Rumination

Abstract

Rumination is an unusual gastrointestinal symptom that is characterized by the repetitive regurgitation of gastric contents into the oropharynx. The regurgitation occurs very soon after a meal and tends to persist for 1 to 2 hours. Rumination is defined by the setting in which it occurs. It is seen in three distinct populations: infants; individuals with psychiatric and neurologic disorders, particularly developmental disabilities; and adults who do not have overt psychiatric or neurologic disorders. The hallmark of rumination, which separates it from other disorders of the upper gastrointestinal tract (such as gastroesophageal reflux disease or cyclic vomiting syndrome), is the fact that in patients with rumination, the gastric contents appear in the oropharynx without retching or nausea. Rather, the patient makes a conscious decision on how to handle the regurgitated material after it presents into the oropharynx. The regurgitated meal usually consists of undigested or partially digested food. The regurgitation is effortless or at most is preceded by a sensation of belching immediately prior to the regurgitation itself. The management of patients with rumination needs to be accomplished in a highly individualized manner. Children with infant rumination syndrome often have symptoms related to significant defects in bonding with their mother. Thus, problems of mother-child bonding in pediatric patients with rumination syndrome should be identified and appropriately addressed. The management of adult patients with developmental disabilities or neurologic impairments who ruminate focuses mainly on behavioral modalities, including adversive conditioning and contingency management. The healthy adult who ruminates and has no evidence of neurologic or developmental disability is best seen as someone with a habit. Management in these patients is directed towards adjunctive therapies (ie, the use of proton pump inhibitors or H(2 )receptor antagonists to decrease acid injury to the esophagus) as well as identifying situations and emotions that trigger the patient's symptoms. Randomized controlled trials of various treatment modalities need to be undertaken; likewise, the evaluation strategy needed to best diagnose rumination is yet to be well defined. At this time, the challenge for gastroenterologists is to understand the nature of rumination, to identify individuals at high risk, and to use the management strategies most associated with good outcomes in patients with rumination in various clinical settings.

Rumination or belching-regurgitation? Differential diagnosis using oesophageal impedance-manometry

“…It has been suggested that clinical examination is the best diagnostic tool available to assess rumination syndrome. 10 Whether additional manometric evaluation is useful, is still under debate. 1,5,25 The primary aim of this study was to improve the diagnosis of rumination using combined impedance-manometry.…”

“…3,5 Rumination has been linked to impaired gastric relaxation, increased lower oesophageal sphincter (LOS) relaxation with gastric distension, 6 achalasia, 7 gastro-oesophageal reflux disease 8 and hiatal hernia. 9 It is becoming increasingly recognized in adults 10 and children 11 and has been associated with mental retardation, 12 behavioural eating disorders 13 and emotional or psychiatric disturbances. 14 Depression, anxiety, or obsessive-compulsive behaviour are reported in onethird of the paediatric patients.…”

Atypical early-onset eating disorders

“…It is seen most commonly in infants and individuals with psychiatric or neurological disorders (Olden 2001). Sensory and/or emotional deprivation are also associated with rumination in children, and increased incidence is therefore seen in institutionalised children, infants in intensive care units and in normal infants with attachment disorders.…”

Pediatric and adolescent GERD

“…Rumination is thought to be a self-stimulatory behavior of young children with neurologic abnormalities. Recently, rumination has been described in adolescents without neuropsychiatric problems [21,22] and should be considered in older children with regurgitation. Reliable diagnostic studies are critical, because therapy differs for these clinical entities.…”