Rumination syndrome is an unusual disorder that involves regurgitation and rechewing of partially digested food — which is then swallowed again or spit out. It can be involuntary or voluntary.1 However, the disorder is not harmless — it has the potential to damage the upper digestive system from teeth to esophagus.
The regurgitation associated with rumination syndrome is not usually associated with nausea or retching; instead, it appears “effortless,” according to medical experts.1 In addition, the material that is regurgitated does not taste sour or bitter. Regurgitation generally will begin within a few minutes of eating, and can last up to one or two hours. It normally occurs every day, after most meals, and can go on for months or even years.
“While the pathophysiology of rumination remains unclear, a proposed mechanism suggests that gastric distention with food is followed by abdominal compression and relaxation of the lower esophageal sphincter; these actions allow stomach contents to be regurgitated and rechewed and then swallowed or expelled,” say authors Cynthia Ellis and Connie Schnoes.1 “Several mechanisms for the relaxation of the lower esophageal sphincter have been offered, including (1) learned voluntary relaxation, (2) simultaneous relaxation with increased intra-abdominal pressure, and (3) an adaptation of the belch reflex (e.g., swallowing air produces gastric distention that activates a vagal reflex to relax the lower esophageal sphincter transiently during belching).”
The results of rumination can include bad breath, malnutrition and weight loss, even “growth failure.” Other consequences may include dehydration, upper respiratory distress, dental problems, pneumonia or death. If the disorder is chronic, patients may develop signs of Barrett’s esophagus.
Rumination syndrome has been described in both adults and children with mental impairment, but also in those of normal intelligence and development. It is most frequently found in infants. In adults, it is difficult to gauge its frequency, as these patients may hide the condition from others. It is thought to be the cause of death in 5 percent to 10 percent of people who have the syndrome, and occurs in both sexes.
If infants have the syndrome, they typically begin to show signs of it between three and six months of age; frequently, the disorder will abate on its own.
Certain physical symptoms are somewhat unusual — the individual may feel pleasure from mouthing the ruminant material, rather than disgust.
There are several hypotheses to explain the genesis of rumination syndrome, which include psychosocial and organic causes. Ellis and Schnoes present several potential causes, including:
- Adverse psychosocial environment
- Learning-based theories (positive or negative reinforcement)
- Organic factors such as GERD or other esophageal/gastric problems
- Heredity
- Cardiospasm
- Insufficient mastication
- Aerophagy (i.e., air swallowing)
- Finger- or hand-sucking
The authors suggest the use of hematology and chemistry tests to rule out anemia due to bleeding; they also recommend barium studies to find hiatal hernias, esophageal atresia, or other disorders. Cultures for Helicobacter pylori might be useful, as well as scintigraphic studies of gastric emptying and pH studies to exclude gastroesophageal reflux.
To treat the patient, healthcare providers should first rectify any caloric deficiencies, treat bronchitis or pneumonia resulting from rumination, and treat any other related disorders such as asthma or bronchospasm. Gastroesophageal fundoplication has been used in some patients when rumination is unquestionably caused by a physical problem, especially if it has been resistant to other treatments.
It may be necessary to call for a behavioral consultation to address psychological or psychosocial causes of the disorder, and the patient will need to be trained out of the habit of rumination.
It appears that many physicians are unaware of this disorder in people of normal intelligence, especially because they are often secretive about the rumination.
In a study of the syndrome in pediatric patients — both children and adolescents — researchers found that physicians are not diagnosing the syndrome early enough. “The diagnosis is often delayed and associated with morbidity,” they write. “Extensive diagnostic testing is unnecessary. Early behavioral therapy is advocated, and patient outcomes are generally favorable.”2
People with the disorder are often misdiagnosed or undergo expensive, invasive testing before diagnosis, they add, saying, “Insufficient awareness of the clinical features of rumination syndrome contributes to the under-diagnosis of this important medical condition. Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease, and upper gastrointestinal motility disorders including gastroparesis and chronic intestinal pseudo-obstruction.”
In its July 15, 2006 issue, the British Medical Journal published a case study of a 22-year old man who had persistent regurgitation and vomiting. Responses to this case study and outcome were addressed later that month, on the journal’s Web site.
Shmuel P. Reis, MD, MHPE, a family physician in Haifa, Israel, wrote, “Primary care physicians (PCPs), as did the literature, usually associated [rumination syndrome] with serious bonding problems in infancy, severe pathology in childhood and adolescence and need for extensive investigation beyond. Your case illustrates a different reality, that of a benign, behavioral mediated condition in adulthood. For developmentally normal children and adolescents this is probably also the most frequent presentation. It may represent some emotional distress and be amenable to supportive or behavioral therapy.”
And Hassan K. Chaudhry wrote, “A careful history and identification of the recurrent, effortless, painless regurgitations is often sufficient to make the diagnosis. Observation of preceding air swallowing and contraction of the abdominal wall (while the lower esophagus and glottis relax) can clinch the diagnosis without need for involved and often unnecessary investigations. If available, antro-duodenal manometry will document the presence of the diagnostic pressure pattern confirming the creation of a ‘common cavity’ between the stomach and the mouth.”
References
- www.emedicine.com/ped/topic2652.htm. Ellis, Cynthia R, and Schnoes, Connie J. Eating Disorder: Rumination.
- http://pediatrics.aappublications.org/cgi/content/full/111/1/158?eaf. Chial, H. J.; Camilleri, M; Williams, D. E.; Litzinger, K.; and Perrault, J. Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and Prognosis. PEDIATRICS Vol. 111 No. 1 January 2003, pp. 158-162
- www.bmj.com/cgi/eletters/333/7559/133