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4 The Esophagus: Rumination Syndrome
Magnus Halland and David A. Katzka
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, New York, USA
Introduction
Rumination syndrome is one of the most misunderstood diagnoses in gastroenterology. It is commonly confused with and treated as gastroesophageal reflux, refractory vomiting, achalasia, or gastroparesis. When the use of proton pump inhibitors (PPIs) fails, patients may undergo fundoplication. Similarly, patients undergo multiple unnecessary and sometimes invasive tests. When the syndrome is recognized, it is often incorrectly assumed to be psychogenic in origin, sometimes as a form of bulimia, and treated by addressing the putative psychiatric disorder and stress reduction. This therapeutic strategy alone is unlikely to lead to resolution of symptoms. Rumination syndrome has a clear pathophysiology that must be understood to provide an adequate treatment response. In this chapter, its presentation, etiology, and therapy will be discussed in detail.
Definition, clinical presentation, and demographic characteristics
The Rome IV criteria for rumination syndrome are given in Table 4.1 [1]. In addition to these criteria, several other typical manifestations are noted [2]. For example, patients are often as likely to regurgitate liquids and solids without relation to the volume consumed. Many patients are not bothered by the symptoms and learn to effectively hide the regurgitation and re‐mastication from others even while sharing a meal. Weight loss occurs in approximately half of patients [3]. In its most severe form, patients may have profound weight loss and dehydration, but search for an additional cause of symptoms in these patients should be sought. Patients commonly have a vague sense of when the regurgitation is starting, which may be during to a few hours after the meal [1, 4]. In most patients, the regurgitation occurs within 30 minutes of finishing a meal. Finally, rumination occurs with almost, if not, every meal and may or may not be volume related.
Rumination was first described in children with developmental disabilities but has since been expanded to include children and adults with normal intelligence [3, 5]. Although often ascribed to individuals with psychiatric illnesses, this is not applicable to many patients. There is little data on the prevalence of rumination syndrome. Two studies based on population‐based data have reported prevalences of 0.8 and 0.9% [6, 7]. This data likely underestimates the true prevalence due to confusion with other esophageal disorders and under‐recognition by physicians. It appears to be more common in certain subsets of patients such as children and teenagers [3, 8], young adults, and patients with fibromyalgia [9]. Interestingly, the geographic distribution of rumination syndrome appears to be worldwide and may occur in patients of all ages, races, and gender.
Differential diagnosis
Three disorders are commonly confused with rumination syndrome (Table 4.2). The most evident is gastroesophageal reflux disease (GERD). In severe GERD manifested by sustained and marked incompetence of the lower esophageal sphincter with or without a hiatal hernia, volumetric reflux of gastric content may occur. Although the regurgitant is typically acidic and therefore sour and bitter‐tasting, if patients have adequate acid suppression with PPIs, refluxed content may be bland in taste. Characteristics that distinguish GERD from rumination are symptoms that are dictated by gravity. Specifically, GERD symptoms occur commonly in the supine position with sleep and with bending over, in contrast to rumination, which stops with sleep.
A second disorder confused with rumination is achalasia. Similar symptoms include regurgitation of bland content, both liquids and solids, typically during or shortly after a meal. Characteristics that distinguish achalasia from rumination syndrome are the likeliness of regurgitation to occur with larger volumes of ingestant, nighttime symptoms, and accompanying chest pain. Weight loss is also more common in achalasia, where patients may stop eating when regurgitation begins and/or eat smaller meals to avoid regurgitation. Patients with achalasia also may have stereotactic movements to facilitate esophageal transit such as sitting up straight and walking postprandially, which are not incorporated into the behavior of ruminators.
The third disorder is bulimia. This is not uncommonly mistaken for rumination since both disorders can occur in female teenagers and young adults. Factors that distinguish bulimia from regurgitation are the need to voluntarily cause regurgitation in contrast to the effortless regurgitation that occurs with rumination syndrome.
Table 4.1 Rome IV criteria of rumination syndrome.
| Main criteria Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or re‐mastication and swallowing. Regurgitation is not preceded by retching. |
| Supportive criteria Effortless regurgitation events usually are not preceded by nausea. Regurgitant contains recognizable food that might have a pleasant taste. The process tends to cease when the regurgitated material becomes acidic. Criteria fulfilled for the past three months with symptom onset at least six months before diagnosis. |
Table 4.2 Differential diagnosis and contrasting features of rumination syndrome.
| Disease | Acid reflux | Night sx | Wt. loss | PPI response | Worse supine | Dysphagia |
|---|---|---|---|---|---|---|
| Rumination | – | – | –/+ | – | – | – |
| GERD | + | + | – | + | + | +/– |
| Achalasia | – | + | + | – | + | + |
| EoE | – | – | – | +/– | – | + |
Pathophysiology
Although the mechanism for rumination is thought to be self‐taught with unconscious maneuvers that facilitate flow of gastric content into the esophagus and mouth, it is unclear what the initiates