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Overview
Rumination syndrome is a condition in which people repeatedly and unintentionally spit up (regurgitate) undigested or partially digested food from the stomach, rechew it, and then either reswallow it or spit it out.
Because the food hasn’t yet been digested, it reportedly tastes normal and isn’t acidic, as vomit is. Rumination typically happens at every meal, soon after eating.Rumination disorder involves the regular regurgitation of food that occurs for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out. Typically, when someone regurgitates their food, they do not appear to be making an effort, nor do they appear to be stressed, upset, or disgusted.
Rumination syndrome, or Merycism, is an under-diagnosed chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation, as there is with typical vomiting. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities (the prevalence is as high as 10% in institutionalized patients with various mental disabilities). Today it is being diagnosed in increasing numbers of otherwise healthy adolescents and adults, though there is a lack of awareness of the condition by doctors, patients and the general public.It’s not clear how many people have this disorder. Treatment may include behavioral therapy or medications. Behavioral therapy that involves teaching people to breathe from the diaphragm is the usual treatment of choice.
Causes
The precise cause of rumination syndrome isn’t clear. But it appears to be caused by an increase in abdominal pressure.
Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) and gastroparesis. Some people have rumination syndrome and linked to rectal evacuation disorder, in which poor coordination of pelvic floor muscles leads to chronic constipation.
The condition has long been known to occur in infants and people with developmental disabilities. It’s now clear that the condition isn’t related to age, as it can occur in children, teens and adults. Rumination syndrome is more likely to occur in people with anxiety, depression or other psychiatric disorders.
The cause of rumination syndrome is unknown. However, studies have drawn a correlation between hypothesized causes and the history of patients with the disorder. In infants and the cognitively impaired, the disease has normally been attributed to over-stimulation and under-stimulation from parents and caregivers, causing the individual to seek self-gratification and self-stimulus due to the lack or abundance of external stimuli. The disorder has also commonly been attributed to a bout of illness, a period of stress in the individual’s recent past, and to changes in medication.
In adults and adolescents, hypothesized causes generally fall into one of either category: habit-induced, and trauma-induced. Habit-induced individuals generally have a history of bulimia nervosa or of intentional regurgitation (magicians and professional regurgitators, for example), which though initially self-induced, forms a subconscious habit that can continue to manifest itself outside the control of the affected individual. Trauma-induced individuals describe an emotional or physical injury (such as recent surgery, psychological distress, concussions, deaths in the family, etc.), which preceded the onset of rumination, often by several months.
Diagnosis
The doctor will ask about your or your child’s current symptoms and medical history. An initial examination, and sometimes observation of behavior, is often enough to diagnose rumination syndrome.
Sometimes high-resolution esophageal manometry and impedance measurement are used to confirm the diagnosis. This testing shows whether there is increased pressure in the abdomen. It can also provide an image of the disordered function for use in behavioral therapy.
Other tests that may be used to rule out other possible causes of your or your child’s symptoms include:
Esophagogastroduodenoscopy. This test allows your doctor to inspect the esophagus, stomach and upper part of your small intestine (duodenum) to rule out any obstruction. The doctor may remove a small tissue sample (biopsy) for further study.
Gastric emptying. This procedure lets the doctor know how long it takes food to empty from your stomach. Another version of this test can also measure how long it takes food to travel through the small intestine and colon.
In adults, the diagnosis is supported by the absence of classical or structural diseases of the gastrointestinal system. Supportive criteria include a regurgitant that does not taste sour or acidic, is generally odourless, is effortless, or at most preceded by a belching sensation, that there is no retching preceding the regurgitation, and that the act is not associated with nausea or heartburn.
Patients visit an average of five physicians over 2.75 years before being correctly diagnosed with rumination syndrome.
Symptoms
- Effortless regurgitation, typically within 10 minutes of eating
- Abdominal pain or pressure relieved by regurgitation
- A feeling of fullness
- Bad breath
- Nausea
- Unintentional weight loss
Symptoms can begin to manifest at any point from the ingestion of the meal to 120 minutes thereafter. However, the more common range is between 30 seconds to 1 hour after the completion of a meal. Symptoms tend to cease when the ruminated contents become acidic.
Abdominal pain (38.1%), lack of fecal production or constipation (21.1%), nausea (17.0%), diarrhea (8.2%), bloating (4.1%), and dental decay (3.4%) are also described as common symptoms in day-to-day life. These symptoms are not necessarily prevalent during regurgitation episodes and can happen at any time. Weight loss is often observed (42.2%) at an average loss of 9.6 kilograms and is more common in cases where the disorder has gone undiagnosed for a longer period of time, though this may be expected of the nutrition deficiencies that often accompany the disorder as a consequence of its symptoms. Depression has also been linked with rumination syndrome,[5] though its effects on rumination syndrome are unknown.
Acid erosion of the teeth can be a feature of rumination, as can halitosis (bad breath).
Causes
The precise cause of rumination syndrome isn’t clear. But it appears to be caused by an increase in abdominal pressure.
Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) and gastroparesis. Some people have rumination syndrome and linked to rectal evacuation disorder, in which poor coordination of pelvic floor muscles leads to chronic constipation.
The condition has long been known to occur in infants and people with developmental disabilities. It’s now clear that the condition isn’t related to age, as it can occur in children, teens, and adults. Rumination syndrome is more likely to occur in people with anxiety, depression or other psychiatric disorders.
In adults and adolescents, hypothesized causes generally fall into one of either category: habit-induced, and trauma-induced. Habit-induced individuals generally have a history of bulimia nervosa or of intentional regurgitation (magicians and professional regurgitators, for example), which though initially self-induced, forms a subconscious habit that can continue to manifest itself outside the control of the affected individual. Trauma-induced individuals describe an emotional or physical injury (such as recent surgery, psychological distress, concussions, deaths in the family, etc.), which preceded the onset of rumination, often by several months.
Treatment
Treatment depends on the exclusion of other disorders, as well as on age and cognitive ability.
Behavior therapy
Habit reversal behavior therapy is used to treat people without developmental disabilities who have rumination syndrome. People learn to recognize when rumination occurs and to breathe in and out using the abdominal muscles (diaphragmatic breathing) during those times. Diaphragmatic breathing prevents abdominal contractions and regurgitation.
Biofeedback is part of behavioral therapy for rumination syndrome. During biofeedback, imaging can help you or your child learn diaphragmatic breathing skills to counteract regurgitation.
For infants, treatment usually focuses on working with parents or caregivers to change the infant’s environment and behavior.
Medication
If frequent rumination is damaging the esophagus, proton pump inhibitors such as esomeprazole (Nexium) or omeprazole (Prilosec) may be prescribed. These medications can protect the lining of the esophagus until behavior therapy reduces the frequency and severity of regurgitation.
Some people with rumination syndrome may benefit from treatment with medication that helps relax the stomach in the period after eating.
Supportive therapy and diaphragmatic breathing have shown to cause improvement in 56% of cases, and total cessation of symptoms in an additional 30% in one study of 54 adolescent patients who were followed up 10 months after initial treatments. Patients who successfully use the technique often notice an immediate change in health for the better. Individuals who have had bulimia or who intentionally induced vomiting in the past have a reduced chance for improvement due to the reinforced behavior. The technique is not used with infants or young children due to the complex timing and concentration required for it to be successful. Most infants grow out of the disorder within a year or with aversive training