What is regurgitation?

Understanding Regurgitation

Regurgitation is defined as the passage of gastric contents into the esophagus, which may reach the mouth or not. It is a common physiological process that occurs several times a day in healthy infants, children, and adults 1.

Types and Characteristics of Regurgitation

Gastroesophageal Reflux (GER)

• GER is considered a normal physiologic process that occurs several times a day in healthy individuals 1
• It is generally associated with transient relaxations of the lower esophageal sphincter independent of swallowing, which permits gastric contents to enter the esophagus 1
• Episodes of GER in healthy adults typically occur after meals, last less than 3 minutes, and cause few or no symptoms 1
• In infants, regurgitation or "spitting up" is reported to occur daily in 50% of all infants 1

Distinguishing GER from GERD

• GER is distinguished from gastroesophageal reflux disease (GERD), which includes troublesome symptoms or complications associated with GER 1
• It's important to identify and distinguish children with GERD, who may benefit from further evaluation and treatment, from those with simple GER, in whom conservative recommendations are more appropriate 1

Rumination Syndrome

• Rumination is differentiated from regurgitation and vomiting as a condition where recently ingested food is effortlessly regurgitated into the mouth, masticated, and reswallowed 1
• It is characterized by near effortless postprandial regurgitation without preceding nausea or retching, occurring only during and up to 2 hours after meals, never at night 1
• The regurgitated food tastes "pleasant" (not acidic) so it can be chewed and re-swallowed 1
• It was previously thought to be confined to childhood and those with developmental disabilities but is now recognized to occur at all ages 1
• The cardinal event during or immediately preceding rumination is voluntary (although subconscious) abdominal wall contraction 1
• Rumination syndrome is a relatively rare clinical entity that involves the voluntary contraction of abdominal muscles 1, 2

Clinical Presentation and Diagnosis

Symptoms and Characteristics

• Regurgitation can present as a bitter taste in the mouth or a sense of fluid moving up from the stomach 3
• It occurs in approximately 80% of GERD patients with varying severity 3
• Regurgitation is less responsive to acid suppression than heartburn in patients with GERD 4
• The symptom is probably mediated more by fluid volume than by the acidity of the refluxate 3

Diagnostic Approaches

• For rumination syndrome, high-resolution manometry with impedance after a test meal can identify diagnostic features when the diagnosis is unclear 1
• Typical features include a pressure rise in the abdomen (>30 mm Hg) and in the esophagus extending to the proximal esophagus, together with an open lower esophageal sphincter and upper esophageal sphincter 1
• The addition of impedance/pH monitoring confirms fluid regurgitation and helps differentiate variants associated with belching and acid reflux episodes 1

Treatment Considerations

Medical Management

• Proton pump inhibitors (PPIs) have a therapeutic gain above placebo of only 17% for regurgitation compared with 41% for heartburn 3, 4
• Increasing PPI dosage is often ineffective for regurgitation, as doubling the PPI dose does not incrementally decrease gastric juice volume 3

Procedural Interventions

• For refractory regurgitation, newer antireflux procedures (magnetic sphincter augmentation and transoral fundoplication) have demonstrated success in over 85% of patients 3
• In contrast, increased PPI dosing helps in approximately only 15% of patients with refractory regurgitation 3

For Rumination Syndrome

• Targeted diaphragmatic breathing is recommended as the primary treatment for rumination syndrome 2

Special Considerations

Valvular Regurgitation

• Valvular regurgitation refers to the backward flow of blood through a heart valve that doesn't close properly 1
• Mitral regurgitation can be acute (life-threatening) or chronic and is often secondary to left ventricular dysfunction 1
• Aortic regurgitation is characterized by diastolic reflux of blood from the aorta into the left ventricle 5
• Acute aortic regurgitation typically causes severe pulmonary edema and hypotension and is a surgical emergency 5

Anesthetic Risk

• Patients taking glucagon-like peptide-1 receptor agonists (GLP-1 RAs) such as semaglutide may be at increased risk of regurgitation under anesthesia due to delayed gastric emptying, even after standard fasting periods 6

Clinical Implications

• Regurgitation significantly lessens quality of life in 10-20% of GERD patients 3
• Persistent regurgitation is a common cause of incomplete treatment response in GERD patients 4
• Precision care of regurgitation should recognize the low therapeutic impact of acid control, while considering antireflux procedures for refractory cases 3