What is the management of Rumination Syndrome (RS), a disorder characterized by regurgitation?

From the Guidelines

Rumination regurgitation disorder management should prioritize a comprehensive approach combining behavioral techniques, such as diaphragmatic breathing and habit reversal training, as the primary treatment, with medications and lifestyle modifications considered as adjunctive therapies. According to the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring 1, rumination syndrome can be confidently diagnosed clinically on the basis of a typical history, and if the diagnosis is unclear, high-resolution manometry (HRM) with impedance after a test meal can be utilized to identify diagnostic features. Key diagnostic criteria include at least 3 months of regurgitation without preceding nausea or retching only during and up to 2 hours after meals, never at night, and the regurgitated food tastes ‘pleasant’ (not acidic) so the food can be chewed and re-swallowed 1. Some important considerations for management include:

• Diaphragmatic breathing exercises to counteract abdominal wall contractions that cause regurgitation
• Habit reversal training to identify warning signs of rumination and implement competing responses
• Biofeedback therapy to help patients visualize and control their abdominal muscles
• Medications such as baclofen to relax the lower esophageal sphincter, and low-dose SSRIs like fluoxetine if anxiety is a contributing factor
• Dietary modifications, including eating smaller, more frequent meals, chewing thoroughly, avoiding trigger foods, and staying upright for 30-60 minutes after eating. These approaches work by addressing the physiological mechanisms of rumination, including the learned pattern of abdominal wall contractions and the pressure gradient between the stomach and esophagus that facilitates regurgitation, as noted in the guidelines by Trudgill NJ, et al. 1.

From the Research

Rumination Regurgitation Disorder Management

• The management of rumination regurgitation disorder is challenging and usually involves a combination of behavioral, pharmacological, and rarely surgical treatment 2.
• Behavioral therapy, consisting of diaphragmatic breathing, with or without biofeedback, remains the most effective treatment strategy for patients with rumination syndrome 3, 4.
• A randomized trial of behavioral therapy, biofeedback therapy led to a 74% reduction in rumination activity, vs. 1% during sham 3.
• Pharmacotherapy with baclofen, at a dose of 10 mg three times daily, is a reasonable next step in refractory patients and has been shown to lead to symptomatic improvement in 63% of patients with rumination syndrome 3, 4.
• Modulated cognitive behavioral therapy (CBT) targeting secondary psychological maintaining mechanisms has also been shown to be a highly effective therapeutic option, almost eliminating regurgitation 5.
• Other proposed adjunctive therapies include chewing gum, prokinetics, and antireflux surgery, but high-quality studies are generally lacking 6.

Diagnostic Approaches

• Rumination syndrome can be diagnosed primarily on the basis of Rome IV criteria after an appropriate medical work-up 4.
• Objective testing with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations 4.
• High-resolution esophageal manometry and 24-h pH impedance testing can also be used to diagnose rumination syndrome, but these tests are slowly losing interest due to their technical nature, time consumption, cost burden, and patient discomfort 2.
• Off-PPI 24-h impedance pH monitoring can suggest the possibility of rumination syndrome when it reveals frequent postprandial, non-acid reflux with a high symptom index 5.