Differential Diagnosis and Treatment of Hypothesized Vagal Nerve Irritation Causing Variably Disabling Eructation over a 12-year Postpartum Period: A Case Report

Research Objectives: To describe the process that a pelvic floor physical therapist (PFPT) employed in evaluating, diagnosing, and treating a patient with a chronic, complex, rare, and disabling case of postpartum eructation (belching).

Design: Case Report

Setting: Ambulatory hospital-based outpatient physical therapy clinic.

Participants: A 49-year-old female presented 12 years postpartum with complaints of intense belching that began immediately postpartum, which occurred daily, usually lasting hours at a time, negatively impacting work and social participation. She was seen by multiple medical providers and underwent numerous diagnostic tests with no apparent cause identified and no improvement in symptoms. During the evaluation by the PFPT, pelvic floor hypertonicity, abdominopelvic weakness, restricted endopelvic fascia and viscera, and reduced flexibility were identified. Eructation symptoms were reproduced with palpation of the deep pelvic floor and ileocecal valve. Differential diagnosis included pelvic floor dysfunction, vagal nerve irritation, and visceral hypomobility. Her diagnosis was multifactorial, but given the function of the vagus nerve and the profound increase in intra-abdominal pressure during childbirth, vagal nerve irritation was hypothesized as the primary symptom driver.

Interventions: Treatment consisted of pelvic floor release using manual therapy techniques, abdominal viscera and endopelvic fascia release, generalized flexibility, core strengthening, dietary modification, diaphragmatic breathing, and a home exercise program that included self-pelvic floor release.

Main Outcome Measures: The atypical presentation of this patient’s symptoms could not be adequately reflected in any available standardized outcome measure. Subjective report, manual muscle testing of the pelvic floor, assessment of abdominopelvic structures, and reproduction of symptoms were utilized to determine effectiveness of the interventions.

Results: Following six months of intervention (25 visits) the patient reported a 70% reduction in symptoms and was able to fully participate in desired social activities and complete required work duties. Follow-up at 6 months post-discharge revealed all improvements had been sustained.

Conclusions: Postpartum functionally impactful eructation due to vagal nerve irritation is not discussed in the literature. The vagus nerve is poorly understood relative to abdominopelvic dysfunction. Treatment of the vagus nerve and pelvic structures demonstrated a subjectively significant improvement in quality of life and function for this patient. Many factors likely contributed to symptom reduction, but specific PFPT was found to be effective. Given the long-term, ongoing presentation of this patient’s symptoms, it is unlikely that spontaneous improvement took place, although this cannot be fully discounted. Further research related to this condition is warranted.

Author(s) Disclosures: Neither author has any disclosures to report.