Rumination syndrome

Specialty: Gastrointestinal.

• Repetitive non-acid regurgitation
• psychogenic rumination
• involuntary regurgitation of recently eaten food

Why it occurs

• Dysfunction of the gastric accommodation reflex with voluntary or involuntary coordinated contraction of the abdominal muscles that overcomes the tone of the postprandial lower esophageal sphincter (disorder of brain-gut interaction according to Rome IV)
• Covert eating disorders or dysfunctional coping mechanisms in the face of severe stress
• Delayed neurodevelopment or autonomic dysfunction with proximal gastric proprioceptive hypersensitivity.

Initial workup

High-resolution esophageal manometry combined with postprandial pH-impedanciometry (shows the "rumination wave" pattern: abrupt increase in intragastric pressure >30 mmHg that precedes retrograde bolus flow) | Upper gastrointestinal endoscopy (EDA, to absolutely rule out gastric outlet obstructions, achalasia or severe esophagitis) | Gastric emptying of solids scan (to differentiate from severe gastroparesis).

Standard management

• Baclofen — drug of choice, 10 mg dose administered 15 to 30 minutes before main meals; acts by increasing the basal tone of the lower esophageal sphincter and reducing transient postprandial relaxations of the same
• Proton pump inhibitors — esomeprazole 40 mg/day to protect the esophageal mucosa in cases where the regurgitated material has become acidified in the stomach
• Prokinetics — metoclopramide 10 mg before eating to accelerate proximal gastric emptying
• Immediate postprandial diaphragmatic breathing techniques (mainstay of treatment, aimed at relaxing the intercostal abdominal muscles).