A Patient’s Story
Eliza, a 38-year-old professional, described constant bloating and pressure in her upper abdomen that worsened as the day progressed. She rarely burped and felt uncomfortably full even after small meals. Standard tests for reflux and food intolerance were normal, leaving her frustrated and unheard.
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Further specialist assessment revealed a lesser-known cause: retrograde upper oesophageal sphincter dysfunction (R-UES).
What Is Retrograde UES Dysfunction?
The upper oesophageal sphincter (UES) is a muscular valve at the top of the oesophagus, just below the throat. Its role is to prevent air from entering the oesophagus during breathing and to stop food or stomach contents from moving upwards.
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In retrograde UES dysfunction, the sphincter does not maintain an effective seal. This allows air to pass backwards from the throat into the oesophagus, eventually reaching the stomach, where it can cause bloating and discomfort.
How R-UES Causes Bloating
Excess Air Swallowing
When the UES fails to close properly, small amounts of air enter the oesophagus repeatedly. This process, known as aerophagia, leads to excess gas in the stomach and a sensation of fullness.
Difficulty Burping
Many patients with R-UES struggle to burp normally. Gas becomes trapped, increasing abdominal pressure and worsening bloating.
Delayed Gastric Emptying
In some cases, R-UES dysfunction is associated with gastroparesis, where stomach emptying is slowed. Gas and food remain in the stomach longer, amplifying bloating.
Reflux-Related Distension
R-UES dysfunction may coexist with gastro-oesophageal reflux disease (GORD). Acid and gas reflux can irritate the upper digestive tract and contribute to a bloated, distended feeling.
Common Symptoms Associated With R-UES
Patients may experience:
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Persistent bloating
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Upper abdominal pressure
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Feeling full quickly
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Minimal or absent burping
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Chest tightness without heartburn
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Throat discomfort or air hunger
Symptoms often worsen later in the day or after meals.
How Is R-UES Diagnosed?
Diagnosis begins with a detailed clinical history, focusing on bloating patterns, swallowing, and burping ability. Investigations may include:
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High-resolution oesophageal manometry to assess sphincter function
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pH impedance testing to evaluate reflux and gas movement
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Endoscopy to exclude structural causes
Accurate diagnosis is key, as R-UES is frequently overlooked.
Treatment Options for R-UES and Bloating
Dietary Adjustments
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Avoid carbonated drinks
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Reduce gas-producing foods
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Consider a low-FODMAP diet
Behavioural Strategies
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Eat slowly and chew thoroughly
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Avoid excessive air swallowing
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Practise mindful eating
Lifestyle Modifications
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Stress management
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Regular physical activity
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Weight optimisation
Medical Treatment
Medications may be used if associated conditions such as GORD or gastroparesis are present.
Speech and Swallowing Therapy
In selected cases, targeted therapy can help improve UES coordination and function.
When to Seek Specialist Advice
If bloating is persistent, unexplained, and resistant to standard treatments, R-UES dysfunction should be considered. Specialist evaluation can identify subtle motility disorders that routine tests often miss.