An-Najah National University

Faculty of Medicine and Health Sciences

Presented to complement the requirements of “nutrition science ”
course
Instructor : Dr.Marah

Students Names :
RUMINATION SYNDROME
SUMMARY :
Rumination syndrome is a functional gastrointestinal condition with easy
postprandial regurgitation. It is rare, but can be diagnosed with objective testing
using postprandial esophageal high-resolution impedance manometry. Behavior
adjustment combined with postprandial diaphragmatic breathing is the major
treatment. Best Practice Suggestion 3 is to use the Rome IV criteria to identify
rumination syndrome. High-resolution esophageal impedance manometry can be
used to objectively test for rumination syndrome. Baclofen is an acceptable next
step for individuals who are resistant.

INTRODUCTION :
Eating disorders are significant mental and life-threatening diseases. Rumination
syndrome is one of them. It is a functional gastrointestinal disorder characterized by
unintentionally regurgitating undigested food from the stomach back to the oral
cavity or regurgitate partially digested food from stomach and re-chew it again
either they vomit it or re-swallow. This happens when no diseases affect the GI
(gastrointestinal) tract .It occurs within the first 15 minutes after finishing the meal,
but it could last for two hours because of repeated mastication and either expel or
swallow it . Having this condition has unclear reasons and unknown risk factors .
However, experts may suggest that is related with altering abdominal and thoracic
pressures and known to occur in infants and people with disabilities but it can also
show in all people with different ages. Rumination syndrome is more likely to
appear in people who suffer from anxiety or depression or any psychiatric
disorders. It is often mistaken or misdiagnosed for bulimia nervosa, gastroparesis
and gastroesophageal disease (GERD) which can delay treatment and increases the
severity of the problem.

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The etiology of rumination syndrome is likely multifactorial, but the reason is still
unclear but the known risk factors that is associated with the disorder includes:
emotional ignoring usually in infants ,stress ,depression ,anxiety ,obsessive
compulsive disorder, attention deficit-hyperactivity disorder (ADHD),
developmental delay, Fibromyalgia and rectal evacuation disorder .

Rumination syndrome can affect people of all ages, but it is more common in infants
and those with developmental impairments. Rumination syndrome may be more
likely to affect kids and adults who experience high levels of stress or worry.

People with this syndrome suffer from the following symptoms : regularly
regurgitating and re-chewing food gastrointestinal issues like indigestion and
abdominal pain , dental issues like tooth decay and bad odor Loss of weight ruffled
lips, In addition to showing signs of gastroesophageal reflux, babies with rumination
syndrome may strain or arch their backs or make sucking sounds with their mouths.

DISCUSSION:
A systemic review was performed for the efficacy of rumination syndrome (RS)
treatment.12 articles have been read but the strongest were 2 articles one is with a
RCT looking at electromyo- graphy (EMG) biofeedback( a special training for
patients before eating meal to control the activity of abdominal thoracic muscles)
and baclofen treatment.12 patients who treated with 3 biofeedback session had
74% decrease of the symptoms compared to a 1%reduction of placebo. Improvment
by these sessions showed that they are continuable in long-term with improvement
of symptoms with each follow up. The second RCT revealed that Baclofen at 5-10
mgthree times daily decreased the symptoms to 63% of patients compared to 26%
of patients who were treated by placebo.

Diaphragmatic breathing or (DB) were part of the biofeedback treatments in the

RCT analysis. DB was also supported by other non-RCT researches and
demonstrated that a single session of DM was enough to make symptoms better but

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because the rumination episodes repeat itself, it was suggested a home exercise for
patients' compliance.

Studies has shown that the reason of RS is yet not known but predicting that the
primary mechanism is process called postprandial gastric pressurization which can
result from anterior abdominal muscle contractions also a low esophageal sphincter
(LES) facilitate the upward movement. Halland study showed that high intragastric
pressure waves that were recorded in the trial led to RS episodes. Other studies
such as gastroduodenal manometry (GDM),abdominal wall electromyo- graphy
(EMG), and postprandial high resolution impedance manometry (HRIM) indicated
that high gastric pressure is associated with lower and upper esophageal relaxation
which causes the meal to return into the mouth. These studies also showed that the
reflux of meal contents into the esophagus is after an elevation of gastric and
esophageal junction (EGJ) into the chest cavity which can cause false hernia by
moving it away from crura thus losing the contribution between crura and EGJ . As a
conclusion of these studies illustrated that increasing in abdominal pressure and a
negative intra-thoracic pressure associated with decreasing in esophagogastric
(EGJ) junction pressure would increase the possibility of having RS episodes. This
helped to reveal that DB may improve the crura function and decrease the ability of
intra gastric pressure to displace the EGJ. Itmaintains high pressure LES tone. A
study ‘’Barba’’ approved that DB reduced the abdomen and thoracic muscles activity
because RS patients have an abnormal tone in abdominothoracic muscles.

Evidence also found that Baclofen had decreased the episodes by minimizing
Transient lower esophageal sphincter relaxation (a mechanism thought to help in
producing episodes of RS) and increasing postprandial LES. Baclofen may have
other mechanisms where authors believed it deplete the voluntary gastric straining
which is related to reduce the sensitivity of the stomach as studies showed that RS
patients have high gastric sensitivity to dilation

There are also social and cognitive reasons that helped to increase the risk of RS.
Stress ,illness, depression and anxiety as studies have proved but still is not known

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if it is a cause or result from RS.A single open label study looked at the supportive
psychotherapy outcome with a specific psychic disease, only 38% of patients
responded to the treatment, thus it is possible to focus on psychotherapy with
behavioral therapy to be effective

five cases interestingly found that they can be treated by a surgery with no
symptoms post-opertaion but could have it risks.

RS nutrition recommendation according for some article reviews this syndrome can
have serious consequences if untreated. Therefore, the clinicians should evaluate
patients with erosions for conditions such as:

Rumination syndrome increases risk of erosion and refer the patient to physician if
eating disorder, or gastroesophageal reflux is suspected. In obese patientsor if
pregnant, requiring screening for gastroesophageal reflux and predictive nutritional
counseling, it has been shown to minimize reflux.

Fresh, minimally processed acidic foods include juice and fresh fruit, tomato and
spicy, vegetables, meats; and mixed dishes. Minimally Processed and fresh acidic
foods, contribute to ChooseMyPlate food categories and provide with the nutrients
they need.

Dietary guidelines prescribe one cup of 100% juice a day and the rest solid fruit.
Dietary recommendations to minimize the risk of erosion include consuming these
foods as part of a mixed diet within a structured eating pattern.

Patients may have certain dietary habits that greatly increase the risk of erosion,
includes drinking vinegar water, or pocketing lemon. Other clients may have very
restrictive diet that can affect their overall health.

Adolescent rumination syndrome (ARS) is an uncommon disorder that few doctors

are familiar with. Patients frequently receive inaccurate diagnoses or expensive
testing, which causes delays in both diagnosis and therapy. Although ARS is not life-
threatening, it does have a negative impact on the patient's health and that of their
family members. The Rome III diagnostic parameters are used to make the ARS

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diagnosis, antroduodenal manometry can be useful for confirming the diagnosis but
it’s not necessary . This disorder's pathogenesis is complicated and poorly known.

And the result is due to the disorder's behavioral component, treating ARS calls for a
multidisciplinary strategy that incorporates both medical symptom management
and the adoption of tactics that address the disorder's behavioral, psychological, and
overall quality of life components.

Children's rumination syndrome is still not studied enough, especially for treatment.
Rumination is often accompanied by other symptoms in the gastrointestinal tract or
anti-FGID.

DIAGNOSIS :
A clinical diagnosis may be made in the majority of patients, even if objective testing
using postprandial esophageal high-resolution impedance manometry is only
accessible in a few referral centers. Behavior adjustment combined with
postprandial diaphragmatic breathing is the major treatment for rumination
syndrome. This clinical practice update discusses rumination syndrome's etiology,
diagnosis, and therapy. In patients who consistently complain postprandial
regurgitation, clinicians should strongly investigate rumination syndrome. Such
individuals are frequently diagnosed with refractory gastric reflux disease or
vomiting. The existence of symptoms like nocturnal regurgitation, dysphagia,
nausea, or symptoms that come on without a meal does not rule out rumination
syndrome, although it does make its presence less likely.

CONCLUSION :
As mentioned earlier, eating disorders are life-threatening mental illnesses,
including rumination syndrome. It is a functional gastrointestinal disorder
characterized by inadvertent ejection of undigested food from the stomach into the
oral cavity or regurgitation of partially digested food from the stomach. The
possibility of infection increases for people who suffer from depression, anxiety, and

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tension, both adults and children, and there are many risk factors that accompany
the syndrome, such as stress, obsessive-compulsive disorder, ADHD , and
developmental delay. Patients may benefit from breathing Diaphragm-guided
biofeedback. There are many symptoms associated with the disease, such as
digestive problems such as indigestion and abdominal pain, dental problems such as
tooth decay and bad breath, weight loss and swollen lips. As for treatment, it takes
several forms, including behavioral therapy for people who do not have problems
with Growth, and it can be with medicines such as Nexium and omeprazole.

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