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

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7559.133 (Published 13 July 2006) Cite this as: BMJ 2006;333:133

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Rumination syndrome in adolescents

Rumination Syndrome is a clinical syndrome characterized by virtually
daily, effortless regurgitation of recently ingested food into the
oropharynx without forceful retching. It is not associated with abdominal
pain or nausea, and the regurgitant does not taste sour or bitter. Food
may be partially or completely rechewed and reswallowed or expelled. The
syndrome is most commonly seen in infants and the developmentally
disabled. However, rumination syndrome does occur in children,
adolescents, and adults with normal intelligence. More recently, otherwise
normal adolescents and adults have been described who exhibit the same
clinical pattern. This occurs more often in females, but it is not
considered an eating disorder. Most individuals with rumination syndrome
regurgitate with every meal. Typically, the regurgitation is effortless
and within 10-20 minutes. The patient may exhibit halitosis or complain of
a sour taste rather than discomfort or typical peptic symptoms.

A careful history and identification of the recurrent, effortless,
painless regurgitations is often sufficient to make the diagnosis.
Observation of preceding air swallowing and contraction of the abdominal
wall (while the lower oesophagus and glottis relax) can clinch the
diagnosis without need for involved and often unnecessary investigations.
If available, antro-duodenal manometry will document the presence of the
diagnostic pressure pattern confirming the creation of a “common cavity”
between the stomach and the mouth.

Individuals with rumination syndrome are often misdiagnosed or
undergo extensive, costly, and invasive testing before diagnosis.
Insufficient awareness of the clinical features of rumination syndrome
contributes to the under diagnosis of this important medical condition.
Rumination syndrome is frequently confused with bulimia nervosa, gastro-
oesophageal reflux disease, and upper gastrointestinal motility disorders
including gastro paresis and chronic intestinal pseudo-obstruction.
Complications of rumination syndrome include weight loss, malnutrition,
dental erosions, halitosis, electrolyte abnormalities, and significant
functional disability.
Rumination syndrome is a clinical diagnosis based on symptoms and the
absence of structural disease.
Proposed Criteria for Rumination Syndrome in Children and Adolescents:-

At least 6 wk, which may not be consecutive, in the previous 12 mo of
recurrent regurgitation of recently ingested food which:

1. Begins within 30 min of meal ingestion.

2. Is associated with either reswallowing or expulsion of food.

3. Stops within 90 min of onset or when regurgitant becomes acidic.

4. Is not associated with mechanical obstruction.

5. Does not respond to standard treatment for gastro-oesophageal
reflux disease ( i.e., medical therapy or lifestyle modification measures)

6. Stops within 90 min of onset or when regurgitant becomes acidic.

7. Is not associated with mechanical obstruction.

8. Does not respond to standard treatment for gastro-oesophageal
reflux disease (i.e., medical therapy or lifestyle modification measures)

9. Is not associated with nocturnal symptoms.

10. Begins within 30 min of meal ingestion.

11. Is associated with either reswallowing or expulsion of food.

In a study conducted on evaluating in detail the motor and sensory
functions of the proximal stomach in patients with rumination syndrome it
was found that with regards to motor function, the study demonstrated two
types of accommodation after meal ingestion among patients with rumination
syndrome: one subgroup with normal postprandial accommodation and a second
group with diminished or absent accommodation. Clearly, this diminished
accommodation is of potential patho- physiological importance in a subset,
not all, of these patients. This impaired accommodation was not due to the
regurgitation episodes per se. It was conceivable that regurgitation
itself may evoke motion artefacts or that abdominal muscle contractions
could artificially decrease intra-bag volume. However, the study excluded
episodes of regurgitation or movements that were associated with abdominal
wall activity from the analysis of tone. Patients who regurgitated in the
postprandial period were equally distributed among the two subgroups; thus
we can exclude artefact from regurgitation as the reason for the
differences in the two subgroups.

However the psychiatric nature of rumination syndrome still holds
importance. In the Diagnostic and Statistical Manual of Mental Disorders
rumination is listed exclusively under "eating disorders of infancy." An
association between rumination and bulimia nervosa has been described, and
rumination is recognized as a collateral behaviour disorder among these
patients. Rumination may be regarded as a "forme frusta" of other eating
disorders such as bulimia, bulimarexia, or anorexia nervosa. In the latter
groups, eating behaviour, mood, body perception, and disturbances in
neurohormonal function have been linked to changes in metabolism of
several monoamines (such as nor epinephrine, dopamine, serotonin) and
endogenous opioids. Whether similar neurohormonal changes are present in
rumination syndrome is unknown and needs further investigation. However,
there is increasing evidence that endogenous monoamines alter gastric
mechanosensory function, through 2-adrenergic receptors and 5HT1D
receptors . Further physiological and pharmacological studies may shed
important light on the mechanism of rumination and its pharmacological
correction. This is particularly important for the subgroup of patients
[at least 20% in our experience ] who do not respond to habit reversal
with diaphragmatic breathing as part of a behavioural therapy, which are
mostly applied. In infants, this involves developmental stimulation. In
adolescents and adults, teaching patients diaphragmatic breathing and
other behavioural techniques seems effective in some, while the rumination
can be stubborn and difficult to dissipate in others. Determination of any
underlying psychiatric disorders and directing appropriate medical and
psychological therapy is important in achieving successful treatment. The
recently reported Mayo Clinic experience suggests a favourable prognosis
in most. There is association of Sandifer syndrome with rumination
syndrome.

References:

1. Heather J. Chial, MD, et al, “Rumination Syndrome in Children and
Adolescents: Diagnosis, Treatment, and Prognosis.” PAEDIATRICS Vol. 111
No. 1 January 2003, pp. 158-162.

2.Miriam Thumshirn, et al, “Gastric mechanosensory and lower
oesophageal sphincter function in rumination syndrome.” American Journal
Physiology Gastrointestinal Liver Physiology. 275: G314-G321, 1998; 0193-
1857/98.

3. Mark Fox, et al, “A 22 year old man with persistent regurgitation
and vomiting: case outcome.” BMJ 2006; 333: 133 .

Competing interests:
None declared

Competing interests: No competing interests

26 July 2006
Hassan K Chaudhry
Studying for PLAB2
DE22 3JB