Rumination syndrome: pathophysiology, diagnosis and practical management

In a recent Rome Foundation global epidemiological study, rumination syndrome was found to have an overall worldwide prevalence of 2.8% with women having a slightly higher prevalence (3.1%) than men (2.5%).16 A higher prevalence of rumination syndrome has been noted in those with eating disorders (20%)17 18 and those with fibromyalgia (8%).14 Despite rumination syndrome being a relatively common disorder of gut–brain interaction, evidence suggests it is not well understood, resulting in patients often having to visit a number of clinicians and undergo several investigations before a diagnosis is eventually reached.19 Consequently, a formal diagnosis can be delayed, leading to weight loss and malnutrition.19 This paper aims to set out the key diagnostic features of rumination syndrome, important differential diagnoses to consider, useful investigations to help dispel uncertainty and current evidence-based therapies. Rumination syndrome is an acquired behavioural disorder and, in some cases, a detailed history can reveal a particular priming episode of psychological stress or gastrointestinal (GI) upset (eg, gastroenteritis) which occurred prior to rumination being noticed.29 30 This event may be relatively minor and swiftly forgotten but it is theorised it prompts patients to tense their abdominal walls in order to relieve discomfort.7 This initial priming episode, later maintained and reinforced, leads to patients habitually tensing their abdomen postprandially.24 While rumination is almost always a primary condition, it is recognised that rumination can occasionally be a secondary response to gastro-oesophageal reflux episodes (secondary rumination), where the rumination behaviour is thought to be a conditioned, maladaptive response to oesophageal discomfort caused by GORD.26 Similarly, patients with established rumination often report postprandial fullness or discomfort occurring before their episodes of regurgitation.7 Subsequent abdominal tensing and regurgitation may also be due to a subconscious, maladaptive method of discomfort reduction. Complications When severe, rumination syndrome can lead to malnutrition and dehydration which, in turn, can lead to electrolyte imbalances and the occurrence of refeeding syndrome when nutrition improves.31–33 Malnutrition and dehydration arise due to either a possible reduced desire to eat or drink so as to avoid episodes of regurgitation or spitting of food and fluids, reducing nutritional intake below what is re