Vomiting
Esophagitis
Prokinetics
Fundoplication
Rumination
During or minutes after meal
No
Not helpful
Not helpful
Achalasia
Hours after meal
Often (from stasis)
Not helpful
Contraindicated
GERD
After large meals or when lying down
Often
Helpful
Helpful
Gastroparesis
Hours after meal
No
Helpful
Not helpful
Cyclic vomiting
Intermittent, unrelated to meal
During episodes
Not helpful
Not helpful
Diagnosis
Rumination syndrome is a clinical diagnosis [6] and very minimal testing should be needed in the classic cases. A patient who satisfies the symptoms-based Rome criteria for this condition (Table 41.2) should need no further investigation. Pointing out to the patients and to the parents how saliva is easily swallowed but even a sip of water causes symptoms is particularly enlightening with regard to the behavioral component of this disorder.
Table 41.2
Rome IV criteria for adolescent rumination syndrome
Diagnostic criteriaa Must include all of the following |
|---|
1. Repeated regurgitation and rechewing or expulsion of food that: |
(a) Begins soon after ingestion of a meal |
(b) Does not occur during sleep |
2. Not preceded by retching |
3. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition. An eating disorder must be ruled out |
Antroduodenal manometry is not always necessary to make the diagnosis, but it can be considered as the “big convincer” in cases when the families or the patients are not yet confident of the diagnosis of rumination syndrome. Manometry may also be used to rule out the presence of an underlying motility disorder, a common fear among families of patients with this disorder. In patients with rumination syndrome, antroduodenal manometry shows essentially normal fasting and postprandial motor patterns [6, 13]. The characteristic manometric abnormality is a synchronous increase in pressure (“r” waves) across both gastric and duodenal recording sites when the rumination occurs. The “r waves” are thought to represent the effect of an increase in intragastric or intra-abdominal pressure generated by the contraction of the skeletal abdominal muscles. Interestingly, under the pressure of being in a laboratory setting with constant attention being paid to their symptoms, some adolescents with rumination are able to eat the test meal during the manometry study with minimal or no symptoms (Fig. 41.1).
Fig. 41.1
An example of an antroduodenal tracing from an adolescent with rumination syndrome. The end of the meal is marked and almost immediately afterwards, the patient begins to have episodes of “small spit up,” marked as such on the tracing. Those events are associated with a simultaneous increase in pressure in all recording sites (known as “r waves”)
Impedance-manometry monitoring allows distinction between rumination from GERD and supragastric belching. During rumination, esophageal liquid retrograde flow is driven by an early rise in intragastric pressure preceding the peak pressure observed during straining [14]. It has been suggested that the diagnosis of rumination syndrome can be made when reflux events extending to the proximal esophagus are associated with an abdominal pressure increase >30 mm, because such increase is usually not seen in patients with GERD. The impedance study will also confirm the characteristic absence of nighttime reflux events in patients with rumination syndrome.
Treatment
As practitioners and researchers strive to understand the pathogenesis of this complex functional disorder, many have proposed mechanisms by which rumination occurs and is maintained. Interestingly, while not formally referring to rumination as a habit disorder, most authors discuss rumination occurrence and treatment very much like that of a habit disorder [10, 15–18]. Therefore, this chapter conceptualizes rumination syndrome in these terms, and the components of treatment described in the literature for rumination syndrome are presented and organized as such.
Education and Reassurance
Several authors have discussed how accurate diagnosis and reassurance often provide considerable relief to families and patients [1, 11, 19]. Education about rumination syndrome may allow for a reduction in anxiety, as patients are provided with a diagnosis and understand that no structural or intrinsic motility problems exist. In addition, accurate description of the disorder may allow patients to be a more active part in their own treatment.
Presentation of rumination syndrome from a biopsychosocial perspective allows families to understand the interplay among physical, behavioral, emotional, and situational factors [15]. The educational intervention should include a discussion of why no further testing is needed, how rumination syndrome can be diagnosed by symptoms (and it is not simply a diagnosis of exclusion), and that the condition is treatable using behavioral interventions. In our experience, families who continue to seek further diagnostic testing and a “medical” explanation for the rumination tend to be less invested and less successful with treatment.
Many patients who have not heard of rumination syndrome often interpret their vomiting as their stomach not being able to “handle” food or fluid, and therefore “rejecting” the food, contracting, and forcing the food upward. An important aspect of the educational process is describing the pathophysiology of rumination with a focus on contraction of the intercostal muscles and abdominal wall as the driving force behind the expulsion of stomach contents [20]. Triggers for the behavior are discussed, including food or fluid intake, the rise of dyspeptic symptoms, or even the anticipation of eating or drinking. Finally, the role of autonomic nervous system arousal (via worry, nervousness, and anxiety) in rumination is discussed with the patient and family.
Behavioral Observation
The importance of observing the patient eat or drink and then ruminate cannot be overemphasized. As described earlier, different mechanisms may underlie the patient’s rumination [11]. In our experience, no two patients with a diagnosis of rumination have been exactly the same with regard to the antecedent sensory experience, the types or amounts of food or fluid that trigger rumination, or the manner in which they manage the rumination (e.g., reswallow, expel). Observation of the rumination allows for both further evaluation of the patient and the ability to increase the patient’s awareness of the behavior.
Awareness Training
In order to increase patient awareness of rumination and its antecedents (as discussed in the educational portion of treatment), patients in our program typically take part in two observation mealtimes. During the first meal, patients are requested to eat a meal at their typical pace, and to ruminate and vomit as they normally would outside of the medical setting. The clinician requests that the patient attend to the abdominal wall contractions as they occur. Information gathered includes how often the patient ruminates during this natural meal (or if rumination does not commence until the mealtime ends), the pace of the patient’s eating, the patient’s posture, how they attempt to manage rumination, and observable symptoms such as belching.
At the second observation meal, the clinician directs the patient as to how much to eat or drink at 5-min intervals. For example, the clinician may request that the patient drink one ounce of juice, or take one bite of mashed potatoes. During this second meal, the clinician continuously records data such as the amount of food or fluid ingested at each interval, the number of times the patient ruminates or vomits, and requests that the patient rate their most common dyspeptic symptoms on a scale of 0–10 every 5 min. By the end of the meal, a picture often emerges of a gradual increase in dyspeptic symptoms, a gradual increase in rumination, and resolution of the dyspepsia with emesis. This information is shared with the patient, as they recognize the relationship between their dyspeptic symptoms and rumination behavior. These observation mealtimes also allow the clinician to obtain a “starting point” for treatment, recognizing the amount of food that can trigger rumination and how soon into a mealtime the rumination commences.
Awareness training continues during treatment mealtimes (typically 3 times each day, lasting around 20–30 min). Using the data from the observation meals as a starting point, the clinician designs mealtimes with the patient tracking rumination frequency, vomiting, and the intensity of dyspeptic symptoms at 5-min intervals. While it is relatively uncommon for the rumination behavior or dyspeptic symptoms to change significantly over the first few days, the data provides a solid baseline for the clinician, and increased awareness on the part of the patient and parent [21].
The use of biofeedback has been described by several authors as a beneficial intervention in patients with rumination syndrome [3, 16, 22, 23], at times with minimal description of the specific biofeedback modality employed or the proposed mechanism by which the biofeedback is thought to have allowed for improvement. To further increase awareness of the physical response to rumination, our program has utilized biofeedback in multiple ways. First, many patients benefit from the use of surface electromyography (sEMG) monitoring the abdominal muscles to further elucidate the muscle contractions that occur during episodes of rumination [20, 24]. Second, when instructing on the use of diaphragmatic breathing, the use of respiration belt or sensor with biofeedback often is particularly beneficial in increasing awareness of and adjusting aspects of respiration such as breathing rate, patterns (e.g., breath holding), and depth of respiration.
Third, heart rate variability (HRV) biofeedback can be beneficial in providing the patient with continuous feedback about their stress response/relaxation response during and after mealtimes. Functional gastrointestinal disorders recently have been understood in terms of the multiple pathways that influence symptom presentation, with autonomic nervous system dysregulation playing a role [25, 26]. The autonomic nervous system’s reactivity and recovery has an impact on symptom presentation in patients with functional gastrointestinal disorders such as irritable bowel syndrome [27]. It also has been demonstrated that biofeedback approaches (i.e., instruction on autonomic nervous system regulation) allow for increased vagal tone as well as symptom improvement in patients with functional abdominal pain [28]. Given the role of autonomic dysregulation in functional disorders, it is likely that similar mechanisms contribute to the challenges demonstrated by patients with rumination syndrome .
Environmental or Internal Factors
The clinician should be aware of environmental factors that may influence the patient’s rumination behavior. While rumination typically is associated with the ingestion of food, there are some patients who begin to ruminate when food is merely present, or when food first touches the tongue. Another common environmental factor to be aware of is the presence of the patient’s emesis container (e.g., a bag, cup, or other vessel into which patients vomit throughout the day). Removal of the container typically allows for improved focus and awareness of rumination on the patient’s part, and greater motivation to control vomiting.
Internally, patients typically have the expectation that everything they eat or drink will be ruminated and or vomited. As such, they inadvertently engage in self-talk that likely serves to diminish motivation and potentially heighten the stress response during mealtimes. Such automatic thoughts (e.g., “This is going to hurt” or “I’m going to throw this up eventually”) often are seen in patients with comorbid anxiety or depressive symptoms.
Related posts:
Integration of Biomedical and Psychosocial Issues in Pediatric Functional Gastrointestinal and Motility Disorders
Familial Dysautonomia and Mitochondrial Disorders
Irritable Bowel Syndrome
Infant Colic
Introduction to Gut Motility and Sensitivity
Chronic Intestinal Pseudo-obstruction Syndrome: Surgical Approach and Intestinal Transplantation
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