What is Rumination Disorder?
Rumination syndrome is a condition related to the digestive system, where someone unintentionally brings up food from their stomach back into their mouth without any signs of an underlying disease. This typically happens within about 15 minutes after finishing a meal. The food that comes up is often chewed again and spit out or swallowed, and this can continue for up to two hours after each meal.
This syndrome can affect both children and adults, and medical guidelines classify it as a functional digestive system condition and also as an eating disorder. Unfortunately, rumination syndrome is often mistaken for other conditions, like acid reflux disease or vomiting. This misdiagnosis can lead to unnecessary tests and treatments and delay the appropriate therapy needed to help relieve the symptoms.
What Causes Rumination Disorder?
Rumination syndrome is a condition we don’t fully understand yet, but it’s likely caused by a number of factors working together. There are several risk factors that have been linked to the condition:
* Emotional neglect in babies
* High levels of emotional stress
* Having mental health conditions like obsessive-compulsive disorder, anxiety, depression, adjustment disorder, PTSD, and ADHD
* Delayed development
* Fibromyalgia, which is chronic pain felt throughout the body
* Rectal evacuation disorder, which is difficulty with bowel movements
Even though these factors have been connected, it’s important to note that everyone’s experience with rumination syndrome can be different.
Risk Factors and Frequency for Rumination Disorder
Rumination syndrome is a condition that is likely underdiagnosed, making its exact prevalence uncertain. This condition can often be hard to spot due to differing criteria for diagnosis, depending on the clinical setting. Patients with rumination syndrome often take a long time to receive an accurate diagnosis and might see several physicians before the condition is identified. This contributes to inaccurate data about the condition.
People with rumination syndrome frequently report symptoms such as vomiting, abdominal pain, and signs consistent with certain food intake disorders. These symptoms often complicate the diagnosis of rumination syndrome, making it particularly challenging to identify. The condition is found across all age groups, and data about its prevalence varies.
- A study by Lewis et al., which gathered 949 responses to an online questionnaire about symptoms tied to rumination syndrome, observed no reported cases.
- On the other hand, a Sri Lankan study by Rajindrajith et al. found a prevalence of 5.1% among over 2000 children between 10 and 16, with equal distribution among boys and girls.
- Rumination syndrome seems to be less common among the general adult population, with an approximate prevalence of 1%.
- About 20% of adults, who didn’t respond to treatments for gastrointestinal reflux disease, displayed symptoms of rumination syndrome when subjected to a specific type of gastrointestinal study called postprandial high-resolution impedance manometry.
Signs and Symptoms of Rumination Disorder
Rumination syndrome is a condition where patients regurgitate their food shortly after eating. This can occur as quickly as 10 minutes after a meal and can last for 1 to 2 hours afterwards. Common symptoms of this syndrome include stomach discomfort, vomiting, and abdominal pain. People often seek medical help for what they believe to be slow gastric emptying, vomiting for no apparent reason, or hard-to-treat acid reflux disease. Rumination syndrome symptoms can persist for a long time, and diagnosis can take between 21 to 77 months on average.
Patient history is crucial in diagnosing this condition. One key detail is distinguishing between vomiting and regurgitation — vomiting is forceful with the person unable to contain the vomitus in their mouth, while regurgitation is effortless, with no gagging or retching, and the person is able to hold the regurgitated matter in their mouth. If they spit it out, it’s a voluntary action. Usually, there’s no feeling of nausea and the regurgitated matter is undigested, can be identified, and can even taste pleasant. Some patients can anticipate when they’re about to regurgitate, as they feel a specific abdominal discomfort referred to as the premonitory urge, which can be so intense that it causes physical distress. Frequently regurgitating can also cause significant weight loss and dehydration.
Rumination syndrome patients often have a history of mental health issues like depression, anxiety, and physical symptom disorders. Having gastroesophageal reflux disease doesn’t disqualify a person from having rumination syndrome. It’s also important to consider and rule out eating and feeding disorders. Serious weight loss, electrolyte abnormalities, tooth erosion, and malnutrition are usually not common in rumination syndrome patients unless they also have an eating disorder, despite being more common in this group than in healthy individuals of the same age.
Testing for Rumination Disorder
When a patient is suspected to have rumination syndrome, a diagnosis can be made in several ways, one of which doesn’t require any invasive testing. This method is known as the Rome IV criteria. On the other hand, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria states that repeated regurgitation should not be due to a physical health issue, which often requires some tests to rule out other causes.
Many patients with rumination syndrome end up waiting years for the correct diagnosis. Once diagnosed, some patients feel disappointed because they were hoping for a more tangible explanation for their symptoms. In such cases, performing tests can help patients understand their diagnosis better.
What tests should be done, and how extensive the evaluation should be, varies from patient to patient. It depends on their specific circumstances, symptoms, and any other health conditions they may have. Here are some typical tests that might be done:
– Checking for possible underlying eating disorders (like bulimia nervosa, anorexia nervosa), which could display similar symptoms.
– An endoscopy or a CT scan might be done to rule out a physical blockage in the digestive tract.
– High-resolution esophageal manometry (HRIM) with impedance testing might be used. This test can confirm rumination syndrome in both adults and children by measuring pressure in the stomach after eating. Normally, this pressure is above 25 to 30mmHg in patients with rumination syndrome.
– A test called electromyography (EMG) of the abdominothoracic muscles might be used. This measures the electrical activity in your muscles. In patients with rumination syndrome, this test will show a characteristic spiking of activity during episodes of rumination.
There are other tests that aren’t necessary for diagnosis, but might be done if your symptoms are unusual or if the doctor needs to rule out other conditions such as gastroesophageal reflux disease (GERD) or gastroparesis.
The DSM-V and Rome IV criteria have a list of signs that can point to rumination syndrome:
1. Repeated regurgitation of food without other causes (such as GERD, or an eating disorder like anorexia nervosa, bulimia nervosa, or binge-eating disorder).
2. Repeated regurgitation is severe enough to need further medical attention.
3. Persistent or recurrent regurgitation of recently eaten food; not preceded by a feeling of needing to vomit.
These signs should be present for at least a month according to the DSM-V criteria, or at least three months according to the Rome IV criteria. The Rome IV criteria also specify that these signs should have started at least six months before diagnosis.
While diagnosing rumination syndrome can be challenging, there are a variety of criteria and tests available that can help guide health professionals towards a more accurate diagnosis and expedite the journey towards proper treatment and management of symptoms.
Treatment Options for Rumination Disorder
When someone is first diagnosed with rumination syndrome, which is a condition that involves repeatedly throwing up food, the first step usually entails learning more about the condition, finding comfort in understanding it, and adopting certain behaviors to lessen the instances of throwing up.
One of the first treatments recommended for this condition is something called diaphragmatic breathing. This is a form of deep breathing that helps to counteract the involuntary muscle contractions in the abdomen and chest area which are typically associated with rumination syndrome. For this exercise, a patient is advised to sit on a chair and put one hand on their chest and the other on their abdomen. As they breathe, only the hand on the abdomen should move – signaling deep, slow breaths of about 6 to 8 times per minute. This deep breathing starts the diaphragm working and causes the stomach to expand.
This type of breathing should be practiced after meals or when the patient feels like they are about to throw up. Observing the effects of this breathing exercise through techniques like EMG (Electromyography, a test to measure muscle response) and HRIM (High Resolution Impedance Manometry, a test that measures pressure in your esophagus) can help some patients see the benefits of the method more clearly. Sometimes, it could be helpful for the patient to work with a behavioral therapist who can provide additional strategies for relaxation and may suggest cognitive behavioral therapy specifically for rumination disorder.
As for medical treatments for rumination syndrome, there is not a lot of research. However, medication is generally reserved for those who don’t see improvement with the behavioral therapy. Some small studies have suggested that certain medications like Baclofen might help reduce the instances of throwing up and improve symptoms overall. Baclofen works by increasing the pressure in the lower part of the esophagus that helps to limit throwing up. Another medication, Buspirone, which is used for treating anxiety disorders, has been suggested as it has certain properties that help to relax the stomach.
Though there aren’t specific studies into the use of Buspirone for rumination syndrome, some medical professionals might consider using it in particularly stubborn cases where other treatments have not worked. It’s always essential for patients to discuss different treatment options with their healthcare providers to ensure the best possible management of their condition.
What else can Rumination Disorder be?
When diagnosing certain stomach or esophagus-related problems, doctors may consider multiple conditions that could cause similar symptoms. These conditions include:
- Gastroesophageal reflux disease (GERD)
- Achalasia (a rare disorder that makes it difficult for food and liquid to pass into your stomach)
- H. pylori infection (a type of bacteria that can infect the stomach)
- Gastritis (inflammation of the stomach lining)
- Peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine)
- Celiac disease (an immune reaction to eating gluten)
- Irritable bowel syndrome (common disorder that affects the large intestine)
- Small intestinal bacterial overgrowth (an increase in the number of bacteria or changes in the types of bacteria present in your small intestine)
- Eosinophilic gastroenteritis (a rare and heterogeneous condition characterized by patchy or diffuse eosinophilic infiltration of gastrointestinal tissues)
- Gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying)
- Cyclic vomiting syndrome (a disorder that causes recurrent episodes of nausea, vomiting, and tiredness)
- Gastric carcinoma (also known as stomach cancer)
- Eating disorders (such as anorexia nervosa, and bulimia nervosa)
- Esophagitis (inflammation that may damage tissues of the esophagus)
- Esophageal stenosis (a narrowing of the esophagus that causes swallowing difficulties)
- Esophageal cancer (cancer that occurs in the esophagus)
- Esophagogastric junction outflow obstruction (a condition where the outflow of content from the esophagus into the stomach is hindered)
- Functional dyspepsia (persistent or recurrent pain or discomfort centered in the upper abdomen)
A detailed examination and appropriate medical tests are necessary to diagnose the exact condition causing the discomfort.
What to expect with Rumination Disorder
Rumination syndrome is viewed as a habit that people pick up and can therefore be reversed. Studies have shown that certain methods like diaphragmatic breathing (deep breathing that engages the diaphragm) can help in reducing regurgitations, the process of bringing undigested food up through the esophagus.
Moreover, there are both drug-based (like baclofen, buspirone) and non-drug treatments available (like cognitive behavioral therapy, chewing gum, and general relaxation techniques). As far as we know, rumination syndrome itself doesn’t decrease someone’s lifespan, but it can lead to unwanted side effects like weight loss and social anxiety, leading individuals to avoid certain social interactions.
What’s more, there isn’t much information to suggest that once you have rumination syndrome, it could come back again. However, a 2018 research study involving 47 teenagers with rumination syndrome over a year did show continuous improvements in symptoms over time, with a complete halt in symptoms for at least six months in 20% of the participants. The result from this research suggests that an intense behavioural treatment for rumination syndrome can lead to long-lasting improvements, although the duration of treatment may need to be longer.
Possible Complications When Diagnosed with Rumination Disorder
Rumination syndrome is generally seen as a non-dangerous condition, but it can negatively impact a person’s mental and physical health, and reduce their quality of life. Regular instances of regurgitating food can lead to significant weight loss, especially in teenagers, and might be misdiagnosed as an eating disorder instead of rumination syndrome. Moreover, unstable electrolyte levels and oral damage are common but are more often observed in cases unresponsive to treatment. Studies have shown that people suffering from rumination syndrome frequently also grapple with anxiety, depression, and physical symptoms related to psychological distress. Therefore, long-term treatment that includes cognitive behavioral therapy is often needed to manage symptoms.
Common Consequences of Rumination Syndrome:
- Impact on mental and physical health
- Reduced quality of life
- Significant weight loss, especially in teenagers
- Possible misdiagnosis as an eating disorder
- Disruption of electrolyte balance
- Dental damage
- Co-existing conditions such as anxiety, depression, and psychosomatic symptoms
- Need for long-term cognitive behavioral therapy
Preventing Rumination Disorder
Doctors need to carefully ask about and identify whether a patient is experiencing vomiting or regurgitation. Both might seem similar, but they are different. Rumination syndrome, which involves frequently regurgitating food from the stomach, is often missed because it’s wrongly confused with vomiting. Spotting the difference can help reach a correct diagnosis faster, sparing the patient from unnecessary discomfort.
Unfortunately, many patients have to wait for several years to get the proper diagnosis. It’s very important then, that patients understand their condition. With rumination syndrome, it’s not dangerous and can be managed without medications. Practising diaphragmatic breathing, which involves deep breathing using your diaphragm, is a common treatment strategy.
However, to effectively manage this condition, patients often need to undergo intensive cognitive-behavioral therapy. This essentially means learning new ways to think and behave to improve their medical condition. They also need thorough, repeated training to practice diaphragmatic breathing properly.
Continuously educating the patient about their disease and the importance of these behavioral changes can significantly reduce their symptoms and improve their wellbeing.
