What is the diagnosis and treatment for Rumination Syndrome?

From the Guidelines

Rumination syndrome can be confidently diagnosed clinically on the basis of a typical history, but if the diagnosis is unclear, High-Resolution Manometry (HRM) with impedance after a test meal can be utilized to identify diagnostic features, as recommended by the British Society of Gastroenterology guidelines 1.

Diagnosis

The diagnosis of rumination syndrome is primarily based on a typical history of regurgitation without preceding nausea or retching, only during and up to 2 hours after meals, and never at night, with the regurgitated food tasting "pleasant" (not acidic) 1.

• A variety of other symptoms may be present, including heartburn, nausea, abdominal pain, and weight loss, making confident diagnosis by history alone not always possible.
• HRM with impedance after a test meal can provide additional confirmatory and diagnostic information, especially when the diagnosis is unclear or objective evidence is required prior to therapy 1.

Treatment

Treatment primarily focuses on behavioral techniques, particularly diaphragmatic breathing exercises, which involve breathing deeply from the diaphragm before and during meals to prevent abdominal contractions that cause regurgitation 1.

• Patients should practice this breathing technique for 5-10 minutes before meals and continue during eating.
• Biofeedback therapy can also help patients gain awareness and control over their abdominal muscles.
• In some cases, medications like baclofen (5-20 mg three times daily) or low-dose antidepressants may be prescribed to reduce symptoms.
• Psychological counseling may be beneficial, especially if stress or anxiety triggers symptoms.
• Maintaining good posture while eating, eating smaller meals, and avoiding distractions during meals can also help manage symptoms.

Key Characteristics

Rumination syndrome differs from conditions like GERD or bulimia as the regurgitation occurs without nausea and the food tastes normal rather than acidic 1.

• The cardinal event during or immediately preceding rumination is voluntary (although subconscious) abdominal wall contraction, associated with low pressure at the gastro-oesophageal junction, which is easily overcome by the sudden rise in intragastric pressure 1.

From the Research

Diagnosis of Rumination Syndrome

• The diagnosis of rumination syndrome is based on the Rome III or Rome IV diagnostic criteria 2, 3.
• A clinical diagnosis can be made in most patients, although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers 3.
• Antroduodenal manometry can be helpful to confirm the diagnosis, but is not required 2.
• A typical history can be highly suggestive, and a thorough medical work-up is necessary to rule out other conditions 3, 4.

Treatment of Rumination Syndrome

• The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing 5, 3.
• Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome 3.
• Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique 3.
• Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients 5, 3.
• Behavioral therapy consisting of diaphragmatic breathing, with or without biofeedback, remains the most effective treatment strategy for patients with rumination syndrome 5.
• Other therapies, such as habit reversal techniques, chewing gum, prokinetics, and antireflux surgery, have been proposed as adjunctive therapies, but high-quality studies are generally lacking 4.

Pathophysiology of Rumination Syndrome

• The pathogenesis of rumination syndrome remains incompletely understood 5, 2, 6.
• The pathophysiology involves a rise in intra-gastric pressure, generated by a voluntary, but often unintentional, contraction of the abdominal wall musculature, at a time of low pressure in the lower oesophageal sphincter, causing retrograde movement of gastric contents into the oesophagus 4.
• Learning-based theories, organic factors such as gastroesophageal reflux disease, and psychological disturbances (e.g., depression, anxiety) have been postulated as potential mechanisms of rumination 6.