Rumination in Adults

Rumination syndrome is a functional gastroduodenal disorder in which food recently swallowed is regurgitated effortlessly into the mouth, within minutes (usually within 30 minutes) of a meal, and is then re-chewed and re-swallowed or spat out. It is not preceded by retching, and is not caused by organic disease.

Diagnosis needs:

• persistent or recurrent regurgitation of recently ingested food into the mouth, for at least 3 months with onset at least 6 months before diagnosis
• subsequent spitting or re-chewing and swallowing
• no preceding retching
• not explained by another disorder

• Prevalence: about 1 to 2% of adults in surveys, but it is under recognised and often misdiagnosed as gastro oesophageal reflux disease, gastroparesis, bulimia nervosa, or functional vomiting.
• It occurs in both sexes (slight female predominance), with a bimodal distribution (young adults and people with intellectual disability or neurodevelopmental disorders), and is common in people with anxiety, depression, a history of trauma or eating disorders, and in athletes.
• Mechanism: a learned, unconscious (or conscious) behaviour in which the abdominal wall muscles contract and the diaphragm descends, causing an increase in intra abdominal and intragastric pressure, along with simultaneous relaxation of the lower oesophageal sphincter (a gastric pressure and oesophageal reflex).
• This is called an increased gastro oesophageal pressure gradient (a "supragastric belch" and rumination events show a rise in intra abdominal pressure and a rapid drop in oesophageal pressure that fills the oesophagus from the stomach).
• Triggers: meals (especially large meals), stress, anxiety, food that was recently eaten, and acute gastroenteritis (post-infectious onset in some). It may be a conditioned behaviour that stays with the patient for years.
• Complications: weight loss and malnutrition (in about 10 to 40%), dental erosion, halitosis, oesophagitis, aspiration, electrolyte disturbance, social embarrassment, avoidance of eating in public, anxiety and depression, and reduced quality of life.
• The condition has a good prognosis when recognised and treated with behavioural therapy. Delay in diagnosis is typically several years.

• Effortless regurgitation of undigested, recently eaten food (which tastes normal, not sour or bitter, since it has not yet been mixed with gastric acid) shortly after beginning a meal or within 30 minutes of a meal. It occurs at least several times per week, and lasts up to 1 to 2 hours (stopping when the regurgitated material becomes acidic).
• The patient may re-chew and re-swallow the material or spit it out. A feeling of fullness, abdominal pressure or a belch often precedes the event.
• Absence of nausea, retching and forceful vomiting (which differentiates it from functional vomiting). Some patients report mild nausea or heartburn, and others have chest and abdominal discomfort, bloating and diarrhoea or constipation.
• Weight loss in some patients, especially those who avoid eating to prevent regurgitation.
• Examination: usually normal. Look for dental erosion, parotid enlargement, low body weight, and signs of dehydration.
• Differential diagnosis: gastro oesophageal reflux disease (regurgitation with sour taste, heartburn, and no re-swallowing, and worse when lying down), functional vomiting, gastroparesis (vomiting of food eaten hours earlier, with nausea).
• Other causes: achalasia (regurgitation of undigested food with dysphagia), oesophageal diverticulum (Zenker diverticulum), cyclic vomiting syndrome, bulimia nervosa (self-induced), supragastric belching, eosinophilic oesophagitis, hiatus hernia, and gastric outlet obstruction.
• Red flags: dysphagia, odynophagia, haematemesis, melaena, significant weight loss, vomiting with nausea and retching, abdominal pain or distension, and fever. Further red flags: regurgitation of food eaten hours before, nocturnal regurgitation with choking or aspiration, neurological signs, age over 50 years with new onset, and a family history of upper gastrointestinal cancer.

• Clinical diagnosis based on a typical history (the key features are effortless regurgitation of food just eaten, absence of nausea and retching, re-chewing, and a pleasant or neutral taste), supported by the response to behavioural therapy.
• Exclude organic disease where red flags are present or the diagnosis is unclear:
  • Upper endoscopy (with oesophageal biopsies for eosinophilic oesophagitis) to exclude oesophagitis, stricture, hiatus hernia, outlet obstruction, and malignancy.
  • Gastric emptying scintigraphy (a 4 hour solid meal study) to exclude gastroparesis (rumination is usually associated with normal or rapid emptying).
  • Barium swallow to exclude achalasia, diverticulum, or stricture.
  • Blood tests: full blood count, electrolytes, urea, creatinine, glucose, albumin, thyroid function tests, and coeliac serology in patients with weight loss or malabsorption.
• High resolution oesophageal manometry with impedance (done after a test meal of about 500 to 1000 kcal): the best test.
• It shows a rise in intragastric pressure (abdominal pressure) of at least 30 mmHg before regurgitation, which is transmitted across the gastro oesophageal junction (R-wave pattern: a pressure spike across the whole oesophagus), followed by a retrograde flow of material on impedance.
• The test is not always needed, but helpful for atypical presentations and for distinguishing supragastric belching and gastro oesophageal reflux.
• 24 hour pH-impedance monitoring when reflux is a differential, since most regurgitation events in rumination are non-acid reflux events immediately after meals.
• Screen for eating disorders (bulimia nervosa, avoidant restrictive food intake disorder), anxiety, depression, trauma, and substance use, and assess weight and nutrition.

• Explain the diagnosis as a learned and habitual behaviour (not a psychiatric illness, not self-induced vomiting, and not a structural problem), and that it is treatable. Treatment starts with this explanation, which in itself helps reduce symptoms.
• Behavioural therapy (diaphragmatic breathing) is the first line and most effective treatment (about 70 to 80% of patients improve):
  • Training (by a trained physiotherapist, psychologist or gastroenterology nurse) in diaphragmatic (abdominal) breathing, to prevent the abdominal contraction that generates the pressure gradient.
  • The patient lies or sits upright with one hand on the chest and one hand on the abdomen, and breathes in through the nose so the abdomen rises. The patient breathes out slowly through pursed lips for 4 to 8 seconds, keeping the chest still, for about 10 breaths.
  • Practise 5 to 10 minutes 3 to 4 times a day, then use the technique for 10 to 30 minutes after every meal (or at the first sign of the urge to regurgitate), and at the first awareness of the urge. Keep a diary of events.
  • Competing response: when the urge occurs, replace the abdominal contraction with slow diaphragmatic breathing, and continue until the urge settles (usually 10 to 20 minutes). The incompatibility of diaphragm relaxation with abdominal wall contraction suppresses rumination.
  • Biofeedback with electromyography of the abdominal wall muscles or manometry provides feedback and improves response (4 to 6 sessions).
  • Add habit reversal, relaxation training, and education about meal related pressure.
• Dietary and lifestyle advice: eat slowly in a relaxed setting, in smaller meals, chew thoroughly, avoid talking while eating, avoid lying down or slouching after meals (sit upright), reduce carbonated drinks, avoid very large or high fat meals, and adopt regular meal times.
• Drug treatment (adjuncts when behavioural therapy is inadequate or is not available):
  • Baclofen 5 mg orally 3 times daily before meals, increased to 10 mg 3 times daily after 1 to 2 weeks (a GABA-B agonist that reduces lower oesophageal sphincter relaxation and the rumination events), with a reduction in events of about 50% in studies. Adverse effects: drowsiness, dizziness, weakness, and confusion. Avoid abrupt cessation. Reduce the dose in renal impairment.
  • Proton pump inhibitor (omeprazole 20 mg once daily for 4 to 8 weeks) when oesophagitis, heartburn, or reflux symptoms coexist.
  • Neuromodulators for anxiety and depression, and visceral hypersensitivity: amitriptyline 10 mg at night, increased to 25 to 50 mg (use caution because of anticholinergic effects), sertraline 25 to 100 mg daily, or citalopram 10 to 20 mg daily.
  • Antiemetics such as ondansetron have little benefit for rumination without nausea.
  • Avoid prokinetic agents unless gastroparesis is proven.
• Treat complications: replace electrolytes, correct dehydration, give dietitian support and oral nutrition supplements (with enteral feeding by nasogastric or nasojejunal tube in severe weight loss). Treat oesophagitis with a proton pump inhibitor, and dental review for erosion (fluoride varnish, and avoiding brushing teeth immediately after regurgitation).
• Psychological therapy: cognitive behavioural therapy, relaxation, and treatment of anxiety, depression, trauma or an eating disorder, with specialist referral when these are present. Distinguish from bulimia nervosa (where vomiting is self-induced with weight and shape concerns).
• Special groups:
  • Children and adolescents: rumination is more common in those with developmental delay, and in adolescents with anxiety. Use behavioural therapy, reassurance, family involvement, and psychological support, with baclofen 5 mg 3 times daily as an adjunct for older children in specialist care.
  • Pregnancy: use behavioural therapy and diet advice, and avoid baclofen unless essential. Differentiate from hyperemesis.
  • Elderly: investigate for organic disease (stricture, diverticulum, neurological disease), and use lower doses of baclofen (2.5 to 5 mg) because of sedation and falls.
  • Intellectual disability: carers and behavioural specialists use environmental and behavioural strategies (diversion, positive reinforcement, and meal supervision).
  • Athletes and those with eating disorders: involve a dietitian and psychologist, and monitor weight.
  • Renal impairment: reduce baclofen to 5 mg 2 to 3 times daily or avoid it.
• Follow up: review at 2 to 4 weeks after starting behavioural therapy, to reinforce technique, and at 3 months. Relapse occurs with stress, so provide a plan for refresher sessions. Refer to a gastroenterologist or specialist psychologist for unclear diagnosis, failure of behavioural therapy, weight loss, or coexisting eating disorders.