Rumination syndrome

Rumination syndrome is a rare behavioral disorder in which undigested food is brought back up from the stomach and into the mouth repeatedly. It is also called rumination disorder or mercyism. It involves regurgitation with no evident physical cause and is different from vomiting. The latter is a reflex of the central nervous system in which organ and skeletal muscles forcefully expel the contents of the stomach. The stomach, small bowel, esophagus, and diaphragm work together during vomiting. Regurgitation does not involve forceful muscle contractions and is not accompanied by nausea. On the contrary, individuals with rumination syndrome often chew the regurgitated food again and swallow it for a second time.

The action is involuntary and usually happens soon after consuming food, typically about ten minutes after every meal. Treatment options include medication and behavioral therapy.

Background

For centuries, the medical model of treating gastrointestinal disorders involved finding a biological cause for symptoms. This approach minimized or ignored the potential impact of the central nervous system and mind in illness. In the mid- to late-twentieth century, researchers and practitioners began to focus on the whole patient and social situation. George Engel developed the biopsychosocial model in 1977, combining physiological pathology, psychological factors including emotions and fears, and socio-economical, socio-environmental, and cultural factors including family and work concerns. Using this method allows practitioners to view symptoms from the physiological point of view with the understanding that sociocultural and psychosocial influences also play a part.

From this perspective, researchers worked during the late twentieth century to understand and classify functional gastrointestinal disorders (FGIDs) in adults. FGIDs are functional as opposed to structural diseases, such as those caused by defects or infections that can be detected and possibly treated. The researchers, who were taking a biopsychosocial approach, sought a consensus on symptoms and diagnostic criteria at a conference in Rome. Subsequent publication of the Rome diagnostic criteria spurred research that produced more information for practitioners and researchers. Going forward, other conferences in Rome updated what was being discovered about FGIDs as testing and understanding of gut function improved. Among these were new discoveries of the importance of gut bacteria and advances in imaging methods to observe the brain’s role in GI function and how it responds to stress, emotions, and other experiences. New pharmaceutical agents were approved for treatment of symptoms such as constipation and diarrhea.

Seven years after the initial results were published, a pediatric team met in Rome to develop criteria for FGIDs in children. In pediatric patients, symptoms were more difficult to detect, because young children cannot articulate what they are experiencing. Researchers classified pediatric disorders based on the primary symptoms observed or reported by caregivers instead of the organs involved as was done with adult patients.

The work done at the Rome conferences helped to increase awareness of FGIDs in the medical community. This spurred further research and attention in clinical training programs and medical school. By 2006, the Rome classification included twenty-eight and seventeen pediatric FGIDs.

Overview

Rumination has been recognized since at least the seventeenth century. Rumination is the regurgitation of food with no discernable physical cause. It is involuntary, and the individual does not experience difficulty swallowing, nausea, or pain. While infants commonly regurgitate, adults with rumination usually have emotional disorders and regurgitate most often while experiencing stress. While stress has been linked to rumination, the exact cause of the disorder is unknown.

Because rumination occurs soon after the food has been swallowed, it usually is not acidic and patients report the taste is normal. They may rechew and swallow the food again or spit it out. Patients may experience a feeling of fullness and abdominal pressure. Possible effects of rumination include bad breath, dental erosion, damage to the esophagus, inhalation of food into the airway, choking, malnutrition, pneumonia, unhealthy weight loss, and death. Individuals may also experience anxiety due to embarrassment and avoid social situations.

Several diagnostic tests may be performed to rule out physical causes of rumination. These include gastric emptying and an esophagogastroduodenoscopy (EGD), often called an upper endoscopy, which allows the doctor to view the duodenum, esophagus, and stomach.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides criteria for diagnosing rumination disorder in adults. Repeated regurgitation of food must occur for at least one month. It is not caused by a medical condition, nor does regurgitation occur with other eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorders. If it is concurrent with another mental disorder, such as intellectual developmental disorder, regurgitation is severe enough to require consideration for treatment.

In pediatric patients, rumination syndrome is believed to be triggered by a stressful event or change or an illness, such as an infection or virus. The trigger causes the nerves of the digestive track to become sensitive, so when food or liquid is introduced, the GI tract nerves cause contractions of the abdominal wall muscles. The condition is diagnosed through observation. Criteria include at least three months of regurgitative actions, such as repeated contractions of the muscles of the abdomen, diaphragm, and tongue, and three or more other symptoms. These include onset of symptoms between three and eight months of age; no changes despite treatment for gastroesophageal reflux disease; no signs of pain or nausea; regurgitation does not occur during sleep or interactions with others. While older patients usually retain enough nutrients, infants may become severely malnourished. Health effects in children can include dehydration and fatigue. School-aged children may miss school and avoid activities such as sports because of embarrassment or anxiety. Rumination is often seen in infants who are in intensive care units, children who are institutionalized, and otherwise normal infants whose caregivers are emotionally distant.

Patients with rumination may benefit from psychiatric evaluation. Therapy commonly involves behavioral techniques. They may learn biofeedback or relaxation. Sometimes they learn how to breathe using the diaphragm instead of chest muscles. Pharmaceuticals such as baclofen may be prescribed to relax muscles.

Treatment of infants and children should include caregivers and focus on improving the relationship they share by helping them find enjoyment. Caregivers may need guidance on nurturing and comforting infants and recognizing and responding to their emotional and physical needs.

Many patients learn to manage their symptoms, although they may not be cured. Those who reduce episodes report symptoms often resurge after an illness. They usually can resume methods they learned in treatment to regain control of symptoms.

Bibliography

Gotfried, Jonathan. “Regurgitaton and Rumination.” Merck Manual, 20 Mar. 2020, www.merckmanuals.com/home/digestive-disorders/symptoms-of-digestive-disorders/regurgitation-and-rumination. Accessed 11 June 2021.

Halland, Magnus, John Pandolfino, and Elizabeth Barba. “Diagnosis and Treatment of Rumination Syndrome.” Clinical Gastroenterology and Hepatology, vol. 16, no. 10, Oct. 2018, pp. 1549–1555, doi.org/10.1016/j.cgh.2018.05.049. Accessed 10 June 2021.

Kroon Van Diest, Ashley. “Rumination Syndrome: Signs, Symptoms and Treatment.” Nationwide Children’s Hospital, 10 Sept. 2019, www.nationwidechildrens.org/family-resources-education/700childrens/2019/09/rumination-syndrome. Accessed 11 June 2021.

Rasquin-Weber, A., et. al. “Childhood Functional Gastrointestinal Disorders.” Gut, vol. 45, no. 2, 1999, pp. 1160–1168, dx.doi.org/10.1136/gut.45.2008.ii60. Accessed 11 June 2021.

“Rumination Disorder.” National Eating Disorders Association, www.nationaleatingdisorders.org/learn/by-eating-disorder/other/rumination-disorder. Accessed 10 June 2021.

“Rumination Syndrome.” Cleveland Clinic, 9 Aug. 2019, my.clevelandclinic.org/health/diseases/17981-rumination-syndrome. Accessed 10 June 2021.

“Rumination Syndrome.” Mayo Clinic, www.mayoclinic.org/diseases-conditions/rumination-syndrome/symptoms-causes/syc-20377330. Accessed 10 June 2021.

“What Are FGIDs?” UNC Center for Functional GI & Motility Disorders, www.med.unc.edu/ibs/patient-education/what-are-fgimds/. Accessed 11 June 2021.