Rumination Disorder

Rumination disorder is a behavioral disorder marked by repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is not due to a medical disorder (GERD or pyloric stenosis) or other eating disorders (avoidant/restrictive food intake disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa). Treatment is multifactorial, focused on treating underlying mood disorders and accompanied by antispasmodic therapy only when refractory to behavioral modification.

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Epidemiology and Pathophysiology

Epidemiology

  • Seen in all ages but emerges sometime between 3 and 12 months of age
  • Observed in infants who soothe and stimulate themselves after having not enough emotional interaction 
  • Prevalence of 0.8% in adults
  • Associated conditions:
    • Anxiety
    • Depression 
    • OCD
    • ADHD

Pathophysiology

  • Effortless and painless regurgitation of partly digested food, which may be rechewed, re-swallowed, or spit out. 
  • Postprandial abdominal contraction
  • Increased intraabdominal pressure 
  • Decreased intraesophageal pressure
  • Upper esophageal relaxation
  • Vomiting

Diagnosis

  • Repeated effortless regurgitation of food, which may be rechewed, re-swallowed, or spit out:
    • Triggered by sensation of abdominal discomfort relieved by emesis
    • Usually within 10 minutes of eating
    • Occurs for at least 1 month
    • No “dry heaving” prior to regurgitation
    • Rarely associated with weight loss, electrolyte disturbances, or erosion of teeth 
  • Patients are often embarrassed by regurgitation, so they modify behavior to compensate (e.g., refuse to eat in public).
  • Exclude physiological causes (e.g., GERD, pyloric stenosis, intellectual disability, pregnancy).
  • Exclude other eating disorders (e.g., avoidant/restrictive food intake disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa).

Management

  • Focuses on changing the learned behavior responsible for regurgitation
  • There are high rates of spontaneous remission.
  • Treatment options include:
    • Diaphragmatic breathing training: 
      • Ask the patient to breathe deeply and relax the diaphragm so that regurgitation cannot occur.
      • Using this technique during and immediately after meals may resolve the problem.
    • Environmental changes: 
      • Changes in posture, both during and right after a meal
      • Removing distractions during mealtimes
    • Psychotherapy: 
      • Biofeedback 
      • May also include improvement in affected child’s psychosocial environment
    • Medication: 
      • Baclofen: increases lower esophageal sphincter tone and stops lower esophageal sphincter relaxation from occurring
      • Used only in cases where all other therapy fails

Differential Diagnosis

  • Anorexia nervosa: an eating disorder characterized by intense fear of gaining weight, restricted dietary habits, and distorted body image. Patients affected by anorexia nervosa are usually underweight and reluctant to seek medical help. Treatment involves CBT with antidepressant medication as an adjunct. Extreme cases may require hospitalization.
  • Bulimia nervosa: an anxiety-driven eating disorder defined by recurrent episodic binge eating paired with recurrent inappropriate compensatory behavior (inducing vomiting, laxative abuse, and excessive exercising). Patients with this condition may have normal or even elevated BMI and are more likely to seek help. The vomiting in bulimia nervosa is self-induced, whereas regurgitation in regurgitation disorder may be unintentional. The presence of bulimia nervosa must be ruled out prior to a diagnosis of regurgitation disorder. 
  • Binge-eating disorder: an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior resulting in fluctuating body weight. Episodes occur at least weekly for 3 months. Treatment consists of a combination of psychotherapy and antidepressant medications.

References

  1. Almansa C, Rey E, Sánchez RG, Sánchez AA, Díaz-Rubio M. (2009). Prevalence of functional gastrointestinal disorders in patients with fibromyalgia and the role of psychologic distress. Clin Gastroenterol Hepatol. https://pubmed.ncbi.nlm.nih.gov/19138763/
  2. Blondeau K, Boecxstaens V, Rommel N, Farré R, Depeyper S, Holvoet L, Boeckxstaens G, Tack JF. (2012). Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching. Clin Gastroenterol Hepatol. https://pubmed.ncbi.nlm.nih.gov/22079512/
  3. Halland M, Parthasarathy G, Bharucha AE, Katzka DA. (2016). Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action. Neurogastroenterol Motil. https://pubmed.ncbi.nlm.nih.gov/26661735/
  4. Vandergriendt, C. (2018). What Is Rumination Disorder? Healthline. https://www.healthline.com/health/rumination-disorder
  5. Rumination syndrome: Symptoms & causes. (2020). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/rumination-syndrome/symptoms-causes/syc-20377330 
  6. Sadock BJ, Sadock VA, Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 31, Child psychiatry, pages 1207-1209. Philadelphia, PA: Lippincott Williams and Wilkins.

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