What Is Rumination Syndrome?

Introduction

Rumination, an involuntary act of regurgitating undigested food from the stomach back into the mouth, is an innate response and not a deliberate choice. In bovine creatures, this phenomenon is a regular part of their digestive process, whereas in humans, it deviates from the norm but is occasionally observed in otherwise healthy individuals.¹

For individuals affected by rumination syndrome, this occurrence usually transpires within 1-2 hours following most meals. It is a persistent ailment, manifesting itself after each meal on a daily basis.¹

This syndrome is found across all age groups, although there is conflicting data regarding its prevalence and incidence. Frequently, rumination disorder is erroneously diagnosed as gastroesophageal reflux disease or vomiting, leading to unnecessary medical assessments and interventions.²

Clinical presentation of rumination syndrome

Symptoms associated with rumination syndrome encompass:³

• Effortless regurgitation
• Abdominal discomfort or pressure relieved through regurgitation
• Sensation of fullness
• Nausea
• Unintentional weight loss

It is worth noting that rumination syndrome is not typically linked with retching.

Causative factors of rumination syndrome

The etiology of rumination syndrome is likely multifactorial, though precise causes remain inadequately comprehended. Various risk factors have been associated with the condition, including:² 

• Emotional neglect (in infants)
• Emotional stress
• Presence of mental health diagnoses such as obsessive-compulsive disorder, anxiety, depression, adjustment disorder, post-traumatic stress disorder, and attention deficit-hyperactivity disorder (ADHD)
• Developmental delay
• Fibromyalgia
• Rectal evacuation disorder

Diagnosing rumination syndrome

The diagnosis of rumination syndrome is primarily based on a healthcare professional's assessment of current symptoms and a review of the patient's medical history. In many cases, this initial evaluation, coupled with behavioural observation, is adequate for a conclusive diagnosis. Occasionally, supplementary tests, such as high-resolution oesophagal manometry and impedance measurement, are employed to validate the diagnosis.³

Treatment of rumination syndrome

The initial approach to managing patients with rumination syndrome involves education about the condition, reassurance, and behavioural adjustments aimed at diminishing the frequency of regurgitation. Diaphragmatic breathing serves as the primary treatment, where patients are instructed to adopt specific breathing techniques following a meal or at the onset of impending regurgitation. Referral to a behavioral therapist for additional strategies such as general relaxation and gum chewing, as well as cognitive behavioral therapy for rumination disorder, can be considered as supplementary measures.²

While there is limited data on medical therapy for rumination syndrome, it is typically reserved for cases unresponsive to initial behavioural therapy. Some studies suggest that baclofen, administered at 10 mg three times daily, may reduce regurgitation events and ameliorate patient-reported symptoms.²

Conclusion

Rumination syndrome, often considered relatively rare due to insufficient data, presents with prolonged, non-specific symptoms that can mimic other gastrointestinal conditions like gastroesophageal reflux disease or gastroparesis. The underdiagnosis of rumination syndrome is primarily attributed to its misclassification as vomiting.²

Discriminating between these two conditions is crucial for an expedited diagnosis, which in turn can lead to improved clinical outcomes through noninvasive treatments like diaphragmatic breathing.²

Patient education plays a pivotal role in ensuring an understanding of the condition's benign course and the potential treatment options, such as diaphragmatic breathing, thereby promoting compliance with behavioural modifications.²