Rumination Syndrome

Overview

Rumination syndrome is a condition in which people repeatedly and unintentionally spit up (regurgitate) undigested or partially digested food from the stomach, rechew it, and then either reswallow it or spit it out.

Because the food hasn't yet been digested, it reportedly tastes normal and isn't acidic, as vomit is. Rumination typically happens at every meal, soon after eating.

It's not clear how many people have this disorder. Treatment may include behavioral therapy or medications. Behavioral therapy that involves teaching people to breathe from the diaphragm is the usual treatment of choice.

Symptoms

• Effortless regurgitation, typically within 10 minutes of eating
• Abdominal pain or pressure relieved by regurgitation
• A feeling of fullness
• Bad breath
• Nausea
• Unintentional weight loss

Rumination syndrome isn't usually associated with retching.

When to see a doctor

Consult a doctor if you or your child persistently regurgitates food.

Causes

The precise cause of rumination syndrome isn't clear. But it appears to be caused by an increase in abdominal pressure.

Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) and gastroparesis. Some people have rumination syndrome linked to a rectal evacuation disorder, in which poor coordination of pelvic floor muscles leads to chronic constipation.

The condition has long been known to occur in infants and people with developmental disabilities. It's now clear that the condition isn't related to age, as it can occur in children, teens and adults. Rumination syndrome is more likely to occur in people with anxiety, depression or other psychiatric disorders.

Complications

Untreated, rumination syndrome can damage the tube between your mouth and stomach (esophagus).

Rumination syndrome can also cause:

• Unhealthy weight loss
• Malnutrition
• Dental erosion
• Bad breath
• Embarrassment
• Social isolation

Diagnosis

The doctor will ask about your or your child's current symptoms and medical history. An initial examination, and sometimes observation of behavior, is often enough to diagnose rumination syndrome.

Sometimes high-resolution esophageal manometry and impedance measurement are used to confirm the diagnosis. This testing shows whether there is increased pressure in the abdomen. It can also provide an image of the disordered function for use in behavioral therapy.

Other tests that may be used to rule out other possible causes of your or your child's symptoms include:

• Esophagogastroduodenoscopy. This test allows your doctor to inspect the esophagus, stomach and upper part of your small intestine (duodenum) to rule out any obstruction. The doctor may remove a small tissue sample (biopsy) for further study.
• Gastric emptying. This procedure lets the doctor know how long it takes food to empty from your stomach. Another version of this test can also measure how long it takes food to travel through the small intestine and colon.

Treatment

Treatment depends on the exclusion of other disorders, as well as on age and cognitive ability.

Behavior therapy

Habit reversal behavior therapy is used to treat people without developmental disabilities who have rumination syndrome. People learn to recognize when rumination occurs and to breathe in and out using the abdominal muscles (diaphragmatic breathing) during those times. Diaphragmatic breathing prevents abdominal contractions and regurgitation.

Biofeedback is part of behavioral therapy for rumination syndrome. During biofeedback, imaging can help you or your child learn diaphragmatic breathing skills to counteract regurgitation.

For infants, treatment usually focuses on working with parents or caregivers to change the infant's environment and behavior.

Medication

If frequent rumination is damaging the esophagus, proton pump inhibitors such as esomeprazole (Nexium) or omeprazole (Prilosec) may be prescribed. These medications can protect the lining of the esophagus until behavior therapy reduces the frequency and severity of regurgitation.

Some people with rumination syndrome may benefit from treatment with medication that helps relax the stomach in the period after eating.

Preparing for your appointment

You may start by seeing your or your child's primary care provider. Or you may be referred immediately to a doctor who specializes in digestive disorders (gastroenterologist).

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything that needs to be done in advance, such as fasting before a specific test. Make a list of:

• Symptoms, including any that seem unrelated to the reason for the appointment
• Key personal information, including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you or your child take, including the doses
• Questions to ask the doctor

Take a family member or friend along, if possible, to help you remember the information you're given.

For rumination syndrome, some basic questions to ask the doctor include:

• What's the most likely cause of these symptoms?
• Are there other possible causes?
• Are any tests needed?
• Is this likely temporary or long lasting?
• What treatment do you recommend?
• Are there any alternatives to the primary approach you're suggesting?
• Are any dietary restrictions recommended?
• Do you have any brochures or other printed material about this condition? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you several questions, such as:

• When did the symptoms begin?
• Do symptoms occur with every meal?
• How severe are the symptoms?
• Does anything make your or your child's symptoms better?
• Does anything seem to worsen the symptoms?

What you can do in the meantime

Chewing gum may help ease some rumination syndrome symptoms for some people.