Rumination disorder is a behavioral disorder causing regurgitation of either undigested or partially digested food back into the mouth from the stomach. The patient may re-chew the food particles and either re-swallow or spit them out. The taste of the regurgitated food is not acidic; the patient can swallow it easily. Rumination is an unconscious behavior. However, it is believed that it is a learned habit. The effort of burping makes the actual food come out instead of gas.
What is Rumination Disorder?
Rumination disorder is the disgorgement of food from the esophagus back into the mouth after some hours of taking food. 1Absah, I., Rishi, A., Talley, N.J., Katzka, D. and Halland, M., 2017. Rumination syndrome: pathophysiology, diagnosis, and treatment. Neurogastroenterology & Motility, 29(4), p.e12954. The mechanism is involuntary and can happen after every meal. The patient doesn’t show many symptoms like retching or nausea and may appear healthy. Merycism and rumination are alternative terms indicating the same condition.
The disgorged food tastes normal because it does not properly mix with the stomach acids, and patients can easily re-chew and swallow it. The patient seems normal and may not have any gastrointestinal disorder but still have rumination syndrome.
Previously the condition was rare, but now the ratio of disorder is increasing; experts suggest it is because the physicians better understand the disease now.
What Causes Rumination Disorder?
The main cause of rumination disorder is still unknown, but the most logical explanation that one should consider is that it happens due to increased abdominal pressure. However, people with stress, anxiety, depression, eating disorders (Bulimia, Anorexia), and rectal evacuation syndrome are more prone to rumination disorder. Rumination disorder is generally confused with other gastrointestinal disorders like GERD, peptic ulcer disease, and gastroparesis.
Back in the day, people thought that it happened mostly to children and mentally disabled people, but now, with greater research, it is found that it has no concern with age and can occur to anyone at any age.
Rumination Disorder Psychology
Since rumination disorder is a subconscious phenomenon, recent studies suggest that a psychological link exists with rumination.
Research highlights that rumination disorder occurs more in patients with psychotic disorders like depression, anxiety, and eating disorders.
In patients with eating disorders like Bulimia, where the person ends up eating large meals and then self-inflicts vomiting through purging, or in patients with Anorexia, where the patient’s food consumption is very low, rumination is also observed. 2MacDonald, D.E., Solomon-Krakus, S., Jewett, R., Liebman, R. and Trottier, K., 2022. Emotion Regulation in Bulimia Nervosa and Purging Disorder. In Eating Disorders (pp. 1-16). Cham: Springer International Publishing.
Rumination vs. Purging
Purging is the act of self-induced vomiting and use of laxatives as a guilty behavior in response to binge eating over a short period, such as in bulimia nervosa. In contrast, rumination is a subconscious behavior where the food regurgitates effortlessly, and the patient doesn’t seem disgusted or disturbed. 3Castillo, M. and Weiselberg, E., 2017. Bulimia nervosa/purging disorder. Current Problems in Pediatric and Adolescent Health Care, 47(4), pp.85-94.
Rumination Disorder Symptoms
The usual symptom is the regurgitation of undigested food, which tastes the same as the original.
The other symptoms of rumination syndrome include:
- Regurgitation of food (usually within 10 minutes after eating)
- A feeling of fullness
- Abdominal pressure
- Dental problems
- Bad breath
- Weight loss
- Avoid eating in public places
- Malnutrition
- Redden lips
- Hiding disease through different postures
- More appetite
Rumination Disorder vs. GERD
The main difference between rumination regurgitation and gastrointestinal regurgitation is that the regurgitated food in rumination disorder does not taste acidic, and patients don’t feel any symptoms of nausea, heartburn, acidity, etc. Whereas, in gastrointestinal diseases like GERD (Gastro-oesophageal reflux disease), the regurgitated food tastes acidic, and patients show initial symptoms of nausea, heartburn, acidity, etc. The regurgitation of rumination syndrome is an unconscious action, whereas the regurgitation in GERD is a conscious action in which patients properly vomit food. 4Kusnik, A. and Vaqar, S., 2021. Rumination Disorder. In StatPearls [Internet]. StatPearls Publishing.
Diagnosis of Rumination Disorder
Rumination disorder is diagnosed by proper patient history and assessing presenting complaints. Hence a positive history like unintentional regurgitation of food for about one month without any other gastrointestinal disease, the regurgitated food that doesn’t taste acidic can point towards rumination.
In case of misdiagnosis, the disease will not respond to the usual acid reflux therapy, even though this is often taken up as a diagnostic strategy.
Below are some diagnostic tests done to diagnose rumination syndrome.
High-Resolution Oesophageal Manometry:
Manometry determines your esophagus’s function and check the abdominal pressure. In addition, this test also visualizes the esophagus’s interior to evaluate the disease’s intensity and to apply the results in behavioral therapy.
Endoscopy:
Endoscopy is a diagnostic test allowing your physician to see through your esophagus, stomach, and small intestine to look for any obstruction through a camera tube.
Gastric Emptying:
Gastric emptying evaluates how long the stomach takes to get emptied and how long food takes to move from the stomach to the small intestine.
24-hour Oesophageal pH Testing:
pH is a measure to determine whether something is acidic or alkaline. Your doctor can rule out pathological acid reflux from rumination through this test. This tests uses a small tube passed through the nose into the oesophagus and is left for 24 hours with a monitor attached that measures the pH.
All these tests in rumination disorder with psychological causes will be negative since patients have no pathological defect. For psychiatric patients, a mental health assessment, a Mini-mental state examination, and a psychiatric evaluation can help determine the cause of rumination.
In addition patients with obsessive-compulsive disorder, rumination is common, where an obsessive rumination disorder test can help.
Rumination Disorder Treatment
The selection of the proper treatment strategy is according to the patient’s age, health status, the severity of the disease, etc. Despite being idiopathic certain medicines can help managed rumination symptoms. However, the most beneficial option is behavioural therapy.
Behavioral Therapy:
A psychologist or behavioral specialist revises patient’s eating habits through various techniques and can counsel the patient to make them understand what is happening. Sometimes counseling, called cognitive behavioral therapy, can also be beneficial.
The best behavioral therapy done for rumination syndrome is diaphragmatic breathing. Diaphragmatic breathing therapy teaches patients the appropriate way to breathe. Diaphragm is a dome-shaped muscle under the surface of the lungs that expands and relaxes upon breathing. A proper breathing technique helps release abdominal pressure, thus decreasing the rumination rate.
Medications:
If continuous rumination destroys the esophagus and stomach lining, proton pump inhibitors will be the next suggestion like omeprazole, lansoprazole and esomeprazole etc. Proton pump inhibitors reduce the production of stomach acids, therefore, reducing acidity.
Lifestyle Modifications:
Using gums, exercising, and eating a healthy diet to reduce abdominal pressure can also help patients manage rumination.
Complications
Untreated rumination disorder can damage the esophagus (a tube for the passage of food between your mouth and stomach), leading to changes in the lining called dysplasia.5Zand Irani, M., Jones, M.P., Halland, M., Herrick, L., Choung, R.S., Saito Loftus, Y.A., Walker, M.M., Murray, J.A. and Talley, N.J., 2021. Prevalence, symptoms and risk factor profile of rumination syndrome and functional dyspepsia: a population‐based study. Alimentary pharmacology & therapeutics, 54(11-12), pp.1416-1431. Moreover, it can cause psychological distress like social embarrassment, isolation, and depression.
Conclusion
Rumination disorder is a behavioral disorder in which food unintentionally regurgitates back into the mouth. It is linked with psychological diseases like stress, depression, and eating disorders and can be misdiagnosed as GERD. Rumination disorder does not affect the patient’s physical appearance, but it affects the patient’s mental health. Although there are no specific medications, we can treat it with behavioral therapies like (diaphragmatic breathing) and counseling.
It is not a life-threatening disease and does not even affect patients’ daily lives, but timely treatment and support can improve their quality of life.
Refrences
- 1Absah, I., Rishi, A., Talley, N.J., Katzka, D. and Halland, M., 2017. Rumination syndrome: pathophysiology, diagnosis, and treatment. Neurogastroenterology & Motility, 29(4), p.e12954.
- 2MacDonald, D.E., Solomon-Krakus, S., Jewett, R., Liebman, R. and Trottier, K., 2022. Emotion Regulation in Bulimia Nervosa and Purging Disorder. In Eating Disorders (pp. 1-16). Cham: Springer International Publishing.
- 3Castillo, M. and Weiselberg, E., 2017. Bulimia nervosa/purging disorder. Current Problems in Pediatric and Adolescent Health Care, 47(4), pp.85-94.
- 4Kusnik, A. and Vaqar, S., 2021. Rumination Disorder. In StatPearls [Internet]. StatPearls Publishing.
- 5Zand Irani, M., Jones, M.P., Halland, M., Herrick, L., Choung, R.S., Saito Loftus, Y.A., Walker, M.M., Murray, J.A. and Talley, N.J., 2021. Prevalence, symptoms and risk factor profile of rumination syndrome and functional dyspepsia: a population‐based study. Alimentary pharmacology & therapeutics, 54(11-12), pp.1416-1431.
