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PRACTICE: Mark Fox, Alasdair Young, Roy Anggiansah, Angela Anggiansah, and Jeremy Sanderson A 22 year old man with persistent regurgitation and vomiting: case outcome BMJ 2006; 333: 133 [Full text]

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time for the true face of rumination syndrome

shmuel p reis   (24 July 2006)

Rumination syndrome in adolescents

Hassan K Chaudhry   (26 July 2006)

time for the true face of rumination syndrome 24 July 2006
shmuel p reis, family physician clalit health services Send response to journal: Re: time for the true face of rumination syndrome	To the editor Thank you for highlighting rumination syndrome. Primary care physicians (PCPs), as did the literature, usually associated it with serious bonding problems in infancy, severe pathology in childhood and adolescence and need for extensive investigation beyond (1). Your case illustrates a different reality, that of a benign, behavioral mediated condition in adulthood. For developmentally normal children and adolescents this is probably also the most frequent presentation. It may represent some emotional distress, as I have described (1), and be amenable to supportive or behavioral therapy (2). Less than 2 decades ago, a practitioner scanning the literature will assume it is a foreboding situation. With reports such as this and others (1, 2) - a probably more realistic and benign one is reflected. Time may be ripe for moving to a general population investigation (probably with the support of a primary care research network) that will finally elucidate the epidemiology of rumination syndrome and it's distribution of underlying causes, severity and natural history. Sincerely Shmuel Reis MD, MHPE Departments of Medical Education and Family Medicine, The R& B Rappaport Faculty of Medicine, The Technion- Israel Institute of Technology, Haifa, Israel E-Mail: reis@netvision.net.il 1. 1. Reis S. Rumination disorder in developmentally normal children. J Fam Prac. 1994; 38:5. 2. Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Pediatrics. 2003 Jan;111(1):158-62. Competing interests: None declared
Rumination syndrome in adolescents 26 July 2006
Hassan K Chaudhry, Studying for PLAB2 DE22 3JB Send response to journal: Re: Rumination syndrome in adolescents	Rumination Syndrome is a clinical syndrome characterized by virtually daily, effortless regurgitation of recently ingested food into the oropharynx without forceful retching. It is not associated with abdominal pain or nausea, and the regurgitant does not taste sour or bitter. Food may be partially or completely rechewed and reswallowed or expelled. The syndrome is most commonly seen in infants and the developmentally disabled. However, rumination syndrome does occur in children, adolescents, and adults with normal intelligence. More recently, otherwise normal adolescents and adults have been described who exhibit the same clinical pattern. This occurs more often in females, but it is not considered an eating disorder. Most individuals with rumination syndrome regurgitate with every meal. Typically, the regurgitation is effortless and within 10-20 minutes. The patient may exhibit halitosis or complain of a sour taste rather than discomfort or typical peptic symptoms. A careful history and identification of the recurrent, effortless, painless regurgitations is often sufficient to make the diagnosis. Observation of preceding air swallowing and contraction of the abdominal wall (while the lower oesophagus and glottis relax) can clinch the diagnosis without need for involved and often unnecessary investigations. If available, antro-duodenal manometry will document the presence of the diagnostic pressure pattern confirming the creation of a “common cavity” between the stomach and the mouth. Individuals with rumination syndrome are often misdiagnosed or undergo extensive, costly, and invasive testing before diagnosis. Insufficient awareness of the clinical features of rumination syndrome contributes to the under diagnosis of this important medical condition. Rumination syndrome is frequently confused with bulimia nervosa, gastro- oesophageal reflux disease, and upper gastrointestinal motility disorders including gastro paresis and chronic intestinal pseudo-obstruction. Complications of rumination syndrome include weight loss, malnutrition, dental erosions, halitosis, electrolyte abnormalities, and significant functional disability. Rumination syndrome is a clinical diagnosis based on symptoms and the absence of structural disease. Proposed Criteria for Rumination Syndrome in Children and Adolescents:- At least 6 wk, which may not be consecutive, in the previous 12 mo of recurrent regurgitation of recently ingested food which: 1. Begins within 30 min of meal ingestion. 2. Is associated with either reswallowing or expulsion of food. 3. Stops within 90 min of onset or when regurgitant becomes acidic. 4. Is not associated with mechanical obstruction. 5. Does not respond to standard treatment for gastro-oesophageal reflux disease ( i.e., medical therapy or lifestyle modification measures) 6. Stops within 90 min of onset or when regurgitant becomes acidic. 7. Is not associated with mechanical obstruction. 8. Does not respond to standard treatment for gastro-oesophageal reflux disease (i.e., medical therapy or lifestyle modification measures) 9. Is not associated with nocturnal symptoms. 10. Begins within 30 min of meal ingestion. 11. Is associated with either reswallowing or expulsion of food. In a study conducted on evaluating in detail the motor and sensory functions of the proximal stomach in patients with rumination syndrome it was found that with regards to motor function, the study demonstrated two types of accommodation after meal ingestion among patients with rumination syndrome: one subgroup with normal postprandial accommodation and a second group with diminished or absent accommodation. Clearly, this diminished accommodation is of potential patho- physiological importance in a subset, not all, of these patients. This impaired accommodation was not due to the regurgitation episodes per se. It was conceivable that regurgitation itself may evoke motion artefacts or that abdominal muscle contractions could artificially decrease intra-bag volume. However, the study excluded episodes of regurgitation or movements that were associated with abdominal wall activity from the analysis of tone. Patients who regurgitated in the postprandial period were equally distributed among the two subgroups; thus we can exclude artefact from regurgitation as the reason for the differences in the two subgroups. However the psychiatric nature of rumination syndrome still holds importance. In the Diagnostic and Statistical Manual of Mental Disorders rumination is listed exclusively under "eating disorders of infancy." An association between rumination and bulimia nervosa has been described, and rumination is recognized as a collateral behaviour disorder among these patients. Rumination may be regarded as a "forme frusta" of other eating disorders such as bulimia, bulimarexia, or anorexia nervosa. In the latter groups, eating behaviour, mood, body perception, and disturbances in neurohormonal function have been linked to changes in metabolism of several monoamines (such as nor epinephrine, dopamine, serotonin) and endogenous opioids. Whether similar neurohormonal changes are present in rumination syndrome is unknown and needs further investigation. However, there is increasing evidence that endogenous monoamines alter gastric mechanosensory function, through 2-adrenergic receptors and 5HT1D receptors . Further physiological and pharmacological studies may shed important light on the mechanism of rumination and its pharmacological correction. This is particularly important for the subgroup of patients [at least 20% in our experience ] who do not respond to habit reversal with diaphragmatic breathing as part of a behavioural therapy, which are mostly applied. In infants, this involves developmental stimulation. In adolescents and adults, teaching patients diaphragmatic breathing and other behavioural techniques seems effective in some, while the rumination can be stubborn and difficult to dissipate in others. Determination of any underlying psychiatric disorders and directing appropriate medical and psychological therapy is important in achieving successful treatment. The recently reported Mayo Clinic experience suggests a favourable prognosis in most. There is association of Sandifer syndrome with rumination syndrome. References: 1. Heather J. Chial, MD, et al, “Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and Prognosis.” PAEDIATRICS Vol. 111 No. 1 January 2003, pp. 158-162. 2.Miriam Thumshirn, et al, “Gastric mechanosensory and lower oesophageal sphincter function in rumination syndrome.” American Journal Physiology Gastrointestinal Liver Physiology. 275: G314-G321, 1998; 0193- 1857/98. 3. Mark Fox, et al, “A 22 year old man with persistent regurgitation and vomiting: case outcome.” BMJ 2006; 333: 133 . Competing interests: None declared