Rumination disorder

WikiDoc Resources for Rumination disorder
Articles
Most recent articles on Rumination disorder Most cited articles on Rumination disorder Review articles on Rumination disorder Articles on Rumination disorder in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Rumination disorder Images of Rumination disorder Photos of Rumination disorder Podcasts & MP3s on Rumination disorder Videos on Rumination disorder
Evidence Based Medicine
Cochrane Collaboration on Rumination disorder Bandolier on Rumination disorder TRIP on Rumination disorder
Clinical Trials
Ongoing Trials on Rumination disorder at Clinical Trials.gov Trial results on Rumination disorder Clinical Trials on Rumination disorder at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Rumination disorder NICE Guidance on Rumination disorder NHS PRODIGY Guidance FDA on Rumination disorder CDC on Rumination disorder
Books
Books on Rumination disorder
News
Rumination disorder in the news Be alerted to news on Rumination disorder News trends on Rumination disorder
Commentary
Blogs on Rumination disorder
Definitions
Definitions of Rumination disorder
Patient Resources / Community
Patient resources on Rumination disorder Discussion groups on Rumination disorder Patient Handouts on Rumination disorder Directions to Hospitals Treating Rumination disorder Risk calculators and risk factors for Rumination disorder
Healthcare Provider Resources
Symptoms of Rumination disorder Causes & Risk Factors for Rumination disorder Diagnostic studies for Rumination disorder Treatment of Rumination disorder
Continuing Medical Education (CME)
CME Programs on Rumination disorder
International
Rumination disorder en Espanol Rumination disorder en Francais
Business
Rumination disorder in the Marketplace Patents on Rumination disorder
Experimental / Informatics
List of terms related to Rumination disorder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mark Warren, M.D., M.P.H.; Fellow, Academy of Eating Disorders [2]; Rithish Nimmagadda,MBBS.[3]; Kiran Singh, M.D. [4]

Synonyms and keywords: Childhood rumination disorder; merycism, rumination syndrome

Overview

Rumination is an eating disorder characterized by having the contents of the stomach drawn back up into the mouth, chewed for a second time, and swallowed again. In some animals, known as ruminants, this is a natural and healthy part of digestion and is not considered an eating disorder. However, in other species (including humans), such behavior is atypical and potentially dangerous as the esophagus can be damaged by frequent exposure to stomach acids. Rumination is also associated with eating disorders such as anorexia nervosa, and can be the result of one's apprehension and nervousness after eating a normal meal. For those with purging behaviors, rumination can take place when the option of getting rid of a meal via throwing up is not available (thus, one might feel worried and visibly upset). Rumination has also been reported in developmentally normal children and adults who experience regurgitation of previously swallowed food, without disgust, nausea or an acidic taste. The food is either chewed and reswallowed or spat out. Remission of these episodes is seen in some cases while others persist. Many claim this as a pleasurable habit.

Historical Perspective , Epidemiology and Demographics

prevalence: Both adults and children are susceptible to rumination syndrome. Out of the 2163 children and adolescents questioned for this study, 110 (5%) met the clinical criteria for rumination syndrome. In one research conducted in the United States, the prevalence of rumination was 5.8 percent

in another, almost 50,000 individuals were questioned in 26 nations. Rumination syndrome may affect as many as 7 to 8 percent of people with fibromyalgia or eating problems. Related disorders

Constipation from a rectal evacuation disorder, anxiety, depression, adjustment disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit-hyperactivity disorder have all been linked to rumination syndrome. While some research indicates that adults and adolescents with developmental delays are more likely to experience rumination syndrome

Pathophysiology

Although the exact cause of rumination syndrome is unknown, one important pathogenetic characteristic that seems to be present is unperceived abdominal wall activity throughout the postprandial interval. Although the precise cause of this activation of the abdominal wall is unknown, given the similarities between rumination syndrome and functional dyspepsia, it is plausible that postprandial dyspeptic symptoms are the trigger for rumination episodes.

In individuals with rumination syndrome, a permissive esophagogastric gradient is created by a combination of elevated intra-abdominal pressure and negative intrathoracic pressure, which causes the retrograde flow of eaten gastric material into the mouth. Rumination occurs after stomach pressurizations surpassing 30 mmHg on postprandial esophageal high resolution impedance manometry. This is linked to lower and upper esophageal relaxation during the gastric pressurization. This suggests that malfunctioning of the upper and lower esophageal sphincters is probably involved in rumination and that elevated intra-abdominal pressure alone is not sufficient to explain it.

It is believed that the activation of the muscles in the abdominal wall is what causes this surge in intraluminal pressure. During electromyography recordings, postprandial abdominal wall activity has also been noted; this activation is correlated with bouts of regurgitation.

Clinical features

The hallmark of rumination syndrome is fast regurgitation, typically starting within ten minutes of meal completion. Episodes often last for one to two hours following the meal, and the regurgitant is made up of partly digested food that tastes similar to what was really swallowed. Easy to perform, regurgitation is frequently caused by an abdominal ache, pressure, or burning feeling that has to be eased.

Retching is not typically seen before an episode. Consciously, the content is regurgitated or reabsorbed. Regurgitation happens usually, if not always, after eating. In order to make up for this, patients frequently modify their eating habits and may stop eating in public.

Patients often express nausea and dyspepsia symptoms such as burning or fullness in the stomach, and there is almost a four-fold increased likelihood of overlap between rumination syndrome and functional dyspepsia than would be predicted by chance. It is unusual to have overt discomfort. About 20 to 40 percent of patients have shown signs of weight reduction. In the absence of a co-occurring eating problem, significant weight loss, electrolyte imbalances, tooth erosions, and malnutrition are uncommon.

Differentiating Rumination disorderfrom other Diseases

Rumination syndrome should be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:

Rumination disorder Diagnosis and Evaluation

The Rome IV diagnostic criteria for rumination syndrome are as follows. The following requirements must be satisfied in order for the Rome IV criteria to be satisfied: both adults and kids

●Repeatedly or persistently vomiting previously consumed food into the mouth, followed by swallowing, spitting, or remastication ●Retching does not occur before regurgitation Additional clinical characteristics that are helpful in supporting the diagnosis of rumination syndrome but are not necessary include:

Rumination stops when the regurgitated material turns acidic. ●Effortless regurgitation episodes often do not include nausea. ●Regurgitant contains identifiable food that may taste good. The diagnostic criteria for rumination in children are identical, with the exception that it cannot happen when the kid is sleeping or react to conventional reflux medication.

Assessment

History and physical examination: The goal of the history should be to determine if the postprandial symptoms are regurgitation or vomiting, as this is what patients frequently describe. Unlike vomiting, regurgitation is painless, doesn't always cause nausea, and doesn't include heaving or retching beforehand. In people with rumination syndrome, vomiting is not something that can be willingly held in the mouth or re-ingested, in contrast to regurgitate. Before the beginning of rumination symptoms, patients with rumination syndrome frequently recall a triggering event.

Based on their medical history, children and adolescents who exhibit symptoms suggestive of rumination syndrome should have eating disorders ruled out. Rule out mechanical obstruction: Using upper gastrointestinal endoscopy and, if in doubt, CT/MR enterography, we rule out mechanical obstruction in patients who are suspected of having rumination syndrome.

Rule out mechanical obstruction: Using upper gastrointestinal endoscopy and, if in doubt, CT/MR enterography, we rule out mechanical obstruction in patients who are suspected of having rumination syndrome. In most cases, upper endoscopy results for rumination syndrome patients are normal. Patients may occasionally show signs of esophagitis. To rule out other conditions, such as H. pylori infection, celiac disease, and eosinophilic gastroenteritis, we do biopsies.

High resolution impedance pH manometry: Reflux episodes that extend to the proximal esophagus and are strongly linked to an increase in stomach pressure to >30 mm Hg are diagnostic findings of rumination syndrome on postprandial high resolution impedance manometry. There are no defined normative norms for traditional manometry.

Based on the high resolution manometry pressure pattern, three rumination variations may be identified:

●First rumination: Retrograde flow occurs before a rise in abdominal pressure. ▏Secondary rumination: When a reflux event starts, there's an instant rise in abdominal pressure. ●Supragastric belch-induced rumination: When a supragastric belch occurs, it's immediately followed by a ruminating episode. Rumination tendencies in children seem to be comparable to those in adults, despite the paucity of research in this area. A diagnostic threshold for retrograde bolus flow into the proximal esophagus, linked to a stomach pressure rise of more than 25 mmHg, has been suggested as the threshold for rumination syndrome in children.

Rumination disorder Management

first-hand supervision

Education and treatment of linked mood disorders: Reassurance and education are crucial parts of the first steps in managing rumination syndrome. Enhancing the patient's comprehension of their illness and motivating them to actively participate in their care are the two main goals of education. Gastroenterologists and psychologists must work together in a multidisciplinary manner, particularly when treating patients who have underlying anxiety disorders, depression, or refractory symptoms.

Diaphragmatic (abdominal) breathing: This technique is the cornerstone of treatment for rumination syndrome (figure 2). The gastroesophageal pressure gradient is restored by diaphragmatic breathing, which lowers postprandial intragastric pressure and raises esophagogastric junction zone pressure. By using this method, patients stretch their abdomen and compress their diaphragm to inhale.

Refractory signs and symptoms

Gamma-aminobutyric acid receptor agonist: Baclofen is only used in people whose symptoms don't respond to first-line treatment. A gamma-aminobutyric acid agonist called Baclofen increases the tone of the lower esophageal sphincter and inhibits brief relaxations of it. The effect of baclofen on regurgitation in rumination syndrome has only been assessed in two trials. For a week, baclofen (10 mg three times daily) was administered to sixteen adult patients with clinically suspected rumination syndrome as part of an open-label experiment. Treatment with baclofen was linked to a substantial decrease in the frequency of postprandial flow episodes and symptoms in 12 individuals who finished the research as compared to baseline.. However, long-term data on efficacy and tolerability are lacking. Baclofen crosses the blood-brain barrier and causes a variety of central nervous system-related side effects. Side-effects primarily include somnolence, confusion, dizziness, lightheadedness, drowsiness, weakness, and trembling. We usually begin by giving 5 to 10 mg at bedtime, which can be increased slowly to 10 mg three times daily while carefully monitoring for side effects.

Disorder	Clinical features												Laboratory findings
	Chronic nausea	Vomiting	Diarrhea	Retching	Lethargy	Social withdrawal	Photophobia	Epigastric pain/burning	Lanugo hair	Hypogonadism	Russel's sign	Body mass index (normal range: 18.5 to 24.9)	Complete blood count (CBC)	Electrolyte imabalance	Lipase and amylase levels	Gastric scintigraphy	Ambulatory esophageal pH and impedance testing
Gastroparesis	✔	✔ (within 1 hour of eating)	-	✔	✔	-	-	✔	-	-	-	↓	Anemia	✔	Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)	Periodic measurement of radiolabeled solid meal:   Grade 1 (mild), 11%-20% retention at 4 h Grade 2 (moderate), 21%-35% retention at 4 h Grade 3 (severe), 36%-50% retention at 4 h Grade 4 (very severe), > 50% retention at 4 h	Impedance testing (antroduodenal manometery): Loss of normal fasting migratory motor complexes (MMCs) and reduced postprandial antral contractions and, in some cases pylorospasm
Anorexia nervosa	✔	✔	✔	-	✔	✔	-	-	✔	✔	-	↓	Leukocytosis, anemia	✔	Increased	Gastric emptying may be delayed but may become normal as feeding recommences (short lived)	Esophageal pH: May be decreased if patient develops gastroesophageal reflux disease
Bulimia nervosa	✔	✔	✔	✔	✔	✔	-	-	-	✔	✔	Normal	Leukocytosis, anemia	✔	Increased	Gastric emptying delayed for a longer duration as compared to anorexia nervosa	Esophageal pH: May be decreased if patient develops gastroesophageal reflux disease
Rumination syndrome	✔	✔ (Regurgitation more common- within minutes of meal intake)	✔	-	✔	✔	✔	✔	-	-	-	↓	Normal	✔	Normal	Delayed gastric emptying	Esophageal pH: Fall in esophageal pH immediately after reguritation (occurs while patient is awake and erect; this is in contrast to GERD, where reflux occurs diurnally and supine position) Impedance testing:Increased intra-abdominal pressure leading to regurgitation of gastric contents (Tall R waves)
Functional dyspepsia	✔	✔	✔	✔	-	-	-	-	-	-	-	Normal	Normal	✔	Increased (especially lipase)	Delayed gastric emptying	Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome	✔	✔	-	✔	✔	-	-	-	-	-	-	↓	Leukocytosis, anemia	✔	Increased (alongwith increased lactic acid - in cases of concomitant mitochondrial disease)	Rapid or normal	Esophageal pH: Decreased
Pancreatitis	✔	✔	✔	✔	✔	-	-	✔	-	-	-	Normal	Leukocytosis	✔	Increased	Not indicated	Esophageal pH: Normal
Gastric outlet obstruction	✔	✔ (within 1 hour of eating)	-	-	-	-	-	✔	-	-	-	↓	Leukocytosis	✔	Increased (in cases of pancreatic disease)	Delayed gastric emptying	Esophageal pH: Increased Esophageal manometery:   High manoraetric score

Other differntials

Other differentials of rumination disorder include the following:

• Gastroesophageal reflux
• Hiatal hernia
• Pyloric stenosis
• Sandifer syndrome

Epidemiology and Demographics

Prevalence

• The prevalence of rumination syndrome is higher among subjects with intellectual disability compared to the overall population.

Risk Factors

• Lack of stimulation
• Neglect
• Problems in the parent-child relationship
• Stressful life situations

Natural History, Complications and Prognosis

Rumination disorder typically occurs within the first 3-12 months of age and can lead to the child becoming malnourished.

While rumination disorder may begin in childhood or infancy, adults may also have this chronic disorder, for which there is presently no known cure nor cause. While those diagnosed with this condition in childhood may 'grow out of it', it is by no means a medical fact that they are bound to do so by adolescence or adulthood.

Remission of these episodes is seen in some cases while others persist.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Rumination Disorder

“

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. AND B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis). AND C. The eating disturbance does not occur exclusively during the course of anorexia nervosa,bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder. AND D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability, Intellectual developmental disorder or another neuro developmental disorder),they are sufficiently severe to warrant additional clinical attention. Specify if: In remission: After full criteria for rumination disorder were previously met, the criteria have not been met for a sustained period of time.

”