BMJ  2006;333:135 (15 July), doi:10.1136/bmj.333.7559.135

Commentary

Lessons on functional diseases

Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia azer2000{at}optusnet.com.au

Kenneth Neville's case raises the question whether we should teach general practitioners and medical students about functional oesophageal disorders.¹ This question is particularly important now that most medical schools are implementing a problem based or case based curriculum. The philosophy of these courses is to focus on key concepts and reduce detail in the subject matter. Conditions such as rumination syndrome will not be considered important and will be omitted.

Interestingly, major medical textbooks also show a deficiency in this area. For example, the last editions of Harrison's Principles of Internal Medicine and Cecil Textbook of Medicine provide only a three line definition of the condition,^{2 3} and Davidson's Principles and Practice of Medicine⁴ and Medicine⁵ do not mention rumination syndrome. The only textbook that provides more detail and criteria for diagnosis is Kumar and Clark's Clinical Medicine.⁶ This lack of information about functional oesophageal disorders might partly explain why the condition is usually misdiagnosed and not considered in the differential diagnosis.⁷

My aim here is not to recommend teaching this syndrome to medical students—what is more important is to highlight common grounds for functional disorders, whatever organ they affect, and what differentiates them from pathological conditions. The common grounds for functional disorders may include:

• Absence of nocturnal symptoms
  
• Absence of mechanical or pathological obstruction
  
• No response to standard treatment
  
• Negative results of standard laboratory investigations
  
• Key for their diagnosis is the medical history.
  

Diagnostic criteria

The second lesson from this case is the need for consensus clinical criteria for the diagnosis of rumination syndrome. Chial and colleagues recently examined the clinical features, results of diagnostic testing, and treatment outcomes for 147 children and adolescents with rumination syndrome.⁸ Their work concluded with proposed clinical criteria.⁸ Such criteria should be used in conjunction with the common grounds differentiating functional from pathological conditions. When patients show the typical clinical features, extensive diagnostic testing including gastroduodenal manometry and oesophageal pH testing is unnecessary.

The third lesson is the value of reviewing the patient's medical history and clinical signs and interpreting laboratory tests in the light of the patient's presentation. This is particularly important when patients do not respond to standard treatment and their condition is not improving. Instead of focusing on a particular diagnosis, clinicians may find it helpful to ask these two open ended questions: "Am I dealing with a pathological or a functional condition? What evidence do I have to justify my answers?"

Case scenarios reflecting challenging conditions, similar to this case, are engaging, thought provoking, and stimulating to self directed learning. Such cases are valuable for continuing medical education and are useful in complementing undergraduate medical curriculums, particularly when they are written with specific educational objectives.

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Competing interests: None declared.

References

1. Fox M, Young A, Anggiansah R, Anggiansah A, Sanderson J. A 22 year old man with persistent regurgitation and vomiting: case outcome. BMJ 2006;333: 133.[Free Full Text]
2. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill, 2005.
3. Goldman CL, Ausiello D, eds. Cecil textbook of medicine. 22nd ed. Philadelphia: Saunders, 2004.
4. Haslett C, Chilvers ER, Boon NA, Colledge NR, Hunter JAA. Davidson's principles and practice of medicine. 19th ed. Edinburgh: Churchill Livingstone, 2002.
5. Axford J, O'Callaghan C. Medicine. 2nd ed. London: Blackwell Science Publishing, 2004.
6. Kumar P, Clark M, eds. Kumar and Clark's clinical medicine. 6th ed. Philadelphia: Saunders, 2006.
7. Thumshirn M, Camilleri M, Hanson RB, Williams DE, Schei AJ, Kammer PP. Gastric mechanosensory and lower esophageal sphincter function in rumination syndrome. Gastrointest Liver Physiol 1998;38: G314-21.
8. Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination syndrome in children and adolescents: diagnosis, treatment and prognosis. Pediatrics 2003;111: 158-62.[Abstract/Free Full Text]

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A 22 year old man with persistent regurgitation and vomiting: case outcome

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