Clinical features

Typical clinical features of rumination syndrome are summarised in box 1. Effortless regurgitation of recently ingested food and liquid is the cardinal symptom of rumination syndrome. This is usually not preceded by nausea or retching.6 ,7 ,10 Symptoms often start within minutes of eating and last for 1–2 h postprandially.1 ,3 ,6 ,9 The regurgitant is often recognisable undigested food, and is typically not described as acidic, bitter, or sour in taste. Sufferers often rechew, and up to 50% of sufferers reswallow the regurgitant.1 ,6 The patients make a conscious decision regarding the regurgitant once it is present in the oropharynx, which may depend upon the social situation at the time.12 Symptoms generally cease when the regurgitant becomes acidic. Halitosis is often a reason for referral.6 Weight loss is seen in a significant proportion (37–42%) of patients.1 ,3 Symptoms of postprandial ‘vomiting’ and weight loss in an adolescent predominantly female population often raise the question of an eating disorder.8 Many patients have prior admissions to hospital, and a small proportion (11% in one study) of patients require enteral or parenteral feeding for nutritional support.9 The symptoms of rumination syndrome may have a severe impact on a patient's quality of life.3 ,9

Diagnosis and investigation

The major difficulty with diagnosis is often a lack of awareness of the condition.1 ,6 ,7

The key to diagnosis is a thorough history, and in the majority of patients a typical history may be all that is required for a diagnosis of rumination syndrome.1 ,9 ,10 The diagnosis of rumination syndrome in adults should be based on the Rome III criteria12 and include both the following:

1. Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing.

2. Regurgitation is not preceded by retching.

The supportive criteria for a rumination diagnosis are first, regurgitation events are usually not preceded by nausea; second, cessation of the process when the regurgitated material becomes acidic; and last, regurgitant contains recognisable food with a pleasant taste (box 2). The diagnostic criteria in adolescents and infants have similar features (box 2).

In patients with an atypical pattern of symptoms, for example, when nausea, gastro-oesophageal reflux symptoms, abdominal pain or swallowing difficulties are reported, GORD, achalasia, gastric outlet or small bowel obstruction and delayed gastric emptying should be considered and ruled out through endoscopy, gastric emptying studies, imaging of the stomach or small bowel and oesophageal manometry and pH studies.13 In patients in whom concerns are raised regarding the possibility of an eating disorder, a psychiatric evaluation should be sought. In the case of diagnostic uncertainty, and in cases of poor patient acceptance of a possible diagnosis of rumination, combined high-resolution manometry (HRM) and impedance monitoring with a test meal may confirm the diagnosis.2 ,10 ,14–17

Rumination is thought to occur due to voluntary, although subconscious, abdominal wall contraction leading to increased intra-abdominal pressure and simultaneous lower oesophageal sphincter relaxation.11 ,18 Combined HRM with impedance monitoring classically shows an abrupt rise in intragastric pressure (abdominogastric strain) of at least 20 mm Hg above baseline with associated retrograde pressure gradient and movement of gastric contents across the lower oesophageal sphincter up to the mouth within 10 s of the strain event (figure 1). This is usually followed by primary or secondary oesophageal peristalsis to return oesophageal contents to the stomach. There may be an overlap with other gastrointestinal disorders such as GORD and belching.2 Combining impedance studies with HRM helps to distinguish between rumination and belching-regurgitation, as it allows differentiation between the liquid reflux typically seen with rumination and the gas reflux seen with belching.16

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Figure 1

Combined high-resolution manometry (HRM) and impedance monitoring following a test meal in a subject with rumination syndrome. The upper oesophageal sphincter is at the top of the figure and the lower oesophageal sphincter and stomach at the bottom. A sudden increase in intra-abdominal pressure due to subconscious abdominal muscle contraction is associated with lower oesophageal sphincter relaxation and there is retrograde movement of gastric contents on HRM and impedance. The rumination episode is followed by reswallowing of the regurgitant. (Figure courtesy of Dr J de Caestecker).

Management

In many patients, recognition and explanation of the diagnosis of rumination syndrome and reassurance may be all that is required as treatment.6 It should be explained that rumination is precipitated by an involuntary habit, with subconscious contraction of the abdominal muscles causing the regurgitation.19

There is a lack of controlled data on effective therapies for rumination syndrome. Behavioural therapies, biofeedback and diaphragmatic breathing are the mainstays of treatment.3 ,9 ,19–23 These therapies aid relaxation of the abdominal wall and reduce the abdominal wall contractions, which may induce symptoms. Even a single, brief intervention can help suppress ruminating events.2 Such behavioural interventions result in significant improvements in patients’ symptoms, with up to 30–43% of patients reporting complete symptom resolution and a further 28–55% reporting partial improvement.2 ,9

Diaphragmatic breathing is easy to learn and can be demonstrated to a patient during a routine clinic visit. Patients are asked to sit in a relaxed position. One hand is placed on the chest and the other on the abdomen just below the rib cage at the bottom of the sternum. The aim is to keep the hand on the chest almost still, while the hand on the abdomen rises and falls with the diaphragmatic breath. Each breath should last at least 3 s. Patients are encouraged to practice, and use, this technique during meals and following an episode of rumination. As a result, this pattern of breathing will begin to feel natural and may occur subconsciously.19 If these brief interventions are not effective then referral to a specialist behavioural psychologist has been recommended.2 ,19

Medications such as proton pump inhibitors (PPI) and antiemetics are often prescribed but are not of clear benefit in reducing symptoms.1 ,2 ,10 PPIs may, in fact, lengthen the period of rumination following a meal, which usually ceases when the food in the stomach becomes acidic.10 Chewing gum in the postprandial period has been shown to reduce rumination in the paediatric population.24 ,25 Baclofen (an agonist of gamma-aminobutyric acid receptor) has recently been shown to be effective in reducing the symptoms of rumination syndrome.26 The reduction in rumination episodes with baclofen appeared to correlate with increasing basal lower oesophageal sphincter pressure rather than with reducing the number of transient lower oesophageal sphincter relaxations, but it is possible that central effects of baclofen play a more important role.26 Unfortunately, baclofen's value in rumination may be limited by the common side effects of sedation and drowsiness with this agent. Low dose tricyclic antidepressants, to reduce gastric hypersensitivity, have been used as an adjunct, when pain is a significant symptom in combination with rumination.2 ,27

In patients refractory to medical and behavioural therapy, surgery in the form of a Nissen fundoplication has been reported to be an effective therapy for rumination syndrome.28 However, reports of successful surgery for rumination are limited to one small case series, with another case series describing five patients who were diagnosed after having had antireflux surgery, three of whom had had unrecognised rumination as the indication for their surgery.2 ,28 Surgery should be considered in refractory cases, particularly with significant nutritional problems, but appropriate counselling is important to mitigate the danger of the patient exchanging rumination for troublesome postfundoplication symptoms such as gas-bloat.