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Rumination Disorder

Rumination disorder is a behavioral disorder marked by repeated regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) of food, which may be re-chewed, re-swallowed, or spit out. This condition is not due to a medical disorder ( GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD) or pyloric stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)) or other eating disorders (avoidant/restrictive food intake disorder, anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa, binge eating disorder Binge Eating Disorder Binge eating disorder is an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior. Episodes occur at least weekly for 3 consecutive months. There is a loss of control during the episodes of binging as well as distress after. Binge Eating Disorder, or bulimia nervosa Bulimia nervosa Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors (laxatives or diuretics use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. Bulimia Nervosa). Treatment is multifactorial, focused on treating underlying mood disorders and accompanied by antispasmodic Antispasmodic Antispasmodics are a group of medications used to reduce excessive GI smooth muscle contractility and spasm. These medications may be helpful in those with abdominal pain due to conditions such as irritable bowel syndrome, although their efficacy is controversial. Antispasmodics therapy only when refractory to behavioral modification.

Last updated: 3 Jun, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of 0.8% in adults
  • Associated conditions:
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
    • Depression 
    • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)
    • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder

Pathophysiology

  • Effortless and painless regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) 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 Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia

Diagnosis

  • Repeated effortless regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) 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 Regurgitation Gastroesophageal Reflux Disease (GERD)
    • Rarely associated with weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, electrolyte disturbances, or erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes of teeth Teeth Normally, an adult has 32 teeth: 16 maxillary and 16 mandibular. These teeth are divided into 4 quadrants with 8 teeth each. Each quadrant consists of 2 incisors (dentes incisivi), 1 canine (dens caninus), 2 premolars (dentes premolares), and 3 molars (dentes molares). Teeth are composed of enamel, dentin, and dental cement. Teeth: Anatomy 
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are often embarrassed by regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD), so they modify behavior to compensate (e.g., refuse to eat in public).
  • Exclude physiological causes (e.g.,  GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD), pyloric stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS), intellectual disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment, pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care).
  • Exclude other eating disorders (e.g., avoidant/restrictive food intake disorder, anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa, binge eating disorder Binge Eating Disorder Binge eating disorder is an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior. Episodes occur at least weekly for 3 consecutive months. There is a loss of control during the episodes of binging as well as distress after. Binge Eating Disorder, or bulimia nervosa Bulimia nervosa Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors (laxatives or diuretics use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. Bulimia Nervosa).

Management

  • Focuses on changing the learned behavior responsible for regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD)
  • There are high rates of spontaneous remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches.
  • Treatment options include:
    • Diaphragmatic breathing training: 
      • Ask the patient to breathe deeply and relax the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy so that regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) 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 Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy
      • Biofeedback Biofeedback The therapy technique of providing the status of one’s own autonomic nervous system function (e.g., skin temperature, heartbeats, brain waves) as visual or auditory feedback in order to self-control related conditions (e.g., hypertension, migraine headaches). Psychotherapy 
      • May also include improvement in affected child’s psychosocial environment
    • Medication: 
      • Baclofen Baclofen A gamma-aminobutyric acid derivative that is a specific agonist of gaba-b receptors. It is used in the treatment of muscle spasticity, especially that due to spinal cord injuries. Its therapeutic effects result from actions at spinal and supraspinal sites, generally the reduction of excitatory transmission. Spasmolytics: increases lower esophageal sphincter Lower Esophageal Sphincter Esophagus: Anatomy tone and stops lower esophageal sphincter relaxation Sphincter relaxation Gastrointestinal Motility from occurring
      • Used only in cases where all other therapy fails

Differential Diagnosis

  • Anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa nervosa: an eating disorder characterized by intense fear of gaining weight, restricted dietary habits, and distorted body image. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship affected by anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa are usually underweight and reluctant to seek medical help. Treatment involves CBT with antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants medication as an adjunct. Extreme cases may require hospitalization Hospitalization The confinement of a patient in a hospital. Delirium.
  • Bulimia Bulimia Eating an excess amount of food in a short period of time, as seen in the disorder of bulimia nervosa. It is caused by an abnormal craving for food, or insatiable hunger also known as ‘ox hunger’. Bulimia Nervosa nervosa: an anxiety-driven eating disorder defined by recurrent episodic binge eating paired with recurrent inappropriate compensatory behavior Compensatory behavior Binge Eating Disorder (inducing vomiting, laxative Laxative Agents that produce a soft formed stool, and relax and loosen the bowels, typically used over a protracted period, to relieve constipation. Hypokalemia abuse, and excessive exercising). Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with this condition may have normal or even elevated BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity and are more likely to seek help. The vomiting in bulimia nervosa Bulimia nervosa Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors (laxatives or diuretics use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. Bulimia Nervosa is self-induced, whereas regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) in regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) disorder may be unintentional. The presence of bulimia nervosa Bulimia nervosa Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors (laxatives or diuretics use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. Bulimia Nervosa must be ruled out prior to a diagnosis of regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) disorder. 
  • Binge-eating disorder: an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior Compensatory behavior Binge Eating Disorder resulting in fluctuating body weight. Episodes occur at least weekly for 3 months. Treatment consists of a combination of psychotherapy and antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants 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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