The condition first appeared in medical literature in 1987 but didn’t get a name until 2019: retrograde cricopharyngeus dysfunction (R-CPD).

More familiarly: no burp syndrome — the inability to burp.

Now, amid growing awareness, thousands are getting relief for a painful condition that previously had gone undiagnosed and untreated. An influx of office visits and subreddit posts suggest it’s not as rare as once thought, and this year, R-CPD was added to the Rome V international diagnostic criteria for disorders of gut-brain interaction.

“R-CPD has crossed, in just 7 years, from my original 2019 description of a previously unrecognized disorder to formal recognition within the gastroenterology world,” said Robert Bastian, MD, the otolaryngologist who published the paper. “My understanding is that this is remarkably fast for a newly described clinical syndrome.”

For Stephanie Carnes, 42, a professor at Marist University in Poughkeepsie, New York, that higher profile changed her life. She had struggled in childhood with constipation (unreleased air stretches the colon), and as she got older, she developed bloating (an uncomfortable fullness after eating only a small meal) and painful pressure in her chest. She loved running but had to quit.

“It felt like I had a balloon in my upper stomach and I couldn’t take a full breath and then I’d feel hot pressure shooting up my esophagus,” she recalled.

A battery of tests led to treatments for irritable bowel syndrome, gastroesophageal reflux disease (GERD), and small intestinal bacterial overgrowth. Nothing helped.

“The word ‘hopeless’ sounds so dramatic, but that’s how I felt,” she said.

Googling her symptoms during an unenjoyable Thanksgiving in 2024 led to a subreddit called r/noburp. “I had this Eureka moment where, for the first time ever, people were describing my weird symptoms that I thought no one in the world had,” she said.

Dysfunction in the Esophagus

R-CPD occurs when the upper esophageal sphincter (UES) doesn’t relax to allow gas to be released. Normally, as gas pushes up from the lower esophagus, it travels quickly and stretches the esophagus, which causes a small muscle, the cricopharyngeus, to pull the sphincter open, releasing a burp.

A leading theory is that in R-CPD, the cricopharyngeus muscle does not relax to pull the upper sphincter open.

The air trapped in the esophagus can cause intense chest pain, a telltale gurgling sound, a feeling of fullness, bloating, and other gastrointestinal (GI) symptoms. Many people with R-CPD have a fear of vomiting (emetophobia).

The condition would likely still be unrecognized if it weren’t for internet forums. In 2015, a Texas car salesman, Daryl Moody, posted on Reddit that he had been successfully treated by Bastian for his inability to burp — and his downstream symptoms, including a painfully distended belly while skydiving. Bastian was quickly flooded with calls from people who couldn’t burp. Today that subreddit has 16,000 followers.

In his paper, Bastian described how he treated 51 patients at his Downers Grove, Illinois, practice by injecting botulinum toxin (Botox) into the cricopharyngeus muscle, paralyzing it so the UES could open. Since then, more than 75 studies have been published on R-CPD, leading to its inclusion in the Rome V criteria.

Not So Rare Anymore

Bastian initially described R-CPD as rare, but he and others no longer believe that, though data on prevalence are sparse. Bastian has treated 2400 patients as of January 2026, and hundreds of specialists worldwide, mostly otolaryngologists, are offering the procedure. A study published in 2024 found an average of 6287 Google searches per month for R-CPD-related content.

“Most patients I treat can identify another person that was affected, and I have patients where several family members are affected, so it’s just not rare,” said Michael Z. Lerner, MD, laryngologist and associate professor of surgery at Yale School of Medicine in New Haven, Connecticut. Lerner has treated about 500 R-CPD patients with Botox.

Lerner said the first patients he treated typically had spent 5-9 years being told that their gastroenterology test results were normal. “And if they mentioned the word burp, they would sometimes feel laughed at and told, ‘Yeah, that’s not a symptom.’”

Many people with R-CPD never see a doctor for their GI symptoms — about half, according to a survey of people on the r/noburp subreddit. Their inability to burp is often thought of as a curiosity rather than a condition.

“I think the reason it went unrecognized for so long was that nobody was looking for it,” said Peter Kahrilas, MD, professor emeritus at the Northwestern University Feinberg School of Medicine in Chicago.

Patients tend to emphasize the GI symptoms — bloating, reflux, constipation, abdominal discomfort, and gas — rather than their inability to burp. Often a patient’s first stop is a gastroenterologist, not an ENT physician.

In one study of 106 patients with R-CPD, the mean age at symptom onset was about 13 years and the mean age at diagnosis was 30 years.

“Recognizing R-CPD required someone to connect a constellation of apparently separate [GI] symptoms to one underlying problem,” said Bastian.

The inclusion of R-CPD in the Rome criteria was announced in Chicago in May at Digestive Disease Week, an international gathering of gastroenterologists and related specialists.

Searching for the Cause

There’s no consensus on what causes the muscle dysfunction associated with R-CPD. “We really don’t fully know the pathophysiology,” said Lerner. For example, he has found that the segment of the esophagus below the cricopharyngeus muscle looks stretched out on examination by endoscopy.

“So there’s more dysfunction to this than this one muscle not functioning properly,” he said. That may partly explain why 10% of patients don’t respond to Botox. (After the treatment, some take behavioral burp training to help the process along.)

Theories abound as to what prevents the cricopharyngeus muscle from relaxing. There appears to be a genetic component, with one study showing a family history in 29% of cases. 

About 15%-20% of people with R-CPD have hypermobility, which affects connective tissue, suggesting a physiologic issue, said Lerner. Some research shows an association with GERD, though it’s unclear which comes first.

Another theory stems from the commonness of emetophobia, with some people recalling a trauma around vomiting, possibly leading them to suppress burping (the burp and vomiting reflexes are governed by the same part of the brain and the same esophageal muscle). And some people with R-CPD believe that anxiety or chronic stress may have caused it, though this has not been studied.

“Some people are born with it, a lot of people develop it earlier in life, and some people develop it in young adulthood,” said Kahrilas. “So it’s all over the place.”

Treatment Works for Most

R-CPD is typically diagnosed based on symptoms. A diagnostic manometry is uncomfortable and may require sedation (a tube needs to be inserted through the nose and into the esophagus), and most otolaryngologists don’t order it, though gastroenterologists tend to prefer the test.

“Rome V legitimizes an individualized decision to proceed to botulinum toxin injection after a characteristic syndromic diagnosis without necessarily requiring extensive diagnostic testing first,” said Bastian. “That matters a great deal. Many patients with R-CPD have historically undergone extensive, expensive, and often unrevealing testing before reaching the correct diagnosis.”

Treatment entails injecting 25-100 units of Botox into the cricopharyngeus muscle, with most patients receiving 50 units, according to published cases. The procedure can be done through endoscopy under general anesthesia or as an in-office procedure with transcutaneous electromyography-guided injection.

The surgery often causes short-term side effects, notably slow swallowing, which can cause food and liquid to get stuck in the throat. Other side effects include acid regurgitation, heartburn, and uncontrollable burping. These effects can last from days to months and can be mild to severe. Slow swallowing, when severe, can make it difficult to eat and drink.

Carnes, the professor who likes to run, was on a liquid diet for 2 months after surgery. She has no regrets. “I would do it a million times over,” she said.

“I never could have imagined how positively being able to burp would change my life,” she said. Her constipation dramatically improved, and she no longer experiences pressure in her chest or stomach pain. “I have become a serious distance runner. I run between 30 and 40 miles a week, and that would not be possible presurgery at all,” she said.

The success rate of the Botox procedure is about 90%, and for reasons not understood, the effects tend to last after the Botox wears off. One study found that after 6 months, 80% of people were still able to burp. Experts say the treatment is permanent for most, but more long-term studies are needed. 

“My theory is that by allowing somebody to burp, meaning you paralyze the muscle so it can no longer prevent it, they slowly learn to burp, so they basically teach themselves how to burp again,” said Kahrilas.

On Reddit, some people report avoiding Botox by training themselves how to burp, with a range of techniques, including the Behavioral Eructation Retraining Protocol.

Steven Shaw, 39, of Stratford, Oklahoma, who could not burp since he was a child, taught himself how to burp without surgery. He was training as a fighter pilot in the Navy and not being able to burp could have been a problem for him. “As you go up to a high altitude, the pressure is reduced, so if you have gas in your body, it’s going to expand and it’s going to cause pain,” he said.

Shaw found inspiration in a comedy video of “hot girls burping.” “It was just a rapid succession of one burp after the other, and I thought, there’s something about the generation of sound that is burping,” he recalled. When he felt gurgling in his chest, he replicated that sound, making a low guttural noise. On the third night of trying, he generated a teeny burp. After about 6 months of faking the burp noise, he began to burp normally.

For many, waiting isn’t an option. When Carnes was told she had to wait for 6 months for her Botox surgery, she burst out crying. Thankfully, a cancellation provided an opening for her the following week. “It was 2 days after Christmas, Manhattan was a madhouse, and I remember running across town to get the pre-op blood work done that day,” she said.

Kahrilas reported being a speaker for Phathom Pharmaceuticals and a consultant for Reckitt, Abbott, and Implantica — all pertain to the management of reflux disease. Bastian and Lerner had no relevant disclosures.