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Himmerich H, Lewis YD, Conti C, Mutwalli H, Karwautz A, Sjögren JM, Uribe Isaza MM, Tyszkiewicz-Nwafor M, Aigner M, McElroy SL, Treasure J, Kasper S. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines update 2023 on the pharmacological treatment of eating disorders. World J Biol Psychiatry 2023:1-64. [PMID: 37350265 DOI: 10.1080/15622975.2023.2179663] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES This 2023 update of the WFSBP guidelines for the pharmacological treatment of eating disorders (EDs) reflects the latest diagnostic and psychopharmacological progress and the improved WFSBP recommendations for the assessment of the level of evidence (LoE) and the grade of recommendation (GoR). METHODS The WFSBP Task Force EDs reviewed the relevant literature and provided a timely grading of the LoE and the GoR. RESULTS In anorexia nervosa (AN), only a limited recommendation (LoE: A; GoR: 2) for olanzapine can be given, because the available evidence is restricted to weight gain, and its effect on psychopathology is less clear. In bulimia nervosa (BN), the current literature prompts a recommendation for fluoxetine (LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1). In binge-eating disorder (BED), lisdexamfetamine (LDX; LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1) can be recommended. There is only sparse evidence for the drug treatment of avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD). CONCLUSION In BN, fluoxetine, and topiramate, and in BED, LDX and topiramate can be recommended. Despite the published evidence, olanzapine and topiramate have not received marketing authorisation for use in EDs from any medicine regulatory agency.
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Affiliation(s)
- Hubertus Himmerich
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Yael Doreen Lewis
- Hadarim Eating Disorders Unit, Shalvata Mental Health Center, Hod HaSharon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chiara Conti
- Department of Psychological, Health, and Territorial Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Hiba Mutwalli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Clinical Nutrition, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Andreas Karwautz
- Eating Disorders Care & Research Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | | | | | - Marta Tyszkiewicz-Nwafor
- Department of Child and Adolescent Psychiatry, Poznan University of Medical Sciences, Poznań, Poland
| | - Martin Aigner
- Universitätsklinikum Tulln, Tulln an der Donau, Austria
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Siegfried Kasper
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
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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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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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Alcala-Gonzalez LG, Serra X, Barba E. Rumination syndrome: Critical review. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:155-163. [PMID: 34023479 DOI: 10.1016/j.gastrohep.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 11/20/2022]
Abstract
Rumination syndrome is a functional disorder characterized by the involuntary regurgitation of recently swallowed food from the stomach into the mouth, from where it can be re-chewed or expelled. Clinically, it is characterized by repeated episodes of effortless food regurgitation. The most usual complaint is frequent vomiting. The physical mechanism that generates regurgitation events is dependent on an involuntary process that alters abdominal and thoracic pressures accompanied by a permissive oesophageal-gastric junction. The diagnosis of rumination syndrome is clinical, highlighting the importance of performing an exhaustive anamnesis on the characteristics of the symptoms. Complementary tests are used to corroborate the diagnosis or rule out organic pathology. Treatment is focused on behavioural therapies as the first line, reserving pharmacological and surgical therapies for refractory cases.
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Affiliation(s)
- Luis Gerardo Alcala-Gonzalez
- Departamento de Gastroenterología, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, España; Facultad de Medicina(,) Universitat Autònoma de Barcelona, Bellaterra, España
| | - Xavier Serra
- Departamento de Gastroenterología, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, España
| | - Elizabeth Barba
- Departamento de Gastroenterología, Unidad de Motilidad Digestiva, Hospital Clínic, Barcelona, España.
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Robles A, Romero YA, Tatro E, Quezada H, McCallum RW. Outcomes of Treating Rumination Syndrome with a Tricyclic Antidepressant and Diaphragmatic Breathing. Am J Med Sci 2020; 360:42-49. [DOI: 10.1016/j.amjms.2020.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/27/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022]
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Vachhani H, Ribeiro BDS, Schey R. Rumination Syndrome: Recognition and Treatment. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:60-68. [PMID: 31960280 DOI: 10.1007/s11938-020-00272-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to discuss current diagnostic and treatments of rumination. Rumination is often underdiagnosed or misdiagnosed in adults, especially when symptoms suggest regurgitation rather than vomiting accompanied by re-chewing and re-swallowing and should be included in the differential diagnosis. It is primarily diagnosed clinically by ROME-IV or DSM-5. RECENT FINDINGS That rumination can be re-affirmed by characteristic patterns on objective testing such as high-resolution esophageal manometry and 24-h pH impedance testing. However, although gastroduodenal manometry and EMG are helpful, these tests are slowly losing interest given their technical nature of data gathering, time consumption, cost burden, and patient discomfort. SUMMARY Rumination is primarily diagnosed clinically by ROME-IV or DSM-5 in addition to high-resolution esophageal manometry and 24-h pH impedance. Management is challenging and usually a combination of behavioral, pharmacological, and rarely surgical treatment. Recent data demonstrate that the combination of behavioral techniques such as diaphragmatic breathing exercises and/or with baclofen has promising results. Further research is necessary to further define objective criteria for diagnosis and other therapeutic modalities for treatment.
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Affiliation(s)
- Herit Vachhani
- Division of Gastroenterology, Department of Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Bruno De Souza Ribeiro
- Neurogastroenterology & Esophageal Program, University of Florida College of Medicine-Jacksonville, Building 1, Suite 300, 4555 Emerson Street, Jacksonville, FL, 32207, USA
| | - Ron Schey
- Division of Gastroenterology, Department of Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
- Neurogastroenterology & Esophageal Program, University of Florida College of Medicine-Jacksonville, Building 1, Suite 300, 4555 Emerson Street, Jacksonville, FL, 32207, USA.
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Ong AML, Tay SW, Wang YT. Treatment options for rumination syndrome: A systematic review. World J Meta-Anal 2019; 7:297-308. [DOI: 10.13105/wjma.v7.i6.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rumination syndrome (RS) is characterized by recurrent effortless postprandial regurgitation of recently ingested food from the stomach to the oral cavity and has been associated with quality of life impairment and malnutrition. There is a general lack of consensus on the most appropriate treatment options for RS.
AIM To summarize the literature on treatment options for RS.
METHODS We conducted a systematic review according to PRISMA guidelines. We searched Medline (1946 to February 2019), EMBASE (1947 to February 2019), PsycINFO (1806 to February 2019) and Cochrane central register of controlled trials for articles discussing treatment options for adult patients (> 18 years) with RS. All relevant articles were accessed in full text. We extracted data on study designs, patient profiles, duration of symptoms, follow up periods, date, diagnostic criteria, interventions and outcomes. Risk of bias assessment was carried out independently by 3 reviewers via Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized controlled trials and Cohort studies respectively.
RESULTS Twelve articles were identified. A total of 254 patients were included in the analysis, with a mean age of 36.1 (range 18-89). 185 patients (72.8%) were females. 5 studies looked into behavioral therapies, primarily diaphragmatic breathing (DB) 2 studies looked at baclofen, 1 fundoplication and 1 supportive lifestyle changes. 3 studies looked at a combination of therapies involving pharmacological, behavioral and psychotherapies.
CONCLUSION Although evidence for treatment options is still limited, the strongest evidence point towards the use of DB and Baclofen, and both should be considered depending on their availabilities.
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Affiliation(s)
- Andrew Ming-Liang Ong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169856, Singapore
- Duke-NUS Graduate Medical School, Singapore 169856, Singapore
| | - Shu-Wen Tay
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169856, Singapore
| | - Yu-Tien Wang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169856, Singapore
- Duke-NUS Graduate Medical School, Singapore 169856, Singapore
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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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9
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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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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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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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Abstract
Rumination is a normal and common phenomenon among ruminant animals; but in humans, it is always regarded as symptom indicative of abnormal function of the upper gastrointestinal tract, and understanding of the mechanisms explaining this event are still evolving. Learning-based theories, organic factors such as gastroesophageal reflux disease and psychological disturbances (eg, depression, anxiety) and the role of life stresses have been postulated as potential mechanisms of rumination. In this review, we take the approach that rumination syndrome is a distinct and discrete functional gastroduodenal disorder. We review current concepts of the pathophysiology of this entity and diagnostic approaches, then detail the treatment paradigms that have been pursued in rumination syndrome in adults. Patients with rumination syndrome have a very distinct set of symptoms. It was focused on the immediate postprandial period, but recently, there is an awareness of an expanding spectrum of the clinical presentation. This includes the concept of "conditioned vomiting" occurring in the setting of delayed gastric emptying (gastroparesis). Physicians' awareness of rumination syndrome is essential in the diagnosis and management of this disorder. Stress and psychological aspects in rumination syndrome are invariably in the background and have to be addressed. The crucial steps in the treatment strategy for rumination syndrome rely on reassurance, education and a physiologic explanation to the patient and family that this is not a "disease," followed by behavioral and relaxation programs and addressing stress factors.
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Rajindrajith S, Devanarayana NM, Crispus Perera BJ. Rumination syndrome in children and adolescents: a school survey assessing prevalence and symptomatology. BMC Gastroenterol 2012; 12:163. [PMID: 23157670 PMCID: PMC3538663 DOI: 10.1186/1471-230x-12-163] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 11/13/2012] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rumination syndrome (RS) is a functional gastrointestinal disorder (FGD) increasingly recognized in children and adolescents. The epidemiology of this condition in school aged children is poorly understood. The main objective of this study was to assess the prevalence of rumination and other related associations in a cohort of Sri Lankan children. METHODS Children aged 10-16 years were randomly selected from 8 schools in 4 provinces in Sri Lanka. RS was diagnosed using Rome III criteria. Data was collected using a self administered questionnaire distributed in an examination setting. It was translated into Sinhala, the native language and pretested before distribution. RESULTS A total of 2163 children were included in the study (55% boys, mean age 13.4 years, SD 1.8 years). Prevalence of RS was 5.1% (n = 110); boys 5.1% and girls 5.0%. When symptoms were analyzed, 73.6% reported re-swallowing of regurgitated food, while the rest spat it out. In 94.5% regurgitation occurred during the first hour after the meal. Only 8.2% had daily symptoms while 62.7% had symptoms weekly. Abdominal pain, bloating and weight loss were the commonest symptoms associated with RS (19.1%, 17.3% and 11.8% respectively). No significant association was observed between exposure to stressful events and rumination (p > 0.05). Twenty (18.2%) with RS fulfilled Rome III criteria for at least one other FGD. School absenteeism was seen in 11.8% of affected children. CONCLUSION RS was reasonably common in this cohort of school-aged children and adolescents in Sri Lanka. However, symptoms were severe enough to affect schooling only in 12% of affected children. Around one fifth with RS had at least one other overlapping FGD.
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Affiliation(s)
- Shaman Rajindrajith
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama 11010, Sri Lanka.
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Tack J, Blondeau K, Boecxstaens V, Rommel N. Review article: the pathophysiology, differential diagnosis and management of rumination syndrome. Aliment Pharmacol Ther 2011; 33:782-8. [PMID: 21303399 DOI: 10.1111/j.1365-2036.2011.04584.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rumination syndrome, characterised by the effortless, often repetitive, regurgitation of recently ingested food into the mouth, was originally described in children and in the developmentally disabled. It is now well-recognised that rumination syndrome occurs in patients of all ages and cognitive abilities. AIM To review a scholarly review on our current understanding of the rumination syndrome. METHODS The review was conducted on the basis of a medline search to identify relevant publications pertaining to the pathophysiology, clinical diagnosis and management of rumination syndrome. RESULTS The Rome III consensus established diagnostic criteria for rumination syndrome in adults, children and infants. A typical history can be highly suggestive but oesophageal (high resolution) manometry/impedance with ingestion of a meal may help to distinguish rumination syndrome from other belching/regurgitation disorders. The pathophysiology is incompletely understood, but involves a rise in intra-gastric pressure, generated by a voluntary, but often unintentional, contraction of the abdominal wall musculature, at a time of low pressure in the lower oesophageal sphincter, causing retrograde movement of gastric contents into the oesophagus. To date, controlled trials in the treatment rumination syndrome are lacking. The mainstay of treatment for rumination syndrome is explanation and behavioural treatment which consists of habit reversal techniques that compete with the urge to regurgitate. Chewing gum, prokinetics, baclofen and even antireflux surgery have been proposed as adjunctive therapies, but high quality studies are generally lacking. CONCLUSIONS Rumination is an under-recognised condition with incompletely understood pathophysiology. Behavioural therapy seems effective, but controlled treatment trials are lacking.
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Affiliation(s)
- J Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Leuven, Vlaanderen, Belgium.
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