What is rumination syndrome

Rumination syndrome is a condition in which people repeatedly and unintentionally spit up (regurgitate) undigested or partially digested food from the stomach, rechew it, and then either reswallow the food or spit it out. It is a reflex response, not a conscious decision. The food hasn’t been digested, so people with rumination syndrome often report that the food tastes normal, not acidic like vomit. Rumination typically occurs every day, and at every meal, usually within 30 minutes up to 1–2 hours after most meals. Rumination syndrome is a chronic condition that typically occurs after every meal, every day. However, rumination syndrome does occur in some otherwise healthy individuals.

The precise cause of rumination syndrome is unknown, but it’s clear that rumination is a subconscious behavior, not a conscious decision. Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) and gastroparesis. Some people have rumination syndrome and constipation caused by a rectal evacuation disorder.

The condition has long been known to occur in infants and people with developmental disabilities, which may be related to an unvoiced desire to reject food. But it can also occur in other children, adolescents and adults. Due to a lack of good data, the exact prevalence and incidence of rumination syndrome are unknown, but rumination syndrome is thought to be relatively rare.

Patients with rumination syndrome are frequently misdiagnosed, and they often misinterpret their own symptoms, with their descriptions of their symptoms being quite different than what is actually happening. Classically, a patient with rumination syndrome presents with “recurrent vomiting.” Other patients present with “regurgitation” or a label of gastroesophageal reflux disease (GERD). Unless a detailed history is obtained, the physician will likely conclude that the patient has gastroparesis or another vomiting syndrome (e.g, an eating disorder), and he or she will prescribe diagnostic tests and treatments for vomiting that will not help the patient.

Therefore, it is important for you to explain your symptoms in a little more detail to your doctor. When patients with rumination syndrome are asked to specify what they mean by “vomiting,” they often state that food or fluid that is undigested and tastes good comes back up into their mouth, and they either spit it out or reswallow it. Patients often assume that vomiting refers to gastric contents coming up. However, in the classic presentation of rumination syndrome, these patients are not experiencing actual vomiting. Vomiting requires forceful ejection of stomach contents; when vomiting, patients cannot retain food in their mouth, as they can with rumination syndrome.

Rumination syndrome causes

The causes of rumination syndrome are unknown. The belch reflex appears to become adapted. Rumination is commonly believed to be an unconscious learned disorder (i.e., a behavioral issue) involving voluntary relaxation of the diaphragm.

Rumination syndrome can begin in childhood or adulthood. In the past, rumination syndrome was reported mainly in children with disabilities, typically mental retardation. Rumination syndrome has been largely unrecognized in adults until relatively recently when physicians began to take more careful histories. It is still a common misconception that rumination syndrome occurs only in children with mental retardation.

Rumination syndrome diagnosis

The key to diagnosing rumination syndrome is obtaining a detailed history. In the absence of a good history, there is an excellent chance that the diagnosis will be missed, because there are no routine diagnostic tests of any value for rumination syndrome.

Doctors may sometimes use other tests to rule out other causes of symptoms of rumination syndrome:

• Esophagogastroduodenoscopy. This test allows your doctor to inspect your esophagus, stomach and the upper part of your small intestine (duodenum) to rule out any obstruction. The doctor may remove a small tissue sample (biopsy) for further study.
  Gastric emptying. This procedure lets your doctor know how long it takes food containing a marker to empty from your stomach. Another version of this test also can measure how long it takes food to travel through your small intestine and colon.
• Single-photon emission computerized tomography (SPECT) of the stomach — lets your doctor see how your stomach functions, and is helpful in deciding whether or not to use medications to relax the stomach. A SPECT scan is a type of nuclear imaging test, which means it uses a radioactive substance and a special camera to create 3-D pictures.

An esophagogastroduodenoscopy may be performed to make sure that the patient does not have esophagitis (which may be identified in a subset of patients); likewise, 24-hour esophageal pH testing may be used to identify pathologic acid reflux (which may be identified in approximately 50% of patients, typically in the first hour after a meal, with rapid changes in pH reflecting food reswallowing). However, these tests diagnose gastroesophageal reflux disease, not rumination, and patient with rumination syndrome will not respond to antireflux therapy.

In contrast, high-resolution gastroduodenal manometry and impedance measurement are of diagnostic value in rumination syndrome and are often used to confirm the diagnosis, but it is invasive. Rumination (tall R waves) can be seen in gastric manometry tracings in approximately 40% of patients. This testing also provides an image of the disordered function for use in biofeedback. Biofeedback is part behavioral therapy for rumination syndrome. During biofeedback, the imaging can help the patient diaphragmatic breathing skills to counteract regurgitation. However, this test is not routinely administered; it is a specialized test that is available in very few centers.

Rumination syndrome treatment

Treatment depends on the exclusion of other disorders, as well as on the person’s age and cognitive ability. Gastroenterologists (digestive disease specialists) work closely with pediatricians and psychologists to treat people with rumination syndrome.

Because rumination syndrome is likely behavioral in origin, it can be unlearned, which is the most effective method for its management.

Behavior therapy

Specialists typically use habit reversal behavior therapy to treat people without developmental disabilities who have rumination syndrome. People learn to recognize when rumination occurs, and to breathe in and out with the abdominal muscles (diaphragmatic breathing) during those times. Diaphragmatic breathing prevents abdominal contractions and regurgitation.

Diaphragmatic rebreathing training teaches patients to relax their diaphragm during and after meals; because rumination syndrome cannot occur in this setting, it is eventually extinguished (unlearned). This technique is relatively easy to learn and to perform. Usually, a behavioral psychologist helps teach the technique to patients, who must then apply it at appropriate times, typically from the beginning of meals. This technique has been effective in most patients.

For people who have mental or developmental disabilities, such behavioral treatment may not be possible. Treatment may involve mild aversive training — associating rumination with negative consequences — or other behavioral techniques.

For infants, treatment usually focuses on working with parents or caregivers to change the infant’s environment and behavior.

Medication

If frequent rumination is damaging the esophagus, proton pump inhibitors may be prescribed. These medications can protect the lining of the esophagus until behavior therapy reduces the frequency and severity of regurgitation.

Some people with rumination syndrome may benefit from treatment with medication that helps relax the stomach in the period after eating.

Untreated, rumination syndrome can damage the tube between your mouth and stomach (esophagitis) and cause unhealthy weight loss in adolescent patients.