Rumination Syndrome: Behavioral Therapy is the Treatment of Choice
This 15-year-old patient has rumination syndrome, a behavioral disorder characterized by effortless regurgitation triggered by stress (public speaking), and the treatment is behavioral therapy with diaphragmatic breathing techniques—not acid suppression. 1
Why This is Rumination, Not GERD
The clinical presentation is pathognomonic for rumination syndrome:
- Effortless regurgitation occurring specifically during stressful situations (public speaking) 1
- No other symptoms (no heartburn, no nausea, no retching) 1, 2
- Adolescent age group where rumination syndrome is increasingly recognized 1, 2
The British Society of Gastroenterology guidelines emphasize that rumination is characterized by "near effortless postprandial regurgitation" that occurs "without preceding nausea or retching," and the regurgitated material tastes "pleasant" (not acidic). 1 This distinguishes it completely from GERD.
Diagnostic Confirmation (If Needed)
If the diagnosis needs objective confirmation or the patient requires convincing evidence before accepting behavioral therapy, high-resolution manometry (HRM) with impedance after a test meal is diagnostic. 1
The diagnostic features include:
- Voluntary (though subconscious) abdominal wall contraction with pressure rise >30 mmHg 1
- Open lower and upper esophageal sphincters during regurgitation episodes 1
- Non-acidic regurgitated material confirmed by pH monitoring 1
However, the British Society of Gastroenterology states that "rumination syndrome usually can be confidently diagnosed clinically on the basis of a typical history" and testing is only needed when "the diagnosis is unclear, the patient needs convincing of the diagnosis or objective evidence is required prior to therapy." 1
Treatment Approach
Primary Treatment: Behavioral Therapy
The mainstay of treatment is behavioral modification, specifically diaphragmatic breathing techniques. 2 This addresses the underlying mechanism—the voluntary abdominal wall contraction that drives regurgitation.
What NOT to Do
Do not prescribe proton pump inhibitors (PPIs) or H2 receptor antagonists as primary therapy. 1, 2 These medications:
- Will not address the behavioral mechanism of rumination 2
- May only be considered as adjunctive therapy to reduce acid injury to the esophagus if there is concern for secondary esophagitis 2
- Should not be used empirically without confirming GERD 1
The American Academy of Pediatrics guidelines explicitly warn against empirical PPI therapy when the diagnosis is unclear, stating that "if acid suppression with PPIs is ineffective, the accuracy of the diagnosis of GERD should be reassessed" and that "clinical conditions, such as cyclic vomiting, rumination, gastroparesis, and eosinophilic esophagitis, should be carefully ruled out before surgery." 1
Common Pitfalls to Avoid
- Misdiagnosing as GERD and prescribing acid suppression therapy that will be ineffective 1, 2
- Failing to recognize the stress-triggered pattern (public speaking) which is the key diagnostic clue 1
- Ordering unnecessary endoscopy when the clinical diagnosis is clear 1
- Not explaining the behavioral nature of the condition to the patient and family, which is essential for treatment acceptance 2
When to Consider Gastroenterology Referral
Refer to pediatric gastroenterology if: