Rumination is a phenomenon characterized by retrograde flow of gastric contents into the mouth, otherwise known as regurgitation. Repetitive excessive occurrence of rumination is considered pathologic and is known as the rumination syndrome. Belching occurs occasionally in everyone and is often not related to a disease or a pathologic condition. Gastric belches are physiologic events caused by retrograde flow of air into the esophagus and mouth; however, supragastric belching is associated with belching disorders and is considered pathologic behavior.
Key points
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The underlying mechanism of rumination is characterized by an increase in intragastric pressure.
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Combined manometry and pH impedance are preferred to distinguish rumination and belching disorders from other esophageal pathologies.
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In supragastric belches air is expelled immediately after ingestion; it is often caused by contraction of the diaphragm, creating negative pressures in the thoracic cavity and esophagus.
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On impedance supragastric belches are observed as an increase in impedance, starting in the proximal channel, and progressing to a distal channel, followed by a return to baseline starting in the distal channel.
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Manometry is crucial for identification of rumination and other esophageal pathologies; however typical patterns of supragastric belches are better observed on impedance.
Introduction
Rumination is a phenomenon characterized by retrograde flow of gastric contents into the mouth, otherwise known as regurgitation. Repetitive excessive occurrence of rumination is considered pathologic and is known as the rumination syndrome ; this is a behavioral disorder, first thought to be only present in children and mentally disabled but currently increasingly recognized in otherwise healthy adult patients as well.
Belching occurs occasionally in everyone and is often not related to a disease or a pathologic condition. There are 2 types of belches: gastric belches and supragastric belches. Gastric belches are physiologic events caused by retrograde flow of air into the esophagus and mouth; however supragastric belching is associated with belching disorders and is considered pathologic behavior.
Clinical diagnosis of the rumination syndrome and belching disorders are based on the ROME III criteria, which strangely enough defines both diseases as functional gastroduodenal disorders. Unfortunately, patients frequently suffer several years and often consult many different physicians before being diagnosed correctly ; this is partly because other diseases such as gastroesophageal reflux disease (GERD) show many similarities in symptomatology with the rumination syndrome and the excessive belching disorder.
Fortunately, recent technological advances, such as high-resolution manometry (HRM) combined with impedance, have allowed us to facilitate the detection and diagnosis of the rumination syndrome and supragastric belching.
In this article, the authors aim to provide an overview of the current diagnostic tools to improve the recognition and diagnostic approach of the rumination syndrome and belching disorders. For better understanding, both disorders will be discussed separately.
Introduction
Rumination is a phenomenon characterized by retrograde flow of gastric contents into the mouth, otherwise known as regurgitation. Repetitive excessive occurrence of rumination is considered pathologic and is known as the rumination syndrome ; this is a behavioral disorder, first thought to be only present in children and mentally disabled but currently increasingly recognized in otherwise healthy adult patients as well.
Belching occurs occasionally in everyone and is often not related to a disease or a pathologic condition. There are 2 types of belches: gastric belches and supragastric belches. Gastric belches are physiologic events caused by retrograde flow of air into the esophagus and mouth; however supragastric belching is associated with belching disorders and is considered pathologic behavior.
Clinical diagnosis of the rumination syndrome and belching disorders are based on the ROME III criteria, which strangely enough defines both diseases as functional gastroduodenal disorders. Unfortunately, patients frequently suffer several years and often consult many different physicians before being diagnosed correctly ; this is partly because other diseases such as gastroesophageal reflux disease (GERD) show many similarities in symptomatology with the rumination syndrome and the excessive belching disorder.
Fortunately, recent technological advances, such as high-resolution manometry (HRM) combined with impedance, have allowed us to facilitate the detection and diagnosis of the rumination syndrome and supragastric belching.
In this article, the authors aim to provide an overview of the current diagnostic tools to improve the recognition and diagnostic approach of the rumination syndrome and belching disorders. For better understanding, both disorders will be discussed separately.
The rumination syndrome
Pathophysiology
Rumination is the voluntary, albeit unconscious, contraction of the abdominal muscles forcing return of food into the mouth, followed by rechewing, swallowing, or spitting. The underlying mechanism is characterized by an increase in intragastric pressure, as a result of gastric straining. When the intragastric pressure overcomes the pressure of the lower esophageal sphincter (LES), gastric content can flow into the esophagus. As a result, relaxation of the upper esophageal sphincter (UES) occurs and gastric content can subsequently flow from the esophagus into the pharynx and mouth. The reason for the relatively “lower” LES pressure is still unclear, but could be caused by a prolonged low LES pressure postprandially or a temporary lowering during transient LES relaxations (TLESRs), which are sensed by the subject. A third hypothesis is a learned, voluntary relaxation of the diaphragmatic crura that allows the normal postprandial increase in intragastric pressure to overcome the resistance to retrograde flow provided by the LES.
The reason for gastric straining in patients suffering from rumination is still unclear. A study conducted by Tucker and colleagues has shown that rumination is often seen as a behavioral response to abdominal pain or other unpleasant digestive symptoms. However, other studies have also suggested that psychological factors, such as stressful life events, lead to rumination.
Clinical Evaluation and Diagnostic Approach
Clinical evaluation of the rumination syndrome is based on the ROME III criteria and is defined as persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing. Patients suffering from rumination syndrome typically present themselves with regurgitation, starting during the meal or in the immediate postprandial period. Regurgitation of gastric contents may occur several times per minute and is often described as having the same taste and consistency as the consumed food. Another commonly seen symptom is weight loss, which can occur in up to 83% of patients with the rumination syndrome. Furthermore, the response to acid suppression is often limited or absent.
Experienced clinicians can recognize patients with rumination syndrome by clinical observation alone. However, only a few physicians have significant experience because of the low prevalence of the syndrome. Thus, patients with rumination syndrome often present to physicians who have never seen a patient with the condition before. Furthermore, the clinical presentation of the rumination syndrome shows many similarities (such as regurgitation) with other conditions and is therefore often mistaken for diseases such as GERD, gastroparesis, and cyclic vomiting. Therefore, the diagnosis of the rumination syndrome is made on both clinical observation and physiologic measurements. Currently, it is preferred to use conventional manometry or HRM combined with pH impedance to distinguish rumination syndrome from belching/regurgitation disorders and GERD.
With combined manometry (conventional/HRM) and pH impedance, 3 variations of the rumination syndrome can be identified: (1) rumination without any leading events (classic rumination), (2) rumination occurring exclusively after a reflux episode (reflux rumination or secondary rumination), and (3) rumination caused by air swallowing and subsequent gastric straining (supragastric rumination). Each subtype has a specific pattern, which can be identified on manometry and impedance measurements. On manometry, classic rumination presents itself with a sharp increase in intragastric pressure, also known as the “R-wave”, before gastric contents are returned into the mouth ( Figs. 1 A and 2 A ). Reflux rumination is caused by a gastric strain that occurs following a TLESR with common cavity pressure, resulting in regurgitation of gastric contents. The manometry of a patient with reflux rumination will display a moment of LES pressure decrease (TLESR), which is not present in a patient with classic rumination (see Figs. 1 B and 2 B). The third subtype, supragastric rumination, is caused by swallowed air and subsequent gastric straining, which is then used to drive esophageal contents into the mouth (ie, never passes into the stomach). In this case, the LES does not relax on manometry (see Figs. 1 C and 2 C). As seen in the figures, each subtype of the rumination syndrome is characterized by an increase in intragastric pressure (gastric strain). This increase in intragastric pressure is a very important characteristic to distinguish rumination from other disorders such as GERD. A study conducted by Kessing and colleagues showed that 70% of patients with rumination exhibited gastric pressure peaks of greater than 30 mm Hg preceding the retrograde gastroesophageal flow, whereas 0% of patients with GERD presented peaks of greater than 30 mm Hg, demonstrating that with the 30 mm Hg cutoff a specificity of 100% was obtained.
The study conducted by Kessing and colleagues also investigated the value of 24-hour pH impedance without manometry, in distinguishing rumination from other disorders. The result was that on average in rumination patients a higher percentage of reflux episodes reached the proximal esophagus; thus this finding alone was not sufficient to differentiate rumination from GERD. However, as Fig. 1 demonstrates, impedance measurements provide a clear view on the development of gastric strain into a rumination episode. On impedance a rumination episode will present itself as a reflux episode, occurring closely after/before gastric straining observed on manometry.
Treatment
Previous studies suggest that the rumination syndrome is a learned behavior caused by gastrointestinal discomfort, as well as a reaction to stressful life events. Treatment of the rumination syndrome is currently based on behavioral breathing therapy or cognitive therapy with biofeedback. Both treatments are believed to compete with the urge to regurgitate and have yielded positive outcomes in previous studies. Current advancements in physiology measurements have made it possible to better identify the rumination syndrome. In theory, each variation of the rumination syndrome could be treated according to the specific mechanism and triggers. For example, one study concluded that supragastric belching responds favorably to behavioral therapy performed by a speech therapist. The latter suggests that patients who exhibit supragastric rumination would also benefit from behavioral therapy. However, secondary rumination appears to be triggered by reflux episodes, which in theory could benefit more from treatment of the reflux disease, because patients will ruminate only when they sense reflux episodes. Based on this idea, proton pump inhibitor could also reduce the number of rumination episodes by decreasing the severity of heartburn. However, in most cases, rumination will still occur, because weakly acidic reflux can also trigger rumination episodes.
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