Retrograde cricopharyngeal dysfunction - RCPD

What is RCPD?

Retrograde cricopharyngeal dysfunction or RCPD, is a condition often called “no burp syndrome” and is caused by a muscle at the top of the oesophagus (called the cricopharyngeus) failing to relax and so preventing the expulsion of swallowed air - a “burp”.

The cricopharyngeus muscle is a sphincter (a doughnut shaped muscle) at the top of the oesophagus that relaxes when we swallow, this allows food and drink to pass into the oesophagus and then on down into the stomach. The muscle then tightens again between swallows to prevent regurgitation of food or liquids and to prevent us swallowing too much air.

However, on eating we all swallow small amounts of air. If the gas in the stomach builds up to certain level, the body allows the gas to re-enter the oesophagus, the cricopharyngeus will relax and the gas released as a “burp or belch”.

In RCPD the muscle will relax to allow the food and drink to pass into the oesophagus as normal, but it fails to relax to allow the expulsion of air from the oesophagus – hence “no burp”. Whilst the inability to burp may seem initially fairly minor – in reality it can cause quite significant issues for patients. The build up of gas can cause bloating and severe abdominal discomfort. The air trapped in the oesophagus often results in loud gurgling noises. Patients often avoid carbonated drinks as these can produce a large amount of gas and can be very painful. The passage of the air through the gut can also result in excessive flatulence. Some patients also avoid social situations where food and drink is present as they can be embarrassed by the symptoms.

Is it common?

RCPD was first described in 1987, and effective treatment only really came about in 2019. Many patients with this condition have been mistakenly diagnosed with gastro oesophageal reflux or irritable bowel syndrome. The true prevalence of the disorder is unknown but as the disorder is becoming more well recognised many more people are coming forward. There is no cause known but there does seem to be a preponderance in some families –members often coming forward when another has been diagnosed.

What is the treatment?

The treatment for RCPD involves injection of Botox into the muscles of the cricopharyngeus. Botox works by paralysing the muscles of the cricopharyngeus - symptom relief is not instant and can take about a week to take effect. In most cases a single dose is effective in overcoming the problem - it is thought that the paralysis may allow the brain to relearn how to relax the muscle and “burp”.

The Botox can be injected into the muscle under a general anaesthetic by directly visualising the muscle or under local anaesthetic. Studies seem to show that direct injection under a general anaesthetic is more effective, as the muscle can be directly identified and a higher dose of Botox injected to exactly where it is needed.

What do I expect on the day?

You would arrive at the hospital on the day of the operation. You would be seen by the surgeon and anaesthetist and the procedure performed under a general anaesthetic in the operating suite. You would eat and drink before leaving and be allowed home the same day.

What are the risks?

Overall, the procedure is a very safe with few risks. The anaesthetic does make you feel tired the following day and you would have a slightly sore throat from the injection. Damage to the teeth and lips is possible but unusual. Some people notice an increase feeling of acid reflux or a lump in the throat. Paralysis of the muscles of the voice box is very rare, but potentially very problematic issue.

Long term?

In most cases a single dose of Botox is enough to cure RCPD. Some patients will need a further dose and a very small number do not respond to the treatment.