AGA Clinical Practice Update: Diagnosis of rumination syndrome

Consider performing a full clinical evaluation for rumination syndrome when patients have symptoms of postprandial regurgitation, vomiting, or gastroesophageal reflux. Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.

“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”

Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.

Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:

• Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
• Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
• Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
• Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
• Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
• Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
• Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.

The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.

“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.

The authors report no relevant conflicts of interest.

SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.

Consider performing a full clinical evaluation for rumination syndrome when patients have symptoms of postprandial regurgitation, vomiting, or gastroesophageal reflux. Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.

“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”

Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.

Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:

• Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
• Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
• Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
• Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
• Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
• Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
• Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.

The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.

“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.

The authors report no relevant conflicts of interest.

SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.

Consider performing a full clinical evaluation for rumination syndrome when patients have symptoms of postprandial regurgitation, vomiting, or gastroesophageal reflux. Additionally, promote diaphragmatic breathing to help manage the condition, advised authors of an expert review of clinical practice updates for rumination syndrome published in Clinical Gastroenterology and Hepatology.

“Patients, not unsurprisingly, typically use the word ‘vomiting’ to describe rumination events, and many patients are misdiagnosed as having refractory vomiting, gastroesophageal reflux disease, or gastroparesis,” Magnus Halland, MD, of the Mayo Clinic in Rochester, Minn., and colleagues wrote in the review. “A long delay in receiving a diagnosis is common and can lead to unnecessary testing, reduced quality of life, and even invasive procedures such as surgery or feeding tubes.”

Rumination syndrome differs from vomiting, the authors noted, because the retrograde flow of ingested gastric content does not have an acidic taste and may in fact taste like food or drink recently ingested. Rumination can occur without any preceding events, after a reflux episode or by the swallowing of air that causes gastric straining but typically happens within 1 hour to 2 hours after a meal. Patients can experience weight loss, dental erosions and caries, heartburn, nausea, bloating, diarrhea, abdominal pain, abdominal discomfort, and belching, among other symptoms, in the presence of rumination syndrome, the authors said.

Dr. Halland and his colleagues provided seven best practice recommendations for rumination syndrome in their updates, which include:

• Patients who show symptoms of consistent postprandial regurgitation, often misdiagnosed with refractory gastroesophageal reflux or vomiting, should be considered for rumination syndrome.
• Patients who have dysphagia, nausea, nocturnal regurgitation, or gastric symptoms outside of meals are less likely to have rumination syndrome, but those symptoms do not exclude the condition.
• Rome IV criteria are advised to diagnose rumination syndrome after medical work-up, which includes “persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing” not preceded by retching where patients fulfill these symptom criteria for 3 months with a minimum of 6 months of symptoms before diagnosis.
• Patients should receive first-line therapy for rumination syndrome consisting of diaphragmatic breathing with or without biofeedback.
• Patients should be referred to a speech therapist, gastroenterologist, psychologist, or other knowledgeable health practitioners to learn effective diaphragmatic breathing.
• Current limitations in the diagnosis of rumination syndrome include need for expertise and lack of standardized protocols, but “testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis.”
• Bacloflen (10 mg) taken three times daily is a “reasonable next step” for patients who do not respond to treatment.

The authors acknowledged that many questions, such as the pathophysiology and initiating factors of rumination syndrome, are unknown and noted future studies are needed to address epidemiology, develop validated tools for measuring symptoms, and study diaphragmatic breathing’s effect on reducing symptoms of rumination syndrome as well as the condition’s impact on quality of life.

“Indeed, the basic question of how subconsciously one can learn to regurgitate still needs to be answered,” Dr. Halland and his colleagues wrote.

The authors report no relevant conflicts of interest.

SOURCE: Halland M et al. Clin Gastroenterol Hepatol. 2018 Jun 11. doi: 10.1016/j.cgh.2018.05.049.