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Rumination Syndrome: an Update on Diagnostic and Treatment Strategies

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GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #19 GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #19 Richard W. McCallum, MD, FACP, FRACP (Aust), FACG, AGAF Rumination Syndrome: An Update on Diagnostic and Treatment Strategies Mena Milad Richard W. McCallum Rumination syndrome is a disorder characterized by the regurgitation of swallowed food with the decision to re-swallow the material or vomit within minutes after eating. Rumination syndrome can occur as a primary disorder or as a conditioned response in the setting of other vomiting disorders, particularly gastroparesis. This article will focus on the importance of history taking to diagnose rumination syndrome and review treatment strategies including breathing and relaxation skills. In addition, we emphasize a new approach, jejunostomy tube placement in patients with the most severe symptoms. INTRODUCTION umination syndrome (RS) is a unique, functional often prompts extensive, costly and time-consuming gastroenterological disorder characterized testing and inappropriate medical management without Rby effortless post-prandial regurgitation. The establishing a diagnosis. With understanding of the first reports of this syndrome were in the early 17th disease process and of the treatment paradigms, good century culminating with a Mauritian physiologist outcomes and symptom resolution can be achieved. and neurologist who acquired the condition after swallowing sponges tied to a string to measure gastric CASE EXAMPLE pH.1,2 This distinct entity has been well described in the An otherwise healthy 47 year-old Caucasian male recently published Rome IV criteria (Table 1)3 and is presented with a chief complaint of nausea, vomiting diagnosed based on clinical symptoms in the absence and worsening intolerance to oral intake over the past of structural disease. Lack of awareness of the disease two years. The patient reported that his symptoms started soon after he was robbed at gunpoint followed Mena Milad, MD, Gastroenterology Fellow, by a difficult divorce. Careful questioning elicited Texas Tech University Health Sciences Center that he regurgitates his food, recently progressing to Richard W. McCallum MD, FACP, FRACP, water and fluids, within five minutes of eating. He has FACG, AGAF, Department of Internal Medicine, experienced a 20-pound unintentional weight loss over Director, Center for Neurogastroenterology the two years and has 8-10 emergency department visits and GI Motility, Texas Tech University, Paul annually for nausea and vomiting, abdominal pain, L. Foster School of Medicine El Paso, TX hypokalemia and dehydration. The patient reported that 68 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2016 Rumination Syndrome: An Update on Diagnostic and Treatment Strategies GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #19 GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #19 his emergency department visits have become more infants and mentally handicapped individuals with a frequent with multiple admissions requiring anti-emetics prevalence between 6 and 10%.4 In adults, RS remains and occasional opioids. None of these admissions were an underdiagnosed entity with limited awareness among for hematemesis, melena or hematochezia. He has patients as well as physicians. It is known, however, seen multiple physicians, has taken many anti-emetics that RS is more prevalent in young adults with females (including ondansetron, promethazine, metoclopramide being more affected than males.5 as well as hydrocodone-acetaminophen) and recently started using marijuana with some resolution of his MECHANISMS symptoms. He experiences gastroesophageal reflux Although the exact pathophysiology of RS in humans (GERD) after his regurgitation episodes which responds is not completely understood, it is currently believed to proton-pump inhibitor (PPI). to be an unconscious, learned disorder. The rumination As part of the workup prior to his referral, the episodes involve relaxation of the diaphragm combined patient had multiple computed tomography (CT) scans with contraction of the abdominal muscles. The lower of his abdomen and pelvis and laboratory evaluation esophageal sphincter (LES) pressure is overcome by [including thyroid stimulating hormone (TSH) levels, the increase in intraabdominal and intragastric pressure. early-morning cortisol, complete blood count and Initially, this manifests as belching (burping) that complete metabolic profile], all of which were normal. evolves into episodes of effortless regurgitation of food Several gastric emptying studies were attempted, but and liquids. 6 Patients have a choice, usually dictated the patient regurgitated the meals immediately. Upper by the social setting, to either vomit the regurgitated endoscopy revealed mild esophagitis with a normal material if they are in a place to do so, or re-swallow the stomach and duodenum. Routine biopsies revealed H. material to avoid embarrassment and delay regurgitation pylori which was successfully treated. until they are in an appropriate setting. This process is The diagnosis of rumination syndrome was made voluntary, but not intentional. Patients are unaware that based on his symptoms in the setting of a negative they are contracting their abdominal muscles, which evaluation. He was started on nortriptyline, titrated to 50 leads to complaints of substantial epigastric abdominal mg before bed, as well as tramadol for pain control. He pain. Essentially, the patient is “trapped” in this post- was provided with instructions for breathing techniques prandial reflex and their stomach has been programmed and tapes for relaxation to precede and accompany eating to respond to oral intake in this manner at every meal, in order to overcome the rumination reflex. Despite these every day. measures, he continued to present to the emergency department with nausea, vomiting, dehydration and DIAGNOSIS weight loss, and was becoming increasingly depressed. A thorough history is important in differentiating RS The decision was made to place a jejunostomy feeding from other disorders. The average time from onset of tube laparoscopically given his failure to respond to symptoms until the diagnosis of RS is approximately 17 the abovementioned treatments. Gastric wall biopsies months.7 Patients undergo expensive, unnecessary, and taken during the surgery to evaluate the interstitial cells sometimes invasive testing prior to being diagnosed. of Cajal as well as the myenteric plexus and smooth Rumination can be a “primary” or a “secondary” muscle were histologically normal. disorder associated with states of chronic nausea and The patient was placed on nightly tube feeds and vomiting, such as gastroparesis. daily relaxation and breathing techniques allowing him The onset of primary rumination syndrome is to slowly increase the content of his diet. He experienced usually preceded by a stressful life event, such as weight gain, while medical and psychological therapy loss of a family member, job loss, financial hardship, improved his oral intake to ultimately allow jejunostomy relocation, relationship hardships including divorce and tube removal after four months. A four-hour gastric others. Primary rumination syndrome episodes occur emptying study was then able to be performed and daily with each meal. Often patients will avoid or skip was normal. meals as they do not wish to vomit in front of family and friends. Over time, the decreased oral intake leads to a EPIDEMIOLOGY gradual weight loss (83%) and dehydration, resulting Rumination syndrome (RS) is well recognized in in visits to the emergency department or primary care PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2016 69 Rumination Syndrome: An Update on Diagnostic and Treatment Strategies GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #19 Table1. The Rome IV Criteria for physician.7 Hypokalemia is a result of regurgitating Rumination Syndrome17 acidic, potassium-rich gastric contents in addition to the ingested material. In women with longstanding Diagnostic Criteriaα for Rumination Syndrome RS, weight loss can be associated with accompanying Must include all of the following: amenorrhea, often signaling severe disease. These patients may continue to work but over time cannot 1. Persistent or recurrent regurgitation of recently sustain the stamina to do so. Diagnostic testing may ingested food into the mouth with subsequent be limited since it can be difficult to obtain a gastric spitting or remastication and swallowing emptying study in patients with rumination because 2. Regurgitation is not preceded by retching they often vomit the meal immediately or within 20 minutes after ingestion. αCriteria fulfilled for the last 3 months with symptom onset In the secondary form of RS, or conditioned vomiting, at least 6 months before diagnosis. the organic vomiting disorder conditions the patients to Supportive remarks: expect and experience postprandial vomiting. Gastric • Effortless regurgitation events are usually emptying is delayed in up to 40% of patients with RS. not preceded by nausea 8 As opposed to typical gastroparesis, where vomiting usually occurs 2-6 hours after eating, in conditioned • Regurgitant contains recognizable food that vomiting it occurs within 5-20 minutes. Stress is usually might have a pleasant taste superimposed in this clinical setting of diabetic or • The process tends to cease when the regurgitated idiopathic gastroparesis. The appearance of RS in the material becomes acidic
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