Rumination Syndrome's Surprisingly High Global Prevalence Makes Identifying It Essential

David A. Johnson, MD


January 12, 2022

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

As gastroenterologists, patients are frequently referred to us for so-called "refractory gastroesophageal reflux disease" or unexplained vomiting. Today's discussion is about making sure we include rumination syndrome in our differential diagnosis of these patients.

Rumination syndrome is defined as a functional disorder involving an effortless return of food contents or liquid back up into the mouth in the absence of preceding retching or nausea. It's well recognized in the functional disease classifications.

I was inspired to have this conversation by a recent publication of data, which the authors describe as the largest study to date on rumination syndrome. Its findings indicate that rumination syndrome has a relatively higher prevalence than most people would suspect to see in a global population.

Investigators asked participants from 26 countries to take part in a health survey assessment. Embedded in the health survey were questions from the Rome IV criteria for diagnosing rumination.

The three questions from the Rome IV criteria are important to remember as discriminant.

The first is to ask patients whether, in the past 3 months, they've had symptoms of regurgitation — that is, an effortless return of food or fluid back up their esophagus and mouth. To qualify, the frequency with which they experienced this had to be at least two to three times a month.

The second question is, if these regurgitation episodes were happening, was they preceded by retching? That was something you did not want to see. To fulfill this criterion, regurgitation should not have been preceded by retching in excess of 20% of episodes.

The third question was about the frequency of symptoms, and specifically whether it had been over 6 months since the problem began.

A Higher-Than-Expected Prevalence

In assessing survey data on 54,127 subjects (mean age, 44.3 years), the investigators found that the blended prevalence rate of rumination syndrome (as determined by Rome IV criteria) for all 26 countries was 3.1%. In the United States, it ranged from 2.8% to 3.1%, comparable to that of other countries. Interestingly, Brazil had the highest correlation at 5.5%.

Investigators also looked at the association with various factors, such as quality of life, psychiatric disease (particularly anxiety and depression), and somatization. These were highly correlated with rumination syndrome.

This was also true for disorders of gut-brain interaction (DGBI). In subjects with one other region with a DGBI, the correlation for rumination syndrome was increased by 4.1 factors, and in those with four regions with a DGBI, the correlation was 15.9 times greater.

There were also notable correlations for increased risk in women, those in middle age (defined as 30-60 years), and those with increased body mass index.

So, when you take a patient's history, it's important to go beyond just these three Rome IV questions. You must consider these other factors thought to increase the risk for rumination syndrome.

Diagnosing and Treating

Clearly, our diagnostic approach for rumination syndrome should be focused on appropriate differentials.

If you weren't already thinking about using it, impedance pH monitoring is really the preferred discriminant. You can diagnose rumination syndrome based on that test alone.

Most times, these patients will invariably get an endoscopy, which I don't think presents any harm. But again, I'd really focus on impedance pH monitoring as the main discriminant. If you don't do that, you won't correctly obtain the diagnosis, and initiating therapy is predicated on the diagnosis.

The primary treatment of rumination syndrome would be diaphragmatic breathing, sometimes including cognitive-behavioral therapy and low-dose antidepressants. But if you don't initiate the right diagnostic testing strategy, you won't get there. That will leave these patients unidentified.

The prevalence for this condition already seems quite high. For those of us gastroenterologists with these referrals, it may be higher. We're already seeing patients deemed refractory to proton-pump inhibitors, as opposed to the general population captured here with that 3.1% prevalence rate.

In conclusion, please think about rumination syndrome in your patients. Ask the three questions from the Rome IV criteria assessing frequency, absence of retching, and duration over 6 months.

By applying these, you'll increase your diagnostic acumen, and your patients will be the benefactors.

I'm Dr David Johnson. Thanks again for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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