Rumination disorder

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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]; Kiran Singh, M.D. [3] ; Rithish Nimmagadda,MBBS.[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.

Differential Diagnosis

Rumination syndrome should be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]

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) - ✔ ✔ - - ✔ - - - ↓ ✔
  • 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 ✔ ✔ ✔ - ✔ ✔ - - ✔ ✔ - ↓ ✔
  • Increased
Bulimia nervosa ✔ ✔ ✔ ✔ ✔ ✔ - - - ✔ ✔ Normal ✔
  • Increased
Rumination syndrome ✔ ✔ (Regurgitation more common- within minutes of meal intake) ✔ - ✔ ✔ ✔ ✔ - - - ↓
  • Normal
 ✔
  • Normal
  • 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)
Functional dyspepsia ✔ ✔ ✔ ✔ - - - - - - - Normal
  • Normal
 ✔
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome ✔ ✔ - ✔ ✔ - - - - - - ↓ ✔
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis ✔ ✔ ✔ ✔ ✔ - - ✔ - - - Normal ✔
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction ✔ ✔ (within 1 hour of eating) - - - - - ✔ - - - ↓ ✔
  • Esophageal pH: Increased
  • Esophageal manometery:   High manoraetric score

Other differntials

Other differentials of rumination disorder include the following:

Epidemiology and Demographics

Prevalence

Risk Factors

  • Lack of stimulation
  • Neglect
  • Problems in the parent-child relationship
  • Stressful life situations[33]

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[33]

“
  • 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

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.
 ”

References

  1. ↑ Parkman HP (2015). "Idiopathic gastroparesis". Gastroenterol. Clin. North Am. 44 (1): 59–68. doi:10.1016/j.gtc.2014.11.015. PMC 4324534. PMID 25667023.
  2. ↑ Werlin SL, Fish DL (2006). "The spectrum of valproic acid-associated pancreatitis". Pediatrics. 118 (4): 1660–3. doi:10.1542/peds.2006-1182. PMID 17015559.
  3. ↑ Noddin L, Callahan M, Lacy BE (2005). "Irritable bowel syndrome and functional dyspepsia: different diseases or a single disorder with different manifestations?". MedGenMed. 7 (3): 17. PMC 1681633. PMID 16369243.
  4. ↑ Gupta R, Kalla M, Gupta JB (2012). "Adult rumination syndrome: Differentiation from psychogenic intractable vomiting". Indian J Psychiatry. 54 (3): 283–5. doi:10.4103/0019-5545.102434. PMC 3512372. PMID 23226859.
  5. ↑ Sağlam F, Sivrikoz E, Alemdar A, Kamalı S, Arslan U, Güven H (2015). "Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction". Ulus Travma Acil Cerrahi Derg. 21 (2): 157–9. PMID 25904280.
  6. ↑ Talley NJ (2011). "Rumination syndrome". Gastroenterol Hepatol (N Y). 7 (2): 117–8. PMC 3061016. PMID 21475419.
  7. ↑ Tutuian R, Castell DO (2004). "Rumination documented by using combined multichannel intraluminal impedance and manometry". Clin. Gastroenterol. Hepatol. 2 (4): 340–3. PMID 15067630.
  8. ↑ Kessing BF, Smout AJ, Bredenoord AJ (2014). "Current diagnosis and management of the rumination syndrome". J. Clin. Gastroenterol. 48 (6): 478–83. doi:10.1097/MCG.0000000000000142. PMID 24921208.
  9. ↑ Parkman HP (2009). "Assessment of gastric emptying and small-bowel motility: scintigraphy, breath tests, manometry, and SmartPill". Gastrointest. Endosc. Clin. N. Am. 19 (1): 49–55, vi. doi:10.1016/j.giec.2008.12.003. PMID 19232280.
  10. ↑ Waseem S, Moshiree B, Draganov PV (2009). "Gastroparesis: current diagnostic challenges and management considerations". World J. Gastroenterol. 15 (1): 25–37. PMC 2653292. PMID 19115465.
  11. ↑ Mearin F, Camilleri M, Malagelada JR (1986). "Pyloric dysfunction in diabetics with recurrent nausea and vomiting". Gastroenterology. 90 (6): 1919–25. PMID 3699409.
  12. ↑ Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, McCallum RW, Nowak T, Nusynowitz ML, Parkman HP, Shreve P, Szarka LA, Snape WJ, Ziessman HA (2008). "Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine". Am. J. Gastroenterol. 103 (3): 753–63. doi:10.1111/j.1572-0241.2007.01636.x. PMID 18028513.
  13. ↑ Jiang CF, Ng KW, Tan SW, Wu CS, Chen HC, Liang CT, Chen YH (2002). "Serum level of amylase and lipase in various stages of chronic renal insufficiency". Zhonghua Yi Xue Za Zhi (Taipei). 65 (2): 49–54. PMID 12014357.
  14. ↑ Szmukler, G. I.; Young, G. P.; Lichtenstein, M.; Andrews, J. T. (1990). "A serial study of gastric emptying in anorexia nervosa and bulimia". Australian and New Zealand Journal of Medicine. 20 (3): 220–225. doi:10.1111/j.1445-5994.1990.tb01023.x. ISSN 0004-8291.
  15. ↑ Diamanti A, Bracci F, Gambarara M, Ciofetta GC, Sabbi T, Ponticelli A, Montecchi F, Marinucci S, Bianco G, Castro M (2003). "Gastric electric activity assessed by electrogastrography and gastric emptying scintigraphy in adolescents with eating disorders". J. Pediatr. Gastroenterol. Nutr. 37 (1): 35–41. PMID 12827003.
  16. ↑ Ferholt J, Provence S (1976). "Diagnosis and treatment of an infant with psychophysiological vomiting". Psychoanal Study Child. 31: 439–59. PMID 981449.
  17. ↑ Lee H, Rhee PL, Park EH, Kim JH, Son HJ, Kim JJ, Rhee JC (2007). "Clinical outcome of rumination syndrome in adults without psychiatric illness: a prospective study". J. Gastroenterol. Hepatol. 22 (11): 1741–7. doi:10.1111/j.1440-1746.2006.04617.x. PMID 17914944.
  18. ↑ Koskenpato J, Kairemo K, Korppi-Tommola T, Färkkilä M (1998). "Role of gastric emptying in functional dyspepsia: a scintigraphic study of 94 subjects". Dig. Dis. Sci. 43 (6): 1154–8. PMID 9635600.
  19. ↑ Urbain JL, Vekemans MC, Parkman H, Van Cauteren J, Mayeur SM, Van den Maegdenbergh V, Charkes ND, Fisher RS, Malmud LS, De Roo M (1995). "Dynamic antral scintigraphy to characterize gastric antral motility in functional dyspepsia". J. Nucl. Med. 36 (9): 1579–86. PMID 7658213.
  20. ↑ Hejazi RA, Lavenbarg TH, McCallum RW (2010). "Spectrum of gastric emptying patterns in adult patients with cyclic vomiting syndrome". Neurogastroenterol. Motil. 22 (12): 1298–302, e338. doi:10.1111/j.1365-2982.2010.01584.x. PMID 20723071.
  21. ↑ "Gastric outlet obstruction - an overview | ScienceDirect Topics".
  22. ↑ Minami H, McCallum RW (1984). "The physiology and pathophysiology of gastric emptying in humans". Gastroenterology. 86 (6): 1592–610. PMID 6370777.
  23. ↑ Humphries LL, Adams LJ, Eckfeldt JH, Levitt MD, McClain CJ (1987). "Hyperamylasemia in patients with eating disorders". Ann. Intern. Med. 106 (1): 50–2. PMID 2431640.
  24. ↑ Hempen I, Lehnert P, Fichter M, Teufel J (1989). "[Hyperamylasemia in anorexia nervosa and bulimia nervosa. Indication of a pancreatic disease?]". Dtsch. Med. Wochenschr. (in German). 114 (49): 1913–6. doi:10.1055/s-2008-1066848. PMID 2480214.
  25. ↑ Okada R, Okada A, Okada T, Okada T, Hamajima N (2009). "Elevated serum lipase levels in patients with dyspepsia of unknown cause in general practice". Med Princ Pract. 18 (2): 130–6. doi:10.1159/000189811. PMID 19204432.
  26. ↑ Sansone RA, Sansone LA (2012). "Hoarseness: a sign of self-induced vomiting?". Innov Clin Neurosci. 9 (10): 37–41. PMC 3508961. PMID 23198276.
  27. ↑ Tack J, Caenepeel P, Arts J, Lee KJ, Sifrim D, Janssens J (2005). "Prevalence of acid reflux in functional dyspepsia and its association with symptom profile". Gut. 54 (10): 1370–6. doi:10.1136/gut.2004.053355. PMC 1774686. PMID 15972301.
  28. ↑ "gut.bmj.com" (PDF).
  29. ↑ Boles RG, Williams JC (1999). "Mitochondrial disease and cyclic vomiting syndrome". Dig. Dis. Sci. 44 (8 Suppl): 103S–107S. PMID 10490048.
  30. ↑ Ranasinghe WK, Smith M (2013). "Gastric outlet obstruction with an elevated serum pancreatic lipase secondary to an infraumbilical hernia". Ann R Coll Surg Engl. 95 (7): 122–4. doi:10.1308/003588413X13629960047795. PMID 24112485.
  31. ↑ Ui, Takashi; Shibusawa, Hiroyuki; Tsukui, Hidenori; Sakuma, Kazuya; Takahashi, Shuhei; Lefor, Alan K.; Hosoya, Yoshinori; Sata, Naohiro; Yasuda, Yoshikazu (2015). "Pretreatment of gastric outlet obstruction with pancrelipase: Report of a case". International Journal of Surgery Case Reports. 12: 87–89. doi:10.1016/j.ijscr.2015.05.023. ISSN 2210-2612.
  32. ↑ 33.0 33.1 33.2 33.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
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