reports, therapies such as stress reduction, cognitive therapy, and biofeedback have been used with variable documentation of their effectiveness in patients without additional underlying contributors to their disease. This is in part because they are typically used in conjunction with diaphragmatic breathing. Similarly, neuromodulators do not appear to have a primary role in treating rumination syndrome unless used for psychologic comorbidities.
Medical therapy
Diaphragmatic breathing is not always effective as a result of inability to learn the technique or assiduously use it postprandially. As a result, pharmacologic therapy can be tried. Two medications have been used for rumination syndrome: baclofen and buspirone. Baclofen is a g‐aminobutyric acid agonist that decreases the number of transient lower esophageal sphincter relaxations [20]. It has been primarily used in patients with refractory GERD [21]. It is used, similarly, in rumination syndrome to maintain greater periods of LES closure to prevent regurgitation of content. In an open‐label study, baclofen taken thrice daily led to a 63% improvement of symptoms in patients with rumination with a reduction in regurgitation events [22]. Unfortunately, side effects, particularly fatigue, are common with baclofen.
Buspirone is a 5‐hydroxytryptamine1A–receptor agonist. Its mechanism of action in rumination syndrome may be related to relaxation of the fundus and/or improvement of gastric compliance [23]. There are no placebo‐controlled trials of this agent in rumination syndrome, but through these mechanisms, efficacy might be achieved.
Fundoplication
The performance of fundoplication in rumination syndrome appears to be contraindicated. This is primarily due to the generation of high intragastric pressures against a newly placed wrap around the gastroesophageal junction. With this physiology, there is a concern about easily undoing the fundoplication and developing gas bloat syndrome. Nevertheless, use of fundoplication in refractory rumination syndrome has been reported in five patients [24]. In this series, all five patients had cessation of regurgitation events with fundoplication, but additionally, one patient required reoperation with reversal of the fundoplication due to persistent dysphagia. Another had severe gas bloat syndrome. Also, in case series of patients with rumination, many report ongoing symptoms respite prior fundoplication [25]. With this data in mind, fundoplication is generally contraindicated and should only be considered for patients with refractory symptoms that cause a major effect on quality of life and health.
Conclusion
Although there are many misconceptions about rumination syndrome, it is hoped that with a clear understanding, this easily diagnosed and treatable condition will become more established in gastroenterology practice. In its simplest form, rumination syndrome can be considered, diagnosed, and treated in one office visit, typically following years of misdiagnosis and spurious testing. In its severe and/or complicated form, physiologic testing primarily with high‐resolution fed manometry is available for confirmation of the diagnosis and initiation of biofeedback therapy. There are aspects of this disease that continue to puzzle us, such as why it starts and how precisely coordination of the mind, abdomen, and esophagus achieve this form of regurgitation, leaving open the hope that future research can find an early preventative rather than treatment alone.
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