Diagnosis and Treatment of Rumination Syndrome: A Critical Review

Abstract

Rumination syndrome (RS) is characterized by the repeated regurgitation of material during or soon after eating with the subsequent rechewing, reswallowing, or spitting out of the regurgitated material. Rumination syndrome is classified as both a “Functional Gastroduodenal Disorder” (by the Rome Foundation’s Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction, 4th edition) and a “Feeding and Eating Disorder” (by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition). Rumination syndrome is a disorder that is often inaccurately diagnosed or missed, resulting in patients experiencing protracted symptoms and not receiving treatment for long periods. There is a lack of clear consensus for RS diagnosis, mechanisms that maintain RS, and treatment. Guided by existing research and our clinical expertise, we synthesize available evidence and provide recommendations for clinical use. We present a case example and critically summarize the literature to date to (i) increase clinicians’ understanding of heterogeneous clinical presentations, (ii) suggest assessment strategies to facilitate accurate diagnosis, and (iii) provide a schematic for intervention options. Overall, we recommend clinicians recognize the heterogeneous features of RS when considering diagnosis, assess for RS symptoms by clinical history, and treat RS with targeted diaphragmatic breathing while using other methods as augmented intervention or alternative treatment.

Detection and characteristics of rumination syndrome in patients presenting for gastric symptom evaluation

“…Rumination is also classified as a feeding and eating disorder by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (as rumination disorder) 2 . Rumination often goes undiagnosed or incorrectly diagnosed (eg, as gastroesophageal reflux or gastroparesis) for long time periods 3–6 . The lack of the diagnosis and treatment of rumination can result in significant psychosocial (eg, social eating avoidance) and medical (eg, weight loss, malnutrition) consequences 1,2 .…”

“…One reason rumination symptoms can be missed is their overlap with other DGBI and motility disorders. Patients may incorrectly describe their rumination symptoms as “reflux” or “vomiting,” or rumination symptoms can be comorbid with other reflux‐ and vomiting‐based conditions that contribute to the pathophysiology of rumination 3,7–9 . Common upper gastrointestinal symptoms of motility/functional disorders (eg, those of functional dyspepsia, gastroparesis) are nausea, vomiting, early satiety, and abdominal pain, but patients may also describe reflux/regurgitation symptoms 10,11 .…”

ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro‐esophageal reflux disease

“…Furthermore, a significant proportion of PPI refractory patients with predominant postprandial regurgitation may have rumination or supragastric belching, 14,101,103 accounting for almost half of these patients in a recent study 97 . This is clinically relevant, because supragastric belching and rumination do not respond to PPIs or pain modulators and require behavioral therapeutic approaches 104,105 …”

Assessing the Merits of a PPI Trial-Based Diagnosis for Gastroesophageal Reflux Disease: Speculations on Efficacy and Pitfalls

“…It can often be confused for reflux given the associated symptoms; however, it is a learned behavior and responds well to behavioral therapy and non-medical intervention in most cases. 32…”