OBJECTIVE Supragastric belching is a distinct belch pattern found in patients with excessive belching (aerophagia). Patients with gastroesophageal reflux disease (GERD) may also complain of belching. It has been shown that GERD patients swallow air more frequently and have more air-containing reflux episodes than do healthy controls. It is not known whether supragastric belches occur in patients with reflux symptoms. METHODS Fifty consecutive patients with typical reflux symptoms and 10 healthy volunteers underwent ambulatory 24-h pH-impedance monitoring off proton pump inhibitor therapy. Patients filled out a questionnaire regarding their symptoms. The number and type of reflux episodes and supragastric belches during the measurement were assessed. RESULTS In 24 of the 50 patients with reflux symptoms, supragastric belches were identified with a median incidence of 13 per 24 h (interquartile range: 6-52). In 5 of the 10 healthy volunteers 2, (1-6) supragastric belches were identified. In patients with reflux symptoms, 48% of the supragastric belches occurred in close temporal association with reflux episodes. Two different association patterns were observed. In 19 patients supragastric belches occurred immediately prior (<1 s) to the onset of the reflux episode. This pattern was observed in 30% of all supragastric belches. In 15 patients the supragastric belch occurred during the reflux episode, with the onset being 4-10 s after the start of the reflux episode. This pattern was observed in 18% of all identified supragastric belches. CONCLUSIONS Supragastric belches occur more frequently in patients with typical reflux symptoms than in healthy subjects. These belches often occur in close association with acid and weakly acidic reflux episodes. Our findings suggest that supragastric belching elicits reflux in some cases and is the patient's response to an unpleasant esophageal sensation in others.