Clinical practice update: Expert review
Diagnosis and Treatment of Rumination Syndrome

https://doi.org/10.1016/j.cgh.2018.05.049Get rights and content

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. The disorder appears uncommon, although only limited epidemiologic data are available. Awareness of the characteristic symptoms is essential for recognizing the disorder, and thus avoiding the long delay in diagnosis, that many patients experience. Although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers, a clinical diagnosis can be made in most patients. The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing. This clinical practice update reviews the pathophysiology, diagnosis, and treatment of rumination syndrome.

Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting.

Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely.

Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up.

Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome.

Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique.

Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations.

Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients.

Section snippets

Methods

The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and Embase (through February 2018) without a formal systematic review of evidence. To identify relevant ongoing trials, we queried clinicaltrials.gov. The Clinical Practice Updates Committee of the American Gastroenterological Association has reviewed these recommendations.

Summary and Conclusions

Rumination syndrome is an uncommon functional gastrointestinal disorder, but likely is under-recognized in clinical practice. We recommend that physicians consider rumination syndrome in the differential diagnosis of patients presenting with regurgitation, refractory gastroesophageal reflux, or vomiting. A clinical diagnosis can be made in most cases. The algorithm in Figure 4 outlines a suggested approach to patients with postprandial regurgitation or vomiting, with a focus on how to evaluate

References (40)

  • M.M. Weakley et al.

    Case study: chewing gum treatment of rumination in an adolescent with an eating disorder

    J Am Acad Child Adolesc Psychiatry

    (1997)
  • E.M. Brockbank

    Merycism or rumination in man

    Br Med J

    (1907)
  • M. Halland et al.

    Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action

    Neurogastroenterol Motil

    (2016)
  • P. Vijayvargiya et al.

    Novel association of rectal evacuation disorder and rumination syndrome: diagnosis, co-morbidities and treatment

    United Eur Gastroenterol J

    (2014)
  • E. Tucker et al.

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

    Aliment Pharmacol Ther

    (2013)
  • A. López-Colombo et al.

    The epidemiology of functional gastrointestinal disorders in Mexico: a population-based study

    Gastroenterol Res Pract

    (2012)
  • X. Wang et al.

    Functional gastrointestinal disorders in eating disorder patients: altered distribution and predictors using ROME III compared to ROME II criteria

    World J Gastroenterol

    (2014)
  • S. Rajindrajith et al.

    Rumination syndrome in children and adolescents: a school survey assessing prevalence and symptomatology

    BMC Gastroenterol

    (2011)
  • D.H. Winship et al.

    Esophagus in rumination

    Am J Physiol

    (1964)
  • D.F. Levine et al.

    Habitual rumination: a benign disorder

    Br Med J (Clin Res Ed)

    (1983)
  • Cited by (48)

    • Rumination syndrome

      2023, Handbook of Gastrointestinal Motility and Disorders of Gut-Brain Interactions, Second Edition
    • Understanding symptoms of gastric dysmotility: Nausea, vomiting, abdominal pain, postprandial fullness, and early satiety

      2023, Handbook of Gastrointestinal Motility and Disorders of Gut-Brain Interactions, Second Edition
    • Global Prevalence and Impact of Rumination Syndrome

      2022, Gastroenterology
      Citation Excerpt :

      The American Gastroenterology Association clinical practice guideline on rumination confirms that the diagnosis of rumination syndrome can be based on the Rome IV criteria. Further evaluation is recommended in cases where there is doubt about the diagnosis, or inadequate response to therapy.1 Previous studies have shown that esophageal impedance manometry with postprandial registration provides the strongest diagnostic evidence for rumination syndrome, making it the best choice for a gold standard.50,51

    • Understanding Disordered Eating Risks in Patients with Gastrointestinal Conditions

      2022, Journal of the Academy of Nutrition and Dietetics
      Citation Excerpt :

      Rumination syndrome is a functional GI diagnosis that can be missed, delayed, or untreated leading to significant health consequences.44 In the GI literature, rumination syndrome is described as the subconscious physiological contraction of abdominal muscles while voluntarily relaxing the lower esophageal sphincter, which allows food and liquid to be regurgitated leading to re-chewing, re-swallowing, or spitting out.45 The true prevalence of rumination syndrome is likely underestimated due to lack of physician awareness; and although it is perceived as predominantly a diagnosis seen in women, this is likely related to women seemingly more likely to seek health care for DBGIs.46

    • Rumination syndrome: Critical review

      2022, Gastroenterologia y Hepatologia
    View all citing articles on Scopus

    Conflicts of interest The authors disclose no conflicts.

    View full text