Rumination Syndrome

Rumination syndrome is a functional gastroduodenal disorder with effortless, repetitive regurgitation of recently ingested food into the mouth, followed by re-chewing and swallowing or spitting.

• Prevalence 1 to 2% in adults, more frequent in adolescents, patients with intellectual disability, eating disorders, anxiety, and after gastroenteritis.
• Mechanism: learned behaviour with voluntary or involuntary abdominal wall contraction raising intragastric pressure, with gastro oesophageal reflux through a relaxed lower oesophageal sphincter.
• Rome IV: persistent or recurrent regurgitation within minutes of eating (not preceded by retching), not occurring during sleep, for 3 months.
• Often misdiagnosed as gastro oesophageal reflux, gastroparesis or bulimia.
• Complications: weight loss, malnutrition, dental erosion, oesophagitis, aspiration.

• Effortless regurgitation of undigested food within 30 minutes of meals, often lasting up to 1 to 2 hours, sometimes followed by re-swallowing.
• Food tastes normal and non acidic (regurgitant is not sour or bitter).
• Absence of nausea and retching preceding episodes, unlike vomiting.
• Abdominal discomfort or bloating before episodes relieved by regurgitation.
• Weight loss in about 40%, and dental problems.

• Clinical diagnosis from history using Rome IV.
• Exclude structural disease and mimic conditions with upper endoscopy and gastric emptying study when indicated.
• High resolution impedance manometry with a test meal: increase in intragastric pressure (abdominal contraction) coincident with retrograde flow of the bolus (R wave pattern).
• Eating disorder screening and psychological evaluation.
• Nutritional assessment: BMI, albumin, electrolytes.

• Explanation and reassurance that the behaviour is learned and reversible.
• Diaphragmatic breathing (first line behavioural therapy): during and for 30 to 60 minutes after meals, in the upright posture, breathing slowly with abdominal expansion, which competes with abdominal wall contraction. Success in 70 to 80% after 3 to 4 sessions; biofeedback with electromyography enhances learning.
• Remove triggers: eat slowly, avoid lying down after meals, gum chewing postprandially.
• Baclofen 10 mg three times daily before meals (GABA B agonist, reduces transient lower oesophageal sphincter relaxation, 50 to 60% reduction in episodes).
• Proton pump inhibitor for oesophagitis if present.
• Cognitive behavioural therapy for associated anxiety and psychological factors; treat eating disorder.
• Surgery (fundoplication) is not routinely indicated.
• Follow up for weight, nutrition and dental health.