Rumination disorder

Signs and symptoms of rumination disorder includes the backward flow of recently eaten food from the stomach to the mouth. This typically occurs immediately to 15 to 30 minutes after eating. Rumination often occurs without retching or gagging. Rumination may be proceeded by a feeling of pressure, the need to belch, nausea, or discomfort. Some people with rumination disorder experience bloating, heartburn, diarrhea, constipation, abdominal pain, headaches, dizziness, or sleeping difficulties. Complications of severe disorder include weight loss, malnutrition, and electrolyte imbalance.^[2]

Rumination disorder may occur following a viral illness, emotional stress, or physical injury.^[2] It is theorized that while the initial stressor improves, an altered sensation in the abdomen persists. This ultimately results in the relaxation of the muscle at the bottom of the esophagus. To relieve this discomfort people with rumination disorder use abdominal wall muscles to expel and regurgitate foods. As a result of the relief of symptoms, the person repeats the same response when the discomfort returns. Overtime the person unconsciously adopts this learned behavior.

Some cases of rumination disorder occur without a precipitating event or illness. Other people with the disorder describe also having ingestion, which may serve as a trigger. Studies have shown that some people with rumination disorder also have depression, anxiety, or an eating disorder. These conditions may likewise play a role in rumination disorder. Conditions like depression and anxiety are known to be more common in people with other functional gastrointestinal conditions as well, for example irritable bowel syndrome.^[2]

Diagnosis can be made by a clinical evaluation of the person’s signs and symptoms and history. The following diagnostic criteria is used to aid in diagnosis.^[1][2] These criteria must be met for the last 3 months, with symptoms beginning at least 6 months prior to diagnosis:^[2]

1. Repeated regurgitation and rechewing or expulsion of food that

     a. Begins soon after eating
     b. Does not occur during sleep
     c. Does not respond to standard treatment for GERD

2. No Retching

3. Symptoms are not explained by inflammatory, anatomic, metabolic, or neoplastic processes

These criteria help distinguish rumination syndrome from other disorders of the GI tract, such as gastroparesis and achalasia where vomiting occurs hours after eating, gastroesophageal reflux where symptoms occur at night, and cyclic vomiting syndrome where the symptoms are chronic/persistent.^[2]

Antroduodenal manometry can assist in making and confirming the diagnosis.^[1][2] Antroduodenal manometry involves putting a catheter through the nose into the stomach and small bowel to measure pressure changes.

The main treatment of rumination disorder is behavioral therapy. This may involve habitat reversal strategies, relaxation, diaphragmatic breathing, and biofeedback. These types of therapies can often be administered by a gastroenterologist.^[2] Other professionals, such as nurse practitioners, psychologists, massage therapists, and recreational therapists may also be involved in care. Ensuring adequate nutrition is essential and treatment will also involve managing other symptoms, such as anxiety, nausea and stomach discomfort (which may involve anti-depressive agents or SSRI’s).^[2]

If behavioral therapy is unsuccessful, treatment with baclofen may be considered. There is limited data regarding optimal treatment of rumination disorder, but success with baclofen has been reported.^[2]