What is rumination syndrome?

Rumination Syndrome

Rumination syndrome is an underreported functional gastrointestinal disorder characterized by near effortless postprandial regurgitation of recently ingested food that can be rechewed, reswallowed, or spit out, occurring during or up to 2 hours after meals 1, 2.

Diagnostic Features

Rumination syndrome can be confidently diagnosed clinically based on typical history, but may require objective testing in unclear cases or when patients need convincing of the diagnosis.

Key clinical features include:

• Effortless regurgitation occurring during or up to 2 hours after meals 1
• Regurgitation absent at night 1
• No preceding nausea or retching 1
• Regurgitated food tastes "pleasant" (non-acidic) 1, 2
• Food can be rechewed and reswallowed 1, 2
• Symptoms present for at least 3 months 1

Associated symptoms may include:

• Heartburn
• Nausea
• Abdominal pain
• Weight loss 1

Pathophysiology

The cardinal mechanism involves:

• Voluntary (though often subconscious) abdominal wall contraction 1, 2
• Low pressure at the gastroesophageal junction 1
• Sudden rise in intragastric pressure (>30 mm Hg) 1, 2
• Open lower esophageal sphincter (LOS) and upper esophageal sphincter (UOS) 1
• Retrograde passage of gastric contents 1

Diagnostic Testing

When diagnosis is unclear or objective evidence is required:

• High-resolution manometry (HRM) with impedance after a test meal is the preferred diagnostic test 1, 2
• Characteristic findings include:
  • Pressure rise in abdomen (>30 mm Hg) 1, 2
  • Pressure rise extending to proximal esophagus 1, 2
  • Open LOS and UOS 1, 2
  • Impedance confirming non-acidic fluid regurgitation 1, 2

This testing helps differentiate rumination from variants associated with:

• Gastric or supragastric belching
• True acid reflux episodes 1

Epidemiology and Population

• Previously thought to be confined to children and those with developmental disabilities 1
• Now recognized to occur at all ages 1
• Relatively rare clinical entity compared to common GER/GERD 1
• Often misdiagnosed as refractory GERD or vomiting, leading to delayed diagnosis 3

Treatment Approaches

The first-line therapy for rumination syndrome is:

• Behavioral modification with diaphragmatic breathing 3
• Can be provided by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique 3

For refractory cases:

• Baclofen at 10 mg three times daily may be considered 3
• Tricyclic antidepressants combined with diaphragmatic breathing/relaxation techniques have shown effectiveness in addressing underlying gastric visceral hypersensitivity and anxiety 4

Differential Diagnosis

Important to differentiate from:

• Gastroesophageal reflux disease (GERD)
• Vomiting disorders
• Eating disorders (though rumination involves involuntary or subconscious behavior without intent to control weight) 2

Clinical Pitfalls and Caveats

• Patients often report "vomiting" or "reflux" rather than regurgitation, leading to misdiagnosis 5
• Diagnosis is frequently delayed (average 36 months from symptom onset to diagnosis in one study) 4
• Presence of nocturnal regurgitation, dysphagia, or nausea does not exclude rumination syndrome but makes it less likely 3
• Weight loss can be significant (ranging from 1.4 to 39.5 kg in some patients) 4
• Psychological factors are important - approximately 66% of patients report onset related to a psychological stressor 4

Early recognition and appropriate behavioral therapy are essential to improve outcomes and prevent complications such as significant weight loss and impaired quality of life.