flatulence can't always be responded to. And so, I'm wondering if it stretches
the descending colon, and maybe reduces its, its "squeeze ability" and therefore causes constipation.
Under evaluation. So there you have it. R-CPD, retrograde cricopharyngis dysfunction, causing
severe daily misery as just described. Well if this is you,
don't live with it any longer! Call nearby large ear nose and throat (ENT) or GI groups, and .
ask the triage nurse in the practice, "Does any of your doctors help people who can't burp?"
If you get silence, or crickets, or a little laugh or something like that, hang up and call the next
group. And in some cases, you may need to travel to a nearby city: New York, Los Angeles, Seattle, Atlanta,
somewhere big. And of course, our group of doctors. All of us can help free you from this terrible,
awful, no good problem. So thanks for listening and all the best in your search for relief!