Rumination syndrome


Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following food consumption.

The occurrence of rumination syndrome within the general population has not been defined.

The disorder has a female predominance.

The typical age of adolescent is 12.9, with males affected sooner than females.

It is to the involuntary contraction of the muscles around the abdomen.

There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation, as there is with typical vomiting, and the regurgitated food is undigested. 

Patients may describe the symptoms as vomiting but generally there is no significant retching preceding the episodes. 

Some patients may have abdominal pains such as burning prior to regurgitation with relief thereafter. 

The process can affect both children and adults and may be more common with comorbid psychiatric, mood, or chronic pain conditions. 

The regurgitation content typically contains undigested food. 

Patients may spit out the undigested food or re-swallow it. 

Affects  only infants, young children, and people with cognitive disabilities.

Its prevalence is as high as 10% in institutionalized patients with various mental disabilities.

It is increasingly being diagnosed in a greater number of otherwise healthy adolescents and adults.

Rumination can adversely affect normal functioning and the social lives of individuals. 

Rumination has been linked with depression.

Clinical similarities between rumination syndrome and other disorders of the stomach and esophagus: gastroparesis and bulimia nervosa.

Diagnosis is based on a history of the individual. 

Diagnosis is made by using the Rome IV criteria requiring persistent or recurrent regurgitation of recently ingested food into the mouth with subsequently spitting or re-mastication and swallowing and regurgitation not preceded by retching.

Esophageal manometry can support the diagnosis but it is not generally available.

Upwards of 85% of individuals responding positively to treatment, including infants and the mentally disabled.

Repetitive regurgitation of undigested food after the start of a meal is always present.

The regurgitation volume may be small, occurring over a long period of time following ingestion, and can be rechewed and swallowed. 

In other sufferers the amount can be bilious and short-lasting, and must be expelled. 

Some only experience symptoms following some meals, most experience episodes following any ingestion, from a single bite to a large meal.

Long-term patients occasionally will find food or drink items that do not trigger a response.

Rumination  regurgitation is typically described as effortless and unforced.

There is seldom nausea preceding the expulsion.

The undigested vomitus lacks the bitter taste and odour of stomach acid and bile.

Symptoms can begin to manifest at any point from the ingestion of the meal up to 120 minutes thereafter.

The most common range is between 30 seconds to 1 hour after the completion of a meal.

Symptoms tend to cease when the ruminated contents become acidic.

Commonly, abdominal pain (38.1%), constipation (21.1%), nausea (17.0%), diarrhea (8.2%), bloating (4.1%), and dental decay (3.4%) are also described as common symptoms in day-to-day life.

Symptoms are not necessarily prevalent during regurgitation episodes, and can happen at any time. 

Weight loss is common, 42.2%, at an average loss of 9.6 kilograms.

Weight loss is more common in patients with a disorder that has gone undiagnosed for a longer period of time.

Nutrition deficiencies are a consequence of its symptoms.

Depression has been linked with rumination syndrome.

Acid erosion of the teeth and  halitosis may be associated.

The cause is unknown. 

In infants and the cognitively impaired, the process has been attributed to over-stimulation and under-stimulation from parents and caregivers, causing the individual to seek self-gratification and self-stimulus due to the lack or abundance of external stimuli. 

Rumination syndrome has also been attributed to a bout of illness, a period of stress in the individual’s recent past, and to changes in medication.

Other hypothesized causes in adults and adolescents: habit-induced, or trauma-induced. 

Habit-induced individuals generally have a history of bulimia nervosa or of intentional regurgitation, which though initially self-induced, forms a subconscious habit that can continues to manifest.

Regurgitation of undigested regurgitation of ingested material occurs because of the combination of increased intra-abdominal pressure and negative intrathoracic pressure.

Individuals with trauma-induced rumination syndrome with an emotional or physical injury precedes the onset of the process, often by several months.

It is suggested that the pathogenesis is that the ingestion of food causes gastric distention, which is followed by abdominal compression and the simultaneous relaxation of the lower esophageal sphincter, creating  a common cavity between the stomach and the oropharynx that allows the partially digested material to return to the mouth. 

The sudden relaxation of the lower esophageal sphincter, may be a learned voluntary relaxation, which is common in those with or having had bulimia. 

The process of rumination is still generally involuntary. 

Relaxation due to intra-abdominal pressure is another proposed mechanism.

A third proposed mechanism is an adaptation of the belch reflex: swallowing of air immediately prior to regurgitation causes the activation of the belching reflex that triggers the relaxation of the LES. 

Patients often describe a  belching sensation preceding rumination.

Rumination syndrome is diagnosed based on a history.

Criteria for diagnosis: regurgitation of recently ingested food, must be consistent, occurring for at least six weeks of the past twelve months; regurgitation must begin within 30 minutes of the completion of a meal; patients may either chew the regurgitated matter or expel it; symptoms must stop within 90 minutes, or when the regurgitated matter becomes acidic;  symptoms must not be the result of a mechanical obstruction; and should not respond to the standard treatment for gastroesophageal reflux disease.

Diagnosis is supported by the absence of common diseases of the gastrointestinal system, by finding a regurgitant that does not taste sour or acidic, is generally odorless, is effortless, or at most preceded by a belching sensation, that there is no retching preceding the regurgitation, and that the act is not associated with nausea or heartburn.

Diagnosis comes after patients visit an average of five physicians over 2.75 years before being correctly diagnosed.

Differential diagnosis: Bulimia nervosa and gastroparesis are especially prevalent among the misdiagnoses of rumination.

Bulimia nervosa is the most common misdiagnosis patients will hear.

Unlike bulimia, rumination is not self-inflicted. 

Patients with rumination syndrome are generally well aware of their gradually increasing malnutrition, but are unable to control the reflex. 

In contrast, those with bulimia intentionally induce vomiting, and seldom re-swallow food.

is another common misdiagnosis, is  gastroparesis, the bring up food following the ingestion of a meal. 

Gastroparesis causes vomiting, in contrast to regurgitation, of food, which is not being digested further, from the stomach. 

Gastroparesis vomiting occurs several hours after a meal is ingested, preceded by nausea and retching, and has the bitter or sour taste typical of vomit.

Rumination syndrome is a

functional gastroduodenal disorder, a 

 non-psychotic mental disorder. 

It is considered a motility disorder instead of an eating disorder, because the patients tend to have had no control over its occurrence and have had no history of eating disorders.

No known cure for rumination exists.

Medications have been used with little or no effect.

Treatment of rumination syndrome  is different for infants and the mentally handicapped than for adults and adolescents of normal intelligence. 

Infants and the mentally handicapped, respond to behavioral aversion therapy, in most cases.

Most infants grow out of the disorder within a year or with aversive training.

In patients of normal intelligence, rumination is not an intentional behavior.

It can be habitually reversed using diaphragmatic breathing.

Diaphragmatic breathing works by physically preventing the abdominal contractions required to expel stomach contents.

With supportive therapy and diaphragmatic breathing improvement occurs in 56% of cases, and total cessation of symptoms in an additional 30% in one study of 54 adolescent patients who were followed up 10 months after initial treatments.

Among the cognitively handicapped, it is described with almost equal prevalence among infants (6–10% of the population) and institutionalized adults (8–10%).

In infants, it typically occurs within the first 3–12 months of age.

There is little evidence concerning the impact of hereditary influence in rumination syndrome, but a case reports involving entire families with rumination exist.

The primary treatment consists of diaphragmatic breathing exercises to inhale through the nose while protruding the abdomen and keeping the chest stationary decreasing postprandial intra-gastric pressure and increasing lower esophageal sphincter pressure.

By decreasing the gradient pressure between the stomach and the esophagus, the rumination events decrease. 

In refractory patients baclofen can be considered. 

Patients should be educated about the disease process and offered reassurance.

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