Four weeks ago we presented the case of Mr Neville, a 22 year old student with persistent severe epigastric pain and regurgitation and vomiting after meals (BMJ 2006;332: 1438, 17 June). Aggressive treatment with acid suppression, prokinetics, and anti-emetics was not effective, and his symptoms led to life threatening weight loss over five months in hospital (BMJ 2006;332: 1496, 24 June).

Clinical observation suggested he had rumination syndrome, and this was confirmed by physiological measurements. In this condition food is returned to the mouth from the stomach by voluntary, although subconscious, contraction of the abdominal wall; the ruminant is then spat …