Rumination Syndrome

Description

• Functional gastrointestinal disorder characterized by effortless regurgitation of recently ingested food into the mouth. The regurgitated food can be chewed, swallowed, or expectorated (1)[C]. Regurgitation of solids and/or liquids may be repetitive and is usually not associated with nausea or retching.
• Three patterns of ruminations are reported.
  • Classic/primary rumination—increase in abdominal pressure precedes rumination
  • Secondary rumination—reflux episode precedes the increase in abdominal pressure and subsequent rumination event
  • Supragastric rumination—supragastric belch (caused by inflow of air into esophagus via diaphragmatic contraction) precedes rumination event
• Diagnosis in adults is based on Rome IV criteria (both criteria must be met; criteria must be fulfilled for the past 3 months with symptom onset at least 6 months prior to diagnosis):
  • (i) Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing
  • (ii) Regurgitation is not preceded by retching.
    • Supportive criteria:
      • Effortless regurgitation events are usually not preceded by nausea.
      • Regurgitant contains recognizable food that might have a pleasant taste.
      • The process tends to cease when the regurgitated material becomes acidic (1).

Epidemiology

Limited data available on prevalence of rumination syndrome. Estimated prevalence is <1% in general adult population. In patients with eating disorders and fibromyalgia, prevalence is ~7–8% (1).

Etiology and Pathophysiology

• Pathogenesis of rumination syndrome is unclear. Postprandial regurgitation is thought to occur secondary to coordinated increased intragastric pressures, lower esophageal sphincter (LES) relaxation, and decreased intrathoracic pressures resulting in a pressure gradient between the esophagus and stomach that exceeds the barrier pressure of the LES. Additionally, there may be an additional central reflex mechanism associated with episodes of rumination (1,2)[C].
• Gastroduodenal manometry has shown “R” (rumination) waves, likely due to an abrupt increase in intra-abdominal pressure associated with rumination episodes; high-resolution esophageal manometry with impedance has shown gastric pressures >30 mm Hg associated with rumination events; abdominal wall electromyography (EMG) shows activation of abdominal wall musculature associated with rumination events.

General Prevention

Pediatric Considerations
Rumination syndrome is associated with dental erosions in children; consider early dental referral for children with rumination syndrome (3)[B].

Commonly Associated Conditions

• Anorexia nervosa and bulimia nervosa have been reported in up to 20% of patients with rumination syndrome (1).
• Rectal evacuation disorder has been shown to co-occur with rumination syndrome in adults and adolescents (1).
• Halitosis was most common initial presenting symptom in those <16 years of age (1).
• Anxiety
• Depression