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Review
Managing a patient with rumination
  1. Benjamin Disney,
  2. Nigel Trudgill
  1. Department of Gastroenterology, Sandwell General Hospital, Lyndon, West Bromwich, UK
  1. Correspondence to Dr N J Trudgill, Department of Gastroenterology, Sandwell General Hospital, Lyndon, West Bromwich B71 4HJ, UK; nigel.trudgill{at}nhs.net

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Clinical case

A young woman with persistent vomiting was referred by her general practitioner. On detailed questioning, the patient reported an 8-month history of daily regurgitation of undigested food within minutes of eating. There was no preceding nausea. She reported no abdominal pain; however, she had lost 19 kg from a weight of 75 kg before her illness. Her family were concerned that she had an eating disorder, which was ruled out after a psychiatric evaluation.

In view of her significant weight loss, she underwent extensive investigation, including an oesophagogastroduodenoscopy, barium follow-through, CT and MRI head and synacthen test, all of which were normal. Standard oesophageal manometry and a 24 h pH study were also normal. She had recurrent admissions to hospital and required periods of enteral feeding for nutritional support. Proton pump inhibitors and antiemetics were of no symptomatic benefit. She was eventually referred for high-resolution manometry (HRM) and impedance monitoring with a test meal, which confirmed the diagnosis of rumination syndrome. The patient subsequently responded well to behavioural therapy.

Introduction

Rumination is derived from the Latin ‘ruminare’, the literal translation being to chew the cud. It has long been recognised in animals (eg, sheep and cattle) in whom food is regurgitated, rechewed and reswallowed, as an essential part of the digestive process.1

Rumination syndrome is the voluntary, albeit subconscious, return of gastric contents into the mouth followed by remastication, reswallowing or expulsion.2 It is underdiagnosed, probably due to limited awareness of the condition, and is often misdiagnosed as dyspepsia, persistent vomiting, gastroparesis, regurgitation associated with gastro-oesophageal reflux disease (GORD), or in some cases as an eating disorder.1 ,3 The exact prevalence of the condition is unknown. Patients are often referred to several different physicians, undergoing multiple and often repeated investigations, and have symptoms for up to 6.5 years before a diagnosis …

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