Biofeedback-Guided Control of Abdominothoracic Muscular Activity Reduces Regurgitation Episodes in Patients With Rumination

doi:10.1016/j.cgh.2014.04.018

Clinical Gastroenterology and Hepatology

Volume 13, Issue 1, January 2015, Pages 100-106.e1

https://doi.org/10.1016/j.cgh.2014.04.018 Get rights and content

Background & Aims

Rumination syndrome is characterized by effortless recurrent regurgitation of recently ingested food into the mouth, with consequent expulsion or re-chewing and swallowing. We investigated whether rumination is under volitional control and can be reversed by behavioral treatment.

Methods

We performed a prospective study of 28 patients who fulfilled the Rome criteria for rumination and had no organic disorders on the basis of a thorough evaluation. The diagnosis of rumination was confirmed by intestinal manometry (abdominal compression associated with regurgitation). Patients were trained to modulate abdominothoracic muscle activity under visual control of electromyographic recordings. Recordings were made after challenge meals, before training (baseline), and during 3 treatment sessions. Outcome was measured by questionnaires administered daily for 10 days before training, immediately after training, and at 1, 3, and 6 months after training.

Results

By the end of the 3 sessions, patients had effectively learned to reduce intercostal activity (by 50% ± 2%; P < .001 vs basal) and anterior wall muscle activity (by 30% ± 6%; P < .001 vs basal). Patients reported 27 ± 1 regurgitation episodes/day at baseline and 8 ± 2 episodes/day immediately after treatment. Regurgitation episodes decreased further to 4 ± 1 episodes at 6 months after training.

Conclusions

Rumination is produced by an unperceived somatic response to food ingestion that disrupts abdominal accommodation and can be effectively corrected by biofeedback-guided control of abdominothoracic muscular activity.

Section snippets

Participants

Patients with clinical criteria for rumination¹ underwent a clinical work-up to rule out relevant organic diseases and gastrointestinal manometry. Gastrointestinal manometry was continuously performed for 3 hours fasting, during ingestion of a solid-liquid meal (450 Kcal), and 2 hours postprandially by using a standard technique, as previously described¹² (Supplementary Material). Patients were provided with an event marker to signal any episode of regurgitation of ingested food back into the

Patient Demographics

Twenty-eight patients (17 women, 11 men; age range, 14–76 years) were included in the study. The mean body mass index was 22 ± 2 kg/m²; 8 patients (42%) reported weight loss in the previous year, and 7 of them had body mass index below normal range (defined as <20.1 kg/m² in men and <18.7 kg/m² in women). At recruitment, mean duration of symptoms was 4.9 ± 1.2 years. Eleven patients reported a sudden onset of symptoms. Overall, half of the patients reported an association of the onset of

Discussion

Our data indicate that rumination is produced by an unperceived somatic response to food ingestion that disrupts abdominal accommodation and that can be effectively corrected by biofeedback-guided control of abdominothoracic muscular activity.

The abdomen and thorax constitute separate compartments of the abdominothoracic cavity, with the diaphragm operating as a dynamic boundary so that changes in one compartment have an immediate repercussion on the other. Our data indicate that regurgitation

Acknowledgments

The authors thank Prof R. Merletti and Dr A. Bottin for help in setting up the electromyography system; Maite Casaus, Purificación Rodriguez, and Anna Aparici for technical support; Gloria Santaliestra for secretarial assistance; and Christine O'Hara for English editing of the manuscript.

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Cited by (45)

Rumination syndrome
2023, Handbook of Gastrointestinal Motility and Disorders of Gut-Brain Interactions, Second Edition
Rumination syndrome is a distinct functional gastrointestinal disorder that is characterized by repetitious, effortless regurgitation that occurs during or shortly after eating, followed by spitting out the regurgitant or re-mastication and re-swallowing. It is an unconscious reflex response that is associated with gastric visceral hypersensitivity, and generally preceded or accompanied by belching, burping, and epigastric abdominal wall pain. The syndrome was first documented in 1618 by an Italian anatomist, Fabricius ab Aquapendente, who described the symptoms in one of his patients. The search for better recognition and understanding of the condition has ensued over the subsequent decades.
Rumination Syndrome “Real Prevalence”: A Need to Increase Awareness, Early Recognition, and Specific Management
2022, Gastroenterology
Rumination syndrome: Critical review
2022, Gastroenterologia y Hepatologia
El síndrome de rumiación es un trastorno funcional caracterizado por la regurgitación involuntaria de los alimentos recientemente ingeridos desde el estómago hacia la boca, donde puede ser remasticados o expulsados. Desde el punto de vista clínico, se caracteriza por episodios repetidos de regurgitación de alimentos sin esfuerzo, con vómitos frecuentes como queja habitual. El mecanismo físico que genera los eventos de regurgitación depende de un proceso involuntario que altera las presiones abdominal y torácica, acompañado de una unión esofagogástrica permisiva. El diagnóstico del síndrome de rumiación es clínico: destaca la importancia de realizar una anamnesis exhaustiva sobre las características de los síntomas. Las pruebas complementarias se utilizan para corroborar el diagnóstico o descartar otra enfermedad orgánica. El tratamiento está enfocado a terapias conductuales como primera línea, reservando las terapias farmacológicas y quirúrgicas para casos refractarios.
Rumination syndrome is a functional disorder characterized by the involuntary regurgitation of recently swallowed food from the stomach into the mouth, from where it can be re-chewed or expelled. Clinically, it is characterized by repeated episodes of effortless food regurgitation. The most usual complaint is frequent vomiting. The physical mechanism that generates regurgitation events is dependent on an involuntary process that alters abdominal and thoracic pressures accompanied by a permissive oesophageal-gastric junction. The diagnosis of rumination syndrome is clinical, highlighting the importance of performing an exhaustive anamnesis on the characteristics of the symptoms. Complementary tests are used to corroborate the diagnosis or rule out organic pathology. Treatment is focused on behavioural therapies as the first line, reserving pharmacological and surgical therapies for refractory cases.
Rumination syndrome. A review article
2021, Revista de Gastroenterologia de Mexico
El síndrome de rumiación es un trastorno funcional gastrointestinal que se caracteriza por la regurgitación posprandial sin esfuerzo de los alimentos ingeridos hasta la boca, en el que la contracción posprandial no percibida de la pared abdominal sería un mecanismo clave. En estos pacientes, el flujo retrógrado del contenido gástrico ingerido hasta la boca se produce debido a la combinación de una presión intraabdominal elevada con una presión intratorácica negativa. La prevalencia estimada es de alrededor del 2% en la población general adulta. Las características clínicas principales incluyen: a) regurgitación posprandial precoz; b) el material regurgitado sin esfuerzo es similar al alimento ingerido; c) el material regurgitado se escupe o se vuelve a tragar. El diagnóstico clínico del síndrome de rumiación requiere el cumplimiento de los criterios clínicos. Las pruebas de manometría esofágica de alta resolución idealmente con impedancia pueden representar un complemento importante para el diagnóstico clínico. Su manejo se basa en la instrucción acerca de la naturaleza del trastorno, la educación en respiración diafragmática posprandial y la evaluación de posible comorbilidad psiquiátrica. El uso del baclofeno se reserva como segunda línea para pacientes con síntomas refractarios.
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation of ingested food into the mouth. An unperceived postprandial contraction of the abdominal wall could be a key mechanism. In those patients, retrograde flow of the ingested gastric content into the mouth is produced due to a simultaneous combination of elevated intra-abdominal pressure and negative intrathoracic pressure. The estimated prevalence is around 2% in the general adult population. The main clinical characteristics include: a) early postprandial regurgitation, b) the effortlessly regurgitated material is similar to the ingested food, c) the regurgitated material is spit out or swallowed again. The clinical diagnosis of rumination syndrome relies on the clinical criteria. High resolution esophageal manometry, ideally including impedance monitoring, can be an important adjunct for making the clinical diagnosis. Its management is based on instruction as to the nature of the pathology, education in postprandial diaphragmatic breathing, and the assessment of possible psychiatric comorbidity. Baclofen use is reserved for second-line treatment in patients with refractory symptoms.
Augmenting Diaphragmatic Breathing With Behavioral Exposure: Single-Case Experimental Design for Rumination Disorder
2020, Cognitive and Behavioral Practice
Citation Excerpt :
Given our findings, it is possible that for some individuals, creating a competing response to abdominal wall contraction is not the mechanism of change in treatment. Diaphragmatic breathing is purportedly used as an action incompatible with abdominal wall contraction to disrupt the habitual reaction to food stimuli (Barba et al., 2015). However, although we hypothesized the primary maintenance pathway for KG’s regurgitations was habitual abdominal wall contraction, diaphragmatic breathing appeared to have little to no effect.
Rumination disorder (RD) is a feeding/eating disorder and disorder of gut-brain interaction characterized by repeated, effortless regurgitations. Diaphragmatic breathing is the most widely used treatment technique for RD, theoretically as a competing response to the habitual contraction of the abdominal wall. However, in light of diaphragmatic breathing’s lack of effectiveness for some patients, we created a comprehensive treatment to test the incremental effect of behavioral exposure on symptom change.
In a single-case experimental design, we present the treatment of a 27-year-old patient with a 9-year history of untreated RD. The patient completed a comprehensive six-session cognitive-behavioral treatment for RD, comprising a 1-week phase of self-monitoring regurgitations + psychoeducation (Phase A), a 6-week phase of diaphragmatic breathing (+ identification of secondary maintenance mechanisms) (Phase B), and a 3-week phase of diaphragmatic breathing + behavioral exposure (Phase C). We compared change in daily symptom data between Phases B and C, and also report 20-month follow-up data.
The patient’s daily regurgitation frequency did not change during Phase B (diaphragmatic breathing alone), even with the elimination of foods that had become associated with regurgitations. However, she achieved a significant reduction in regurgitations during Phase C, with symptom remission extending to 20-month follow-up. Phase C included purposefully breaking learned associations with food stimuli using behavioral exposure.
Our data suggest that when diaphragmatic breathing alone is not effective in reducing symptoms, further cognitive and behavioral techniques like behavioral exposure can augment the effect of diaphragmatic breathing on symptom reduction.
30-Year-Old Woman With Intractable Vomiting
2019, Mayo Clinic Proceedings

View all citing articles on Scopus

: Current address for Dr Burri: Department of Internal Medicine, Stadspital Triemli, Zürich, Switzerland.

: Conflicts of interest The authors disclose no conflicts.

: Funding Supported in part by the Spanish Ministry of Education (Dirección General de Investigación, SAF 2009-07416) and European Community (project OASIS, QLRT-2001-00218); Ciberehd is funded by the Instituto de Salud Carlos III. Dr Burri was supported by grants from the Freiwillige Akademische Gesellschaft (Basel, Switzerland) and the Gottfried und Julia Bangerter-Rhyner-Stiftung (Bern, Switzerland). English editing of the manuscript was funded by SAF 2009-07416.

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Original articleAlimentary tractBiofeedback-Guided Control of Abdominothoracic Muscular Activity Reduces Regurgitation Episodes in Patients With Rumination

Background & Aims

Methods

Results

Conclusions

Section snippets

Participants

Patient Demographics

Discussion

Acknowledgments

Gastroenterology

Gastroenterology

Dig Liver Dis

Clin Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis

Pediatrics

Review article: the pathophysiology, differential diagnosis and management of rumination syndrome

Aliment Pharmacol Ther

Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies

Aliment Pharmacol Ther

Impedance measurements and high-resolution manometry help to better define rumination episodes

Scand J Gastroenterol

Objective manometric criteria for the rumination syndrome

Am J Gastroenterol

The rumination syndrome in adults: a characteristic manometric pattern

Ann Intern Med

Original article
Alimentary tract
Biofeedback-Guided Control of Abdominothoracic Muscular Activity Reduces Regurgitation Episodes in Patients With Rumination