If you look up air swallowing, or aerophagia, on the Internet, you’ll encounter a surprising amount of misinformation.

What exactly is aerophagia?

Simply put, aerophagia is the act of swallowing air. Since our gastrointestinal (GI) tract is open to the outside world, it’s natural for small amounts of air to enter it. In fact, a well-known study found that the average person expels 200 milliliters of air daily through flatulence. In the grand scheme of things, this is a relatively insignificant volume.

Pathological aerophagia, however, involves air swallowing at levels far beyond the norm. Interestingly, this term doesn’t refer to a single condition but rather to three distinct forms. The most recognized form, as defined by the Rome IV Criteria, occurs exclusively in children. Another version appears loosely defined on the Internet, often accompanied by dubious treatment recommendations. Finally, there is the extreme, documented case of an adult living with a severe manifestation of the condition—which, incidentally, is my own experience.

In this blog, I’ll delve into all three forms of aerophagia, with particular attention to the Internet’s portrayal, where much of the information seems fabricated. By exploring the science and sharing my personal insights, I aim to clarify the science about this condition.

I am going to begin with a review of my own situation. I can tell you up front it’s a night and day difference between any example of aerophagia that’s ever been seen, and it indeed represents an entirely novel condition, previously completely unknown to medical science. This condition was so novel that we documented it in the medical literature, as referenced below.

On the evening of February 24, 1995, I started feeling unwell and by morning, I was experiencing a strange sensation across the top of my abdomen. The only thing I could liken it to was something electrical and because it cut across the top of my abdomen as if it were following the transverse colon, I called it the transverse eel (short for electric eel). I also had a fever that rose all the way to 104.4 degrees Fahrenheit by Sunday evening (40.22 Celsius). 

By Monday, the fever started to break. By Wednesday, I felt like my old self, and I thought that was it.

But, no, a week later, in the morning, I became extremely nauseous. By evening, my abdomen became rigid as if I had appendicitis or peritonitis, a sign known as abdominal rigidity. After some hours, it relaxed. An abdominal CT showing nothing abnormal. 

For the next four months I felt unwell with what I suppose you could call dyspepsia. I also had this periodic, odd feeling as if there was a little man sitting on my diaphragm with a fishing rod hooked on my liver, and he was pulling up on it, a symptom I now call the liver fisherman.

I endured this situation for four months when over the course of a week or two it all cleared up spontaneously. 

And I thought that was that. 

It was actually just the beginning. 

In September, on my short 10 minute drive to and from work, I noticed I was always passing flatus without fail. Then I noticed it during the day too. I pulled out my chronograph and timed it. Every 7 minutes. I was passing flatus without fail every 7 minutes.

At this point, this was my only symptom. Eventually, I decided to get to the bottom of it. All the world’s research clearly pointed to the cause: malabsorption of carbohydrates. So in an effort to confirm this, I took a weekend in March and ate no food. This, I reasoned, should bring the flatulence to a halt. However, it had no effect whatsoever. This was not what I was expecting, and I was puzzled by it. 

In May of 1996, two other strange intestinal symptoms appeared. Their details aren’t critical to our understanding other than it jumpstarted a more aggressive test schedule. (Remember, that from September 96 through May 1996, I had only one symptom from the gas—excessive flatulence.)

The first of which was the D-xylose absorption test. The test result was completely normal, and this also made no sense. 

During the summer, I decided to go carb-free entirely. That had no effect whatsoever, and like the previous results was just strange. To top it off, I had done a 72-hour fecal fat study that also was entirely normal. Finally, in October 1996, I had small bowel biopsy which as you can guess by now, was entirely normal.

At this point, it was clear that I could not possibly have malabsorption and that the cause being attributed to my flatulence by the world’s medical literature was absolutely, positively wrong. 

In searching for my condition, I came across this paper by one Dr. Michael D. Levitt, https://pubmed.ncbi.nlm.nih.gov/947086/. 

According to it, the gut flora of the subject of the paper morphed, becoming overzealous gas producers. 

So I reasoned that I, too, had been suffering from the same condition as Dr. Levitt’s patient. 

To remedy this, I started on a series of antibiotic trials and eventually probiotics and then more antibiotics. 

At one point, I got my own hydrogen breath meter. The way this works is that as the gut bacteria process carbohydrates, some produce hydrogen gas, some of which is absorbed into the circulation, which is then excreted into the breath. I was expecting something like 150 ppm (parts per million) or more. However, when I tried it, I was repeatedly getting 6, an oddly miniscule value. 

For reasons relating to the overall strangeness of my symptoms, I was without a doctor in the spring of 97. I had to take matters into my own hands, so I wrote a fake prescription for amoxicillin. The fake prescription worked, but the antibiotic had no detectable effect on my flatulence (or any other symptom for that matter). 

Finally, in desperation, I decided to seek help from Dr. Levitt himself. Luckily, he agreed to help, and in the early fall of 97, I arrived at his lab. In the first set of experiments, we measured the volume of my farts, and there was no question at this point that I was one of two (the other person was subject of the aforementioned paper) most flatulent humans on Earth.

Next up, he analyzed the different gases in my farts. I will never forget his reading me the numbers. The hydrogen and carbon dioxide levels were crazy low, and before I could process how that made no sense, he read me the nitrogen number and that it made up almost all the gas. He immediately told me this was air swallowing. I was paralyzed in shock. It felt completely surreal like I had left reality. I had only seen brief mentions of air swallowing and couldn’t understand what this really meant and how this was even possible. To be fair, I am in much shock today as I was back then.

One more experiment we did was to analyze the gas production of the stool itself to confirm that it wasn’t somehow producing nitrogen. It wasn’t. (Nitrogen production in stool has actually never reproducibly confirmed to occur in humans despite what you may read in the medical literature.)

Back to the literature, there were articles relating to Rome-based aerophagia. At the time, Rome I criteria were in force, but I can’t seem to find them referenced anywhere these days. The oldest criteria for the next closest thing, Rome II for aerophagia, are as follows:

Patients should experience for at least 12 weeks, which need not be consecutive, in the preceding 12 months, air swallowing that is objectively observed plus troublesome belching.

This is of course, ridiculous. Aerophagia is an unobservable process (this feature is so critical, I put that in my own criteria), and it results in flatulence, never belching. Clearly, the Rome criteria are describing an entirely different disorder and the committee is just mis-naming it aerophagia. They obviously never encountered a patient with true aerophagia and are completely unaware it exists or even that it can exist. 

At some point, the Rome criteria dropped this condition, which it turns out is a belching disorder, and they focus on an aerophagia-like condition of children that they insist is aerophagia. There is no recognition of my condition, the true aerophagia. This is most likely because it is extremely rare. Remember I had a very peculiar infection before the aerophagia and the other odd GI symptoms started. This is one of those cases where correlation does equal causation.

So what are the features of true aerophagia?

The sole symptom of true aerophagia is excessive flatulence. I fart about 75 times every day, for example. X-rays will show gas evenly distributed across GI tract. 

The Rome criteria for what are now called Disorders of Gut-Brain Interactions (DGBI) has undergone four revisions.

For aerophagia, they are currently defined in children as follows:

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 must be fulfilled for at least 2 months before diagnosis

Right away, you may notice something very fishy regarding the first criterion. Aerophagia as I explained earlier is “excessive air swallowing”. This is circular reasoning. It’s the same as saying one has cirrhosis if they have a cirrhotic liver. It doesn’t tell us anything about how to recognize excessive air swallowing. I scoured the Rome Criteria documentation and there really is no guidance as to how diagnose it, which makes me wonder how there are so many papers on this topic and with a few exceptions the children are summarily being assigned the diagnosis without explanation. I will come back to this shortly.

Given that the first criterion is the same as the condition itself, it’s not clear why there needs to be any further criteria. Anyway, let’s consider these criteria in light of my aerophagia since I have the real deal. What happens is the condition produces one long tube of air equally distributed across the whole bowel. It does not show distension because that is not how a healthy gut behaves when experiencing aerophagia. What goes in on one end moves to the other end rather quickly (say about 30 minutes!). From an evolutionary standpoint, this makes sense; you don’t want a digestive tract that gets stuck doing its job.

The odd time-dependent notion is another puzzle. I can understand the beginning of the day, but what I don’t follow is the increasing distension as the day progresses and then what happens? All the papers are oddly silent on this question.

Second, I presume the children are eating their normal meals during this period, so how does this factor into their symptoms? That is, is there gastroparesis (delayed stomach emptying) or impaired transit of liquids and solids throughout the small bowel and even the colon, too? Not only are the criteria silent on this, but also are all the papers covering this condition. It almost appears intentional that those affected are not being subject to any kind of motility testing. Motility testing might include antroduodenal manometry, colonic manometry, and a gastric emptying scan (GES).

I reached out to several researchers who have written papers on this strange set of symptoms seeking particularly an explanation for how aerophagia is being diagnosed. Most of the researchers ignored my queries. Might this suggest a lack of rational answers? One said the parents diagnosed the condition. That’s pretty amazing given that I spent about a year and half with doctors chasing the wrong diagnoses and then needed to travel halfway across the US and utilize the tools of an academic laboratory to diagnose mine. Another claimed with no specific evidence that the children make a frog-like sound when they swallow air. Was she making this up? However, a few papers do claim the aerophagia is noisy and visible. Neither of which is even remotely the case in true aerophagia where the only symptom is excessive flatulence. Finally, one paper makes reference to an “esophageal air sign”. What exactly this is unclear and how it’s evidence for aerophagia is unclear. In true aerophagia, nothing out of the ordinary is seen other than the air filling the stomach rather rapidly as if by magic.

Here is where things tend to get funny. A few papers utilize Brendenoord’s multichannel intraluminal impedance to presumably confirm the first criterion and lo and behold, it does indeed confirm it. Of course, as I stated earlier, this technique has never been verified on a person with known true aerophagia, so we can’t definitively say these results aren’t the result of confirmation bias.

What happens to these children after they are diagnosed? Some are referred to “behavioral therapy” whatever that means as if altering one’s behavior (behavior of what exactly? How I lock my doors perhaps? Who knows?) could somehow alter the unknowable disease process. I have had aerophagia for each and every day for 29 years. I can’t imagine any treatment for it. Even if the presumed mechanism, that of a spontaneously enlarged pharyngeal chamber were demonstrated how could any therapy go about reducing its size?

It is pretty clear that what the Rome committee refers to as aerophagia is not even remotely related to the true aerophagia I suffer from. However, the committee ought to consider the significant deficiencies not only in its criteria, but why so few of these patients haven’t been subject of investigations. It would interesting to know what causes their guts to distend over the course of a day and then what triggers whatever happens next, for example.

There are quite few pages on the Internet covering aerophagia. It’s clear what they are covering to be exact. True aerophagia, my condition, has been diagnosed only in person on the Earth, me. The Rome criteria used to consider a belching condition as aerophagia, but once they made the discovery, they dropped it from Rome and instead created a new category for children whose gut distend across the course of a day. It appears, then, most of what is on the Internet doesn’t refer to any of these entities, but perhaps some imaginary entity instead. In any case, all these papers are loaded with misinformation. 

Let’s start with this article, https://www.healthline.com/health/aerophagia. This article encompasses much of the misinformation on aerophagia on the Internet so it’s a great place to dispel it.

It starts with…

We all ingest some air when we talk, eat, or laugh

This statement is made up. Air swallowing as the name suggests requires actual swallowing. Imagine the esophagus as a party balloon. Have you ever seen the balloon fill itself with air spontaneously? Of course not. It’s the same with the esophagus. Outside from a little dead space air, there’s no way for air to rush in all on its own and expand the balloon. It must be pumped in somehow, and the only thing that’s going to do that is swallowing. I can’t see how a person can talk or laugh and swallow at the same time, so that makes air swallowing impossible when we are talking or laughing.

What about eating? My suspicion is that air swallowing here too is mostly if not entirely impossible. When are we are swallowing, there might be a little dead space air in the pharyngeal chamber. When we swallow a food or liquid bolus, the upper esophageal sphincter starts out closed, so the material as it moves into the chamber forces the air out back into the mouth. Otherwise, every time, we’d eat we’d pushing that volume into the stomach and that doesn’t correlate with the mere 200 ml we pass as flatus as I mentioned earlier.

I will have more to say later why I think air swallowing while eating/drinking is mostly impossible.

The next thing it says, and this one is a doozy is

We swallow about 2 quarts of air a day just eating and drinking. We burp out about half of that.

It is referencing another article, this one:

https://www.pharmacytimes.com/view/peintestinalgas-0810

This article really takes the cake in terms of fiction. As I already established, we pass a mere 200 ml of air as flatus every day. If we were to assume we belch half of what we consume, that would mean the intake volume to be a mere 400 ml, not the gargantuan 2 quarts the author wants us to believe. I don’t believe we belch anywhere near that much, so this 200 ml figure probably reflects the total we swallow in a day.

It then says, More than 1 cup of air is swallowed when we drink a full glass of water.

If you think this number is crazy, it is because it is. As I explained above, I don’t believe we can swallow any air while drinking beyond the initial dead space air in the pharynx.

To be fair, there is a crazy paper by Dr. Peter Kahrilas, https://pubmed.ncbi.nlm.nih.gov/8613047/, where he claims finding in his subjects that they swallow about 17.4 mil of air per swallow. But as we have seen, this number is outrageous and can’t even be remotely accurate.  Dr. Kahrilas tried to resolve the discrepancy between his 17.4 ml and the 200 ml by claiming that the subjects are belching micro-belches a gazillion times a day undetectably. Of course, there is no evidence to back up this ridiculous claim. A more realistic explanation is that what he measured as air was simply a vacuum.

The article goes on to make several other false claims. For example, it says

Patients with flatulence can experience abdominal pain, stomach cramps, dizziness, and even headaches.

This is purely made up. Flatulence is a symptom and symptoms don’t cause other symptoms. Some people may say, wait a minute, I have experienced abdominal pain from gas, but this is not the case. Gas in the intestine cannot cause pain. It’s the misbehavior of the gut-brain axis giving you the pain. In a working GI tract, gas is passed quickly with no other symptoms.

It says about 75 medications are linked to excess gas, but outside of antibiotics, that linking is almost certainly not a cause-effect relationship, just a coincidence.

It also makes the claim that you can tell whether you are excessively flatulent by how many times you pass flatus, but that’s not necessarily true because the amount per pass itself can be excessive. Unfortunately, we don’t have a foolproof way to know whether we are excessive, although a high number, say at least double, is probably suggestive of it.

It further says: Several over-the-counter products exist, including Beano, lactase supplements (eg, Lactaid), simethicone (eg, Gas-X, Mylanta), and activated charcoal tablets.

Beano is known to be ineffective, though this information had not been publicly known until now. Simethicone merely causes small gas bubbles to become big bubbles. I’m not clear on how that would help anything. Activated charcoal is well-known to not have any effect on gas in the GI tract.

There’s more: Try smaller but more frequent meals, and eat slowly. Avoid carbonated beverages and beer. Do not drink with a straw.

How would changing meal size and frequency make any difference? How would the eating speed make any difference? It reminds me of the age-old question, which is heavier a pound of feathers or a pound of bricks. The answer: neither; they weigh the same.

The gas from carbonated beverages, carbon dioxide, is absorbed in the GI tract pretty quickly. It couldn’t affect aerophagia, anyway.

A straw is not likely to contribute more than a tiny amount of air.

I’m not done; the article says: If you wear dentures, make sure they fit properly. People with poorly fitting dentures swallow more air.

How could it do this? How do we know this? Once again, it sounds made up.

Now let me get back to bogus healthline article. The biggest problem with the article is presumes the existence of some kind of generic aerophagia condition that can somehow be ameliorated by following some pretty absurd recommendations. At the same time, it references some old articles on aerophagia that are no longer relevant. In 2024, Rome IV criteria for aerophagia is based on the premise that a form of aerophagia is limited to children. The old articles are now believed to refer to a belching, not an aerophagic, disorder. However, I don’t know why it wasn’t included in Rome IV.

The article refers to the mechanics of aerophagia but everything is says is just fiction. The truth is we know very little about its mechanics other than it must involve swallowing to obtain great volumes.

The CPAP references are irrelevant because I’m focusing on aerophagia as an intrinsic condition and not something where there’s an outside source of air being pumped inadvertently into the gut.