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Jia MR, Lu PL, Khoo JS, Sabella J, Yang DM, Puri NB, Vaz K, Yacob D, Di Lorenzo C, Kroon Van Diest AM. Delay in diagnosis is associated with decreased treatment effectiveness in children with rumination syndrome. J Pediatr Gastroenterol Nutr 2024. [PMID: 39129392 DOI: 10.1002/jpn3.12345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVES Rumination syndrome (RS) is challenging to diagnose, which can lead to diagnostic delays. Our objective was to evaluate the length of time from RS symptom onset to diagnosis in patients referred to our institution and to examine whether this duration predicts treatment outcomes. METHODS We conducted a review of patients with RS evaluated at our institution. Data were collected from chart review and patient/family reported questionnaires. We evaluated the time from symptom onset to diagnosis over time and whether it was associated with symptom resolution. RESULTS We included 247 patients with RS (60% female, median age of 14 years, interquartile range [IQR]: 9-16 years). The median age at symptom onset was 11 years (IQR: 5-14 years) and median age at diagnosis was 13 years (IQR: 9-15 years) for a median duration of 1 year (IQR: 0-3 years) between symptom onset and diagnosis. Length of time between symptom onset and diagnosis did not change significantly at our institution from 2016 to 2022. Among the 164 children with outcome data, 47 (29%) met criteria for symptom resolution after treatment. A longer time to diagnosis was associated with a lower likelihood of symptom resolution after treatment (p = 0.01). CONCLUSION In our experience, the time to RS diagnosis after symptom onset is shorter than previously described. A longer delay in diagnosis is associated with lower likelihood of symptom resolution after treatment, emphasizing the importance of a prompt recognition of rumination symptoms and a timely diagnosis.
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Affiliation(s)
- Margaret R Jia
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Janice S Khoo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Julia Sabella
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Dennis M Yang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Neetu B Puri
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karla Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ashley M Kroon Van Diest
- The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio, USA
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Yang DM, Sabella J, Kroon Van Diest A, Bali N, Vaz K, Yacob D, Di Lorenzo C, Lu PL. Early childhood-onset rumination syndrome is clinically distinct from adolescent-onset rumination syndrome. J Pediatr Gastroenterol Nutr 2024; 78:565-572. [PMID: 38504395 DOI: 10.1002/jpn3.12116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Rumination syndrome (RS) beginning in early childhood or infancy is understudied and challenging to treat. Our objective is to compare the characteristics and outcomes of early-onset (EO) and adolescent-onset (AO) patients with RS. METHODS We conducted an ambidirectional cohort study of children diagnosed with RS at our institution. Patients were included in two groups: EO (RS symptom onset ≤5 years and diagnosis ≤12 years) and AO (onset >12 years). Patient characteristics, severity, and outcomes were compared between the groups. RESULTS We included 49 EO and 52 AO RS patients. The median ages of symptom onset and diagnosis in EO were 3.5 and 6 years, respectively; AO, 14.5 and 15 years. EO RS had a slight male predominance while AO was predominantly female (p = 0.016). EO patients were more likely to have developmental delay (24% vs. 8%, p = 0.029) and less likely to have depression (0% vs. 23%, p < 0.001) or anxiety (14% vs. 40%, p = 0.004). At baseline, EO RS was less severe than AO RS: EO RS had greater regurgitation frequency (p < 0.001) but lower vomiting frequency (p = 0.001), resulting in less meal skipping (p < 0.001), reliance on tube feeding or parenteral nutrition (p < 0.001), and weight loss (p = 0.035). EO RS symptoms improved over time: at follow-up, patients had lower regurgitation (p < 0.001) and vomiting frequency (p < 0.001) compared to baseline. CONCLUSION EO RS is clinically distinct from AO RS, with differences in sex distribution, comorbid conditions, and severity of initial presentation. The pathogenesis and natural history of EO RS may be distinct from that of AO RS.
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Affiliation(s)
- Dennis M Yang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Julia Sabella
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ashley Kroon Van Diest
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Neetu Bali
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karla Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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Gupta SR, Lu PL, Vaz KH, Yacob D, Wall J, Van Diest AMK, Di Lorenzo C, Bali N. A Retrospective Review of Baclofen Treatment for Children with Rumination Syndrome at a Single Center. Paediatr Drugs 2023; 25:359-363. [PMID: 36943582 DOI: 10.1007/s40272-023-00567-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Baclofen can decrease rumination frequency in adults with rumination syndrome. Outcomes of baclofen treatment in children with rumination syndrome have not been described. The aim of this study was to examine the safety and efficacy of baclofen in children with rumination syndrome in combination with behavioral therapy at a single center. METHODS We performed a retrospective review of children aged 0-18 years with rumination syndrome based on Rome criteria and prescribed baclofen by a pediatric gastroenterologist at the Nationwide Children's Hospital, Columbus, Ohio, USA, between 2012 and 2019. Children without follow-up data or who were prescribed baclofen for other symptoms were excluded. RESULTS We identified 44 children with rumination syndrome who were prescribed baclofen by a pediatric gastroenterologist. Seventeen either did not have follow-up data or never started the medication. We included 27 patients in the study: 22 (81.5%) female, median age 14.5 years (range 10-18 years) and 100% Caucasian. Twenty patients (74%) received baclofen 5 mg and seven patients (26%) received baclofen 10 mg three times daily. Most patients received behavioral therapy and baclofen simultaneously. Thirteen patients (48%) reported improvement in symptoms, primarily a decrease in rumination frequency, at their first follow-up visit. Regurgitation frequency per week decreased after starting baclofen (p < 0.05). One patient experienced dizziness. No other side effects were reported. CONCLUSION Nearly half of our patients with rumination syndrome improved after baclofen. It was well tolerated with minimal side effects. This suggests that baclofen in addition to behavioral therapy can improve symptoms of rumination syndrome. Prospective, controlled studies in a larger cohort of children with rumination syndrome are needed to confirm these findings.
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Affiliation(s)
- Shivani R Gupta
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Peter L Lu
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Karla H Vaz
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Desale Yacob
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Jody Wall
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Ashley M Kroon Van Diest
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carlo Di Lorenzo
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Neetu Bali
- Department of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
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Multidisciplinary Tiered Care Is Effective for Children and Adolescents With Rumination Syndrome. J Pediatr Gastroenterol Nutr 2023; 76:282-287. [PMID: 36731032 DOI: 10.1097/mpg.0000000000003637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Rumination syndrome (RS) can be challenging to treat and data on treatment outcomes in children are limited. The objective of this study was to evaluate outcomes of children with RS treated with tailored outpatient and inpatient strategies. METHODS We performed a retrospective cohort study of children <18 years old with RS evaluated at our institution from 2018 to 2020. At our institution, we use a multidisciplinary, tiered approach to treatment based on presentation severity. Children with RS either undergo outpatient treatment program (OP) or participate in an intensive outpatient program (IOP) or an intensive inpatient program (IP). We reviewed baseline characteristics and assessed severity (including frequency of regurgitation/vomiting, route of nutrition, and weight loss) at baseline, at completion of treatment, and at a follow-up time point. RESULTS We included 171 children with RS (64% female, median age 13 years, interquartile range (IQR) 10-15), 123 of whom had post-treatment data after completing OP, IOP, or IP. At baseline, 66% of patients were vomiting daily and 40% were losing weight. After treatment, 72% of OP, 95% of IOP, and 96% of IP patients reported that symptoms were better or fully resolved compared to baseline. In all 3 treatment groups, patients were vomiting, losing weight, and skipping meals significantly less after treatment compared to baseline. At follow-up (median 5.3 months), 86% of IOP and 66% of IP patients had symptoms that remained better or resolved. CONCLUSIONS RS can cause severe symptoms, impacting nutritional status and school participation. However, multidisciplinary care in a tiered approach leads to significant symptomatic improvement.
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Intensive Outpatient Treatment of Pediatric Rumination Syndrome in the Era of Telemedicine. J Pediatr Gastroenterol Nutr 2023; 76:278-281. [PMID: 35897133 DOI: 10.1097/mpg.0000000000003577] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We have had success treating children with severe rumination syndrome using a multidisciplinary intensive outpatient program (IOP) involving multiple treatment sessions daily. During the coronavirus disease 2019 (COVID-19) pandemic, we temporarily transitioned care to telemedicine. The objective of this study is to compare outcomes of patients with rumination syndrome who completed IOP treatment in person versus by telemedicine. METHODS We performed a retrospective review of patients diagnosed with rumination syndrome who participated in IOP treatment from 2018 to 2020. Similar treatment sessions were performed involving medical and behavioral techniques provided by a multidisciplinary team during telemedicine visits. Families/patients were asked to complete a survey outlining their child's current rumination symptom severity and review the IOP. RESULTS We included 34 patients (79% F, median age 15 years, range 7-19 years) who completed IOP treatment. Twenty-six patients (76%) were treated in person and 8 patients (24%) by telemedicine. For patients treated in person, 76% (19/25) had improvement in symptoms while 16% (4/25) had complete resolution of symptoms. For patients treated by telemedicine, 88% (7/8) had improvement in their symptoms. There were no significant differences between groups in likelihood of improvement. Overall, 78% (18/23) preferred in person therapy while 17% (4/23) did not have a preference. All 18 of the in-person cohort who completed follow-up surveys preferred in-person management. CONCLUSIONS Multidisciplinary intensive outpatient treatment for children and adolescents with severe rumination syndrome is effective. Although telemedicine may be an alternative to in person therapy, majority of families prefer in person visits.
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Protocol and Outcome Evaluation of Comprehensive Outpatient Treatment of Adolescent Rumination Syndrome. J Pediatr Gastroenterol Nutr 2022; 75:e38-e42. [PMID: 35687569 DOI: 10.1097/mpg.0000000000003524] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Rumination syndrome (RS) is an increasingly recognized functional gastrointestinal condition with limited treatment research. Current treatment recommendations emphasize diaphragmatic breathing (DB), despite limited outcomes, and the most robust results have originated from inpatient treatment models. This paper described the protocol for Comprehensive Behavioral Treatment for Rumination Syndrome (CBT-R) utilized in an outpatient setting and evaluation of preliminary outcomes. METHODS The CBT-R protocol is described in detail, grounded in behavioral theory and phased treatment approach to symptom elimination. The treatment is evaluated via a retrospective case series design of pediatric patients (aged 8-18) with a primary diagnosis of RS treated in an outpatient setting by a pediatric psychologist. RESULTS Twenty-eight patients met inclusion criteria and are included in intent-to-treat analysis, with 23 patients evaluated for outcomes (47.8% female, M age = 14.3; SD = 2.8). Sample included 17.4% with comorbid psychiatric diagnosis and 43.5% with comorbid medical diagnoses. Outcome results demonstrate improvement for a majority of patients (87.0%), with most demonstrating complete resolution of symptoms (73.9%). Treatment length varied significantly, ranging from 1 to 22 visits (M = 4.8, SD = 5.4) and was complicated by necessary admission or supplemental nutrition in 21.7% of patients. Psychological factors were related to poor treatment outcomes and longer treatment duration. CONCLUSIONS CBT-R results in positive treatment outcomes for majority of patients, with most patients demonstrating complete resolution of symptoms, providing a superior outpatient treatment option for some pediatric patients. Sample characteristics challenge previous understanding of RS as female dominated and with high levels of psychiatric comorbidity.
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Sasegbon A, Hasan SS, Disney BR, Vasant DH. Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterol 2022; 13:440-446. [PMID: 36046491 PMCID: PMC9380772 DOI: 10.1136/flgastro-2021-101856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Syed Shariq Hasan
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin R Disney
- Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Dipesh Harshvadan Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK,Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Chahuan J, Rey P, Monrroy H. Rumination syndrome. A review article. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021. [DOI: 10.1016/j.rgmxen.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chahuan J, Rey P, Monrroy H. Rumination syndrome. A review article. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:163-171. [PMID: 33602544 DOI: 10.1016/j.rgmx.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023]
Abstract
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation of ingested food into the mouth. An unperceived postprandial contraction of the abdominal wall could be a key mechanism. In those patients, retrograde flow of the ingested gastric content into the mouth is produced due to a simultaneous combination of elevated intra-abdominal pressure and negative intrathoracic pressure. The estimated prevalence is around 2% in the general adult population. The main clinical characteristics include: a) early postprandial regurgitation, b) the effortlessly regurgitated material is similar to the ingested food, c) the regurgitated material is spit out or swallowed again. The clinical diagnosis of rumination syndrome relies on the clinical criteria. High resolution esophageal manometry, ideally including impedance monitoring, can be an important adjunct for making the clinical diagnosis. Its management is based on instruction as to the nature of the pathology, education in postprandial diaphragmatic breathing, and the assessment of possible psychiatric comorbidity. Baclofen use is reserved for second-line treatment in patients with refractory symptoms.
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Affiliation(s)
- J Chahuan
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Rey
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Laboratorio de Fisiología Digestiva, Red de Salud UC-Christus, Santiago, Chile
| | - H Monrroy
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Laboratorio de Fisiología Digestiva, Red de Salud UC-Christus, Santiago, Chile.
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Murray HB, Juarascio AS, Lorenzo CD, Drossman DA, Thomas JJ. Diagnosis and Treatment of Rumination Syndrome: A Critical Review. Am J Gastroenterol 2019; 114:562-578. [PMID: 30789419 PMCID: PMC6492032 DOI: 10.14309/ajg.0000000000000060] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rumination syndrome (RS) is characterized by the repeated regurgitation of material during or soon after eating with the subsequent rechewing, reswallowing, or spitting out of the regurgitated material. Rumination syndrome is classified as both a "Functional Gastroduodenal Disorder" (by the Rome Foundation's Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction, 4th edition) and a "Feeding and Eating Disorder" (by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition). Rumination syndrome is a disorder that is often inaccurately diagnosed or missed, resulting in patients experiencing protracted symptoms and not receiving treatment for long periods. There is a lack of clear consensus for RS diagnosis, mechanisms that maintain RS, and treatment. Guided by existing research and our clinical expertise, we synthesize available evidence and provide recommendations for clinical use. We present a case example and critically summarize the literature to date to (i) increase clinicians' understanding of heterogeneous clinical presentations, (ii) suggest assessment strategies to facilitate accurate diagnosis, and (iii) provide a schematic for intervention options. Overall, we recommend clinicians recognize the heterogeneous features of RS when considering diagnosis, assess for RS symptoms by clinical history, and treat RS with targeted diaphragmatic breathing while using other methods as augmented intervention or alternative treatment.
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Affiliation(s)
- Helen B. Murray
- Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Douglas A. Drossman
- Center for Education and Practice of Biopsychosocial Care, Drossman Gastroenterology, Chapel Hill, North Carolina, USA
- Center of Functional GI and Motility Disorders, Division of Digestive Diseases and Nutrition, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Rome Foundation, Chapel Hill, North Carolina, USA
| | - Jennifer J. Thomas
- Eating Disorders Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Halland M, Pandolfino J, Barba E. Diagnosis and Treatment of Rumination Syndrome. Clin Gastroenterol Hepatol 2018; 16:1549-1555. [PMID: 29902642 DOI: 10.1016/j.cgh.2018.05.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023]
Abstract
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. The disorder appears uncommon, although only limited epidemiologic data are available. Awareness of the characteristic symptoms is essential for recognizing the disorder, and thus avoiding the long delay in diagnosis, that many patients experience. Although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers, a clinical diagnosis can be made in most patients. The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing. This clinical practice update reviews the pathophysiology, diagnosis, and treatment of rumination syndrome. Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting. Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely. Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up. Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome. Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique. Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations. Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients.
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Affiliation(s)
- Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Northwestern Memorial Hospital, Chicago, Illinois.
| | - Elizabeth Barba
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
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Giménez Casado A, López Liñán MJ, Barba Orozco E, Accarino Garaventa A, Álvarez Beltrán M, Azpiroz Vidaur F, Segarra Cantón O. Rumination syndrome: Diagnostic and therapeutic difficulties of a not so uncommon disorder. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Rumination syndrome is one of the functional gastroduodenal disorders. Effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by rechewing and reswallowing or spitting are the characteristic clinical features. This disorder is believed to be uncommon, but many patients with this disorder are overlooked by their physicians. Rumination might be caused by a reversal of the gastric contents through the esophagogastric junction, which is initiated by an increase in intragastric pressure. The characteristic symptoms are sufficient for the diagnosis of rumination syndrome. Postprandial high resolution esophageal impedance manometry can detect gastric pressurization exceeding 30 mmHg associated with the return of ingested material into the proximal esophagus, which is a pathognomonic finding of rumination syndrome. An extensive explanation of the condition and the underlying mechanism is the first step of the treatment of rumination syndrome. Behavioral therapy through diaphragmatic breathing is the mainstay of treatment. Further studies on the long term effects of biofeedback therapy as well as a proper strategy for refractory rumination syndrome are needed.
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Affiliation(s)
- Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Giménez Casado A, López Liñán MJ, Barba Orozco E, Accarino Garaventa A, Álvarez Beltrán M, Azpiroz Vidaur F, Segarra Cantón O. [Rumination syndrome: Diagnostic and therapeutic difficulties of a not so uncommon disorder]. An Pediatr (Barc) 2017; 88:100-105. [PMID: 28460821 DOI: 10.1016/j.anpedi.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/20/2017] [Accepted: 03/17/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Rumination syndrome is an uncommon gastrointestinal functional disorder that may be difficult to diagnose, as not many physicians are aware of this condition. In many cases, patients undergo numerous tests and are prescribed several treatments based on erroneous diagnoses. When the correct diagnosis is eventually made, therapy for the syndrome can be difficult and complex because of its multifactorial nature. The aim of this study was to present our experience with this condition, by presenting an analysis of the clinical, diagnostic, and therapeutic data of our patients. PATIENTS AND METHOD A prospective and retrospective study was conducted on all cases of rumination syndrome diagnosed between January 2010 and May 2016 in patients attending the Paediatric Gastroenterology Departments of two hospitals: Consorci Sanitari de Terrassa and Hospital Materno-Infantil Vall d'Hebron (Barcelona, Spain). RESULTS The analysis included 12 patients, with a mean age at the onset of symptoms of 9 years and 1 month, and the mean time period to make the diagnosis was 2 years and 3 months. A mean of 8.1 complementary tests were carried out before establishing the diagnosis. In 10 of the 12 patients, some type of treatment had been given before the diagnosis of rumination syndrome, but was unsuccessful in all cases. Ten of our patients underwent the novel, experimental biofeedback therapy. CONCLUSIONS Due to the limited knowledge of this condition among attending professionals in terms of the clinical presentation, diagnosis, and treatment, patients with rumination syndrome are often misdiagnosed and undergo numerous avoidable complementary tests, and invasive, costly treatments.
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Affiliation(s)
- Aida Giménez Casado
- Unidad de Gastroenterología Pediátrica, Servicio de Pediatría, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España.
| | - María José López Liñán
- Unidad de Gastroenterología Pediátrica, Servicio de Pediatría, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España
| | - Elisabeth Barba Orozco
- Unidad de Motilidad Digestiva, Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Anna Accarino Garaventa
- Unidad de Motilidad Digestiva, Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Marina Álvarez Beltrán
- Unidad de Gastroenterología, Hepatología, Soporte Nutricional y Trasplante Hepático Pediátrico, Servicio de Pediatría, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Fernando Azpiroz Vidaur
- Unidad de Motilidad Digestiva, Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Oscar Segarra Cantón
- Unidad de Gastroenterología, Hepatología, Soporte Nutricional y Trasplante Hepático Pediátrico, Servicio de Pediatría, Hospital Universitario Vall d'Hebron, Barcelona, España
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15
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Rosen R, Rodriguez L, Nurko S. Pediatric rumination subtypes: A study using high-resolution esophageal manometry with impedance. Neurogastroenterol Motil 2017; 29:10.1111/nmo.12998. [PMID: 28002887 PMCID: PMC5393952 DOI: 10.1111/nmo.12998] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/26/2016] [Accepted: 10/25/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND The differential diagnosis of intractable reflux in children includes rumination syndrome, but confirming the diagnosis using antroduodenal manometry is invasive, is costly, and requires anesthesia. High-resolution esophageal manometry with impedance (HRM-MII) overcomes these limitations, and the goal of this study is to validate the use of HRM-MII as a diagnostic tool for rumination and to describe the subtypes of pediatric rumination. METHODS We reviewed the HRM-MII tracings of 21 children presenting with symptoms of intractable reflux in whom rumination was being considered. Patients underwent a standard and post-prandial HRM-MII. Peak intraluminal esophageal pressures, baseline gastric and thoracic pressures, and the timing of the R wave relative to LES relaxations and bolus flow were recorded. Chi-square analyses were used for comparison of proportions and means were compared using t-tests or non-parametric equivalent. KEY RESULTS Forty-one (55.5%) primary and 33 (44.5%) secondary rumination episodes were seen. Three types of primary rumination were identified: i) LES relaxation without retrograde flow preceding the R wave (51% of episodes); ii) LES relaxation after the R wave (20% of episodes); and iii) R waves with no LES relaxation (29% of episodes). Eleven patients had rumination episodes with a peak gastric pressure <30 mm Hg. A total of 44 (60%) rumination episodes occurred during the standard HRM-MII, and 30 (40%) occurred during or after the meal. CONCLUSIONS & INFERENCES HRM-MII can accurately diagnose rumination in children. We identify three types of primary rumination which may provide insight into therapeutic response.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Leonel Rodriguez
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
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16
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Singendonk MMJ, Oors JM, Bredenoord AJ, Omari TI, van der Pol RJ, Smits MJ, Benninga MA, van Wijk MP. Objectively diagnosing rumination syndrome in children using esophageal pH-impedance and manometry. Neurogastroenterol Motil 2017; 29. [PMID: 28078818 DOI: 10.1111/nmo.12996] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/20/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rumination syndrome is characterized by recurrent regurgitation of recently ingested food into the mouth. Differentiation with other diagnoses and gastroesophageal reflux disease (GERD) in particular, is difficult. Recently, objective pH-impedance (pH-MII) and manometry criteria were proposed for adults. The aim of this study was to determine diagnostic ambulatory pH-MII and manometry criteria for rumination syndrome in children. METHODS Clinical data and 24-hour pH-MII and manometry recordings of children with a clinical suspicion of rumination syndrome were reviewed. Recordings were analyzed for retrograde bolus flow extending into the proximal esophagus. Peak gastric and intraesophageal pressures closely related to these events were recorded and checked for a pattern compatible with rumination. Events were classified into primary, secondary, and supragastric belch-associated rumination. KEY RESULTS Twenty-five consecutive patients (11 males, median age 13.3 years [IQR 5.9-15.8]) were included; recordings of 18 patients were suitable for analysis. Rumination events were identified in 16/18 patients, with 50% of events occurring <30 minutes postprandially. Fifteen of 16 patients showed ≥1 gastric pressure peak >30 mmHg, while only 50% of all events was characterized by peaks >30 mmHg and an additional 20% by peaks >25 mmHg. Four patients had evidence of acid GERD, all showing secondary rumination. CONCLUSIONS AND INFERENCES Combined 24-hour pH-MII and manometry can be used to diagnose rumination syndrome in children and to distinguish it from GERD. Rumination patterns in children are similar compared with adults, albeit with lower gastric pressure increase. We propose a diagnostic cutoff for gastric pressure increase >25 mmHg associated with retrograde bolus flow into the proximal esophagus.
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Affiliation(s)
- M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - J M Oors
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - T I Omari
- Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, SA, Australia.,Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium.,School of Medicine, Flinders University, Bedford Park, SA, Australia
| | - R J van der Pol
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - M J Smits
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - M P van Wijk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
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17
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Absah I, Rishi A, Talley NJ, Katzka D, Halland M. Rumination syndrome: pathophysiology, diagnosis, and treatment. Neurogastroenterol Motil 2017; 29. [PMID: 27766723 DOI: 10.1111/nmo.12954] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/29/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Rumination syndrome is a functional gastrointestinal disorder characterized by effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by either re-swallowing or spitting. Rumination is thought to occur due to a reversal of the esophagogastric pressure gradient. This is achieved by a coordinated abdominothoracic maneuver consisting of a thoracic suction, crural diaphragm relaxation and an increase in intragastric pressure. Careful history is important in the diagnosis of rumination syndrome; patients often report "vomiting" or "reflux" and the diagnosis can therefore be missed. Objective testing is available with high resolution manometry or gastroduodenal manometry. Increase in intra-gastric pressure followed by regurgitation is the most important characteristic to distinguish rumination from other disorders such as gastroesophageal reflux. The mainstay of the treatment of rumination syndrome is behavioral therapy via diaphragmatic breathing in addition to patient education and reassurance. PURPOSE The purpose of this review was to critically appraise recent key developments in the pathophysiology, diagnosis and therapy for rumination syndrome. A literature search using OVID (Wolters Kluwer Health, New York, NY, USA) to examine the MEDLINE database its inception until May 2016 was performed using the search terms "rumination syndrome," "biofeedback therapy," and "regurgitation." References lists and personal libraries of the authors were used to identify supplemental information. Articles published in English were reviewed in full text. English abstracts were reviewed for all other languages. Priority was given to evidence obtained from randomized controlled trials when possible.
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Affiliation(s)
- I Absah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - A Rishi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - N J Talley
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - D Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - M Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Definitions and Outcome Measures in Pediatric Functional Upper Gastrointestinal Tract Disorders: A Systematic Review. J Pediatr Gastroenterol Nutr 2016; 62:581-7. [PMID: 26348686 DOI: 10.1097/mpg.0000000000000973] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Functional disorders of the upper gastrointestinal tract are frequently diagnosed in children. Four different clinical entities are addressed by the Rome III committee: functional dyspepsia (FD), cyclic vomiting syndrome (CVS), adolescent rumination syndrome (ARS), and aerophagia. Management of these disorders is often difficult leading to a wide variety in therapeutic interventions. We hypothesize that definitions and outcome measures in these studies are heterogeneous as well. Our aim is to systematically assess how these disorders and outcomes are defined in therapeutic randomized controlled trials (RCTs). STUDY DESIGN CENTRAL, Embase, and MEDLINE/PubMed were searched from inception to February 25, 2015. Search terms were FD, CVS, ARS, and aerophagia. Therapeutic RCTs, or systematic reviews of RCTs, in English language including subjects ages 4 to 18 years (0-18 years for CVS) were evaluated. Quality was assessed using the Delphi list. RESULTS A total of 1398 articles were found of which 8 articles were included. Seven concerned FD and 1 concerned CVS. In all of the studies, Rome criteria or similar definitions were used; all the studies however used different outcome measures. Seventy-five percent of the trials were of good methodological quality. Only 57% used validated pain scales. CONCLUSIONS Different outcome measures are used in therapeutic trials on functional disorders of the upper gastrointestinal tract. There is a clear paucity of trials evaluating different treatment regimens regarding CVS, ARS, and aerophagia. Uniform definitions, outcome measures, and validated instruments are needed to make a comparison between intervention studies possible.
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