Rumination syndrome.

What is Rumination syndrome?

Rumination syndrome, or Merycism is an under-diagnosed chronic eating disorder, characterized by effortless regurgitation of most meals following consumption. There is no retching, nausea, heartburn, odours, or abdominal pains associated with the regurgitation, as there is with typical vomiting. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities.

Today it is being diagnosed in increasing numbers of otherwise healthy adolescents and adults, though there is a lack of awareness of the condition by doctors, patients and the general public.

Rumination syndrome presents itself in a variety of ways, especially when comparing an adult without a mental disability to an infant or to a mentally impaired individual. Like most eating disorders, rumination can adversely affect normal functioning and the social lives of individuals. It has been linked with depression.

There is little comprehensive data regarding rumination syndrome in otherwise healthy individuals. Most people with the disorder are private about their illness, and are often misdiagnosed due to the number of symptoms, and the clinical similarities between rumination syndrome and other disorders of the stomach and esophogus, such as gastroparesis and bulimia nervosa. These include the acid-induced erosion of the esophagus and teeth (causing dental decay), halitosis, malnutrition, severe weight loss and an unquenchable appetite. Individuals may begin regurgitating within a minute following ingestion, and the full cycle of ingestion and regurgitation can mimic the binging and purging of bulimia.

Signs and symptoms

While the number and severity of symptoms varies among individuals, repetitive regurgitation of undigested food (known as rumination) after the start of a meal is always present.

In some individuals, the regurgitation is small, occurring over a long period of time following ingestion, and can be rechewed and swallowed. In others, the amount can be bilious and short lasting, and must be expelled. While some only experience symptoms following some meals, most experience episodes following any ingestion, from a single bite to a massive feast.

Unlike typical vomiting, the regurgitation is typically described as effortless and unforced. There is seldom nausea preceding the expulsion, and the undigested food lacks the bitter taste and odour of stomach acid and bile.

Symptoms can begin to manifest at any point from the ingestion of the meal to 120 minutes thereafter. However, the more common range is between 30 seconds to 1 hour after the completion of a meal. Symptoms tend to cease when the ruminated contents become acidic.

Abdominal pain, lack of fecal production or constipation, nausea, diarrhea, bloating, and dental decay are also described as common symptoms in day-to-day life. These symptoms are not necessarily prevalent during regurgitation episodes, and can happen at any time. Weight loss is often observed at an average loss of 9.6 kilograms, and is more common in cases where the disorder has gone undiagnosed for a longer period of time, though this may be expected of the nutrition deficiencies that often accompany the disorder as a consequence of its symptoms. Depression has also been linked with rumination syndrome, though the effects of it on rumination syndrome are unknown.

Causes

The cause of rumination syndrome is unknown. However, studies have drawn a correlation between hypothesized causes and the history of patients with the disorder. In infants and the cognitively impaired, the disease has normally been attributed to over-stimulation and under-stimulation from parents and caregivers, causing the individual to seek self-gratification and self-stimulus due to the lack or abundance of external stimuli. The disorder has also commonly been attributed to a bout of illness, a period of stress in the individual's recent past, and to changes in medication.

In adults and adolescents, hypothesized causes generally fall into one of either category: habit-induced, and trauma-induced. Habit-induced individuals generally have a past history of bulimia nervosa or of intentional regurgitation (magicians and professional regurgitators, for example), which though initially self-induced, forms a subconscious habit that can continue to manifest itself outside the control of the affected individual. Trauma-induced individuals describe an emotional or physical injury (such as recent surgery, psychological distress, concussions, deaths in the family, etc.), which preceded the onset of rumination, often by several months.

Treatment and prognosis

There is presently no known cure for rumination. Proton pump inhibitors and other medications have been used to little or no effect.

In patients of normal intelligence, rumination is not an intentional behavior and is habitually reversed using diaphragmatic breathing to counter the urge to regurgitate. Alongside reassurance, explanation and habit reversal, patients are shown how to breathe using their diaphragms prior to and during the normal rumination period. A similar breathing pattern can be used to prevent normal vomiting. Breathing in this method works by physically preventing the abdominal contractions required to expel stomach contents.

Supportive therapy and diaphragmatic breathing has shown to cause improvement in 56% of cases, and total cessation of symptoms in an additional 30% in one study of 54 adolescent patients who were followed up 10 months after initial treatments. Patients who successfully use the technique often notice an immediate change in health for the better. Individuals who have had bulimia or who intentionally induced vomiting in the past have a reduced chance for improvement due to the reinforced behavior.