GASTROINTESTINAL MOTILITY AND FUNCTIONAL BOWEL DISORDERS, SERIES #26
Rumination Syndrome in the Setting of a Nissen Fundoplication: Its Atypical Clinical and Diagnostic Features
by Zorisadday Gonzalez, Richard W. McCallum
Rumination syndrome is a behavioral disorder characterized by the subconscious regurgitation of recently ingested food into the mouth.Although a widely unrecognized disorder, rumination syndrome should be an important consideration in the differential diagnosis of postprandial regurgitation and vomiting resistant to treatment.
Zorisadday Gonzalez, MD, Adult Hospitalist, Presbyterian Healthcare Services, Presbyterian Healthcare Services Richard W. McCallum, MD, FACP, FRACP (AUST), FACG, AGAF, Professor of Medicine and Founding Chair, Division of Gastroenterology, Director, Center for Neurogastroenterology and GI Motility, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX
INTRODUCTION
Rumination syndrome is a functional gastrointestinal disorder characterized by effortless regurgitation of recently ingested food back into the mouth within 5-20 minutes of ingestion, followed by re-swallowing or spitting of the food bolus.1 We report a case of a 20-year old male with history of a Nissen fundoplication as an infant who presented with a three month history of severe postprandial abdominal pain and nausea resulting in significant weight loss. Extensive work-up was unrevealing including numerous imaging, diagnostic, and laboratory studies. A thorough physical examination and history confirmed a diagnosis of rumination syndrome, an atypical presentation given his prior fundoplication history. Although a widely unrecognized disorder, rumination syndrome should be an important consideration in the differential diagnosis of postprandial regurgitation and vomiting resistant to treatment.
Presentation
A 20-year old male presented to the hospital with three months of severe postprandial abdominal pain, early satiety, and intractable nausea resulting in a 20 pound weight loss. The onset of his symptoms were within 5-20 minutes of food ingestion. He denied fevers, diarrhea, dysphagia, melena, hematochezia or change in stool caliber. He denied bulimic behavior and did not desire losing weight. His past medical history was significant for severe reflux as an infant resulting in failure to thrive, and underwent a Nissen fundoplication at that time. As a result of his fundoplication, he was unable to regurgitate food or vomit. His family history was negative for gastrointestinal (GI) malignancy. He had recurrent emergency department (ED) visits with these symptoms and had visited numerous physicians without definite diagnosis. Proton pump inhibitors, opioids, and anti-emetics were ineffective in alleviating his symptoms. He had recently experienced several stressful situations at home. Extensive laboratory testing, upper endoscopy, upper gastrointestinal and small bowel series, computed tomography (CT) angiogram of the abdomen and pelvis, gastric emptying study, and CT of the head failed to explain his symptoms. He refused nasogastric tube feeding. Total parenteral nutritional therapy was initiated to support both hydration and nutrition. He was transferred to the University Medical Center (UMC) at Texas Tech University Health Sciences Center after two weeks without clinical improvement. Physical exam findings were remarkable for postprandial contraction of the rectus abdominis muscle. Following meal intake, the patient was noted to burp and belch as he attempted to ruminate, but he was unsuccessful because of his fundoplication. A jejunostomy tube was ultimately placed in approximation of his fundoplication. Biopsy of antral smooth cells obtained during jejunostomy placement revealed normal number of Cajal cells implying normal gastric emptying. The patient was educated on behavioral therapy and discharged home. At two month follow up, he endorsed marked improvement of his gastrointestinal symptoms with diaphragmatic breathing skills, and his jejunostomy tube was removed. At five months follow up, he reported complete resolution of symptoms and was tolerating food well. He had gained weight and had returned to work and school.
Discussion
Rumination syndrome is the subconscious and effortless regurgitation of recently ingested food from the stomach back into the mouth with subsequent spitting out of the regurgitant or remastication with re-swallowing.1 Episodes occur within 5-20 minutes after ingestion and symptoms can last up to one to two hours.7 These patients often describe their symptoms as vomiting and are therefore incorrectly diagnosed with GERD or another upper gastrointestinal disorder such as gastroparesis or dyspepsia. Furthermore, the presence of additional GI symptoms including abdominal discomfort, nausea, or heartburn does not exclude the diagnosis of rumination syndrome which can further confound the differential diagnosis.5 Many of these patients undergo extensive, invasive, and costly testing before a diagnosis is reached. Even though rumination syndrome can imitate GERD or gastroparesis, a careful history can help differentiate the diagnosis. In rumination syndrome, symptoms always occur in the early postprandial period as opposed to GERD or gastroparesis where symptoms occur late postprandially. Additionally, anti-reflux medications do not improve symptoms of rumination syndrome. In gastroparesis, nausea and/or retching usually precede vomiting which is not always the case in rumination syndrome. Another gastrointestinal disorder which can present with effortless postprandial regurgitation is achalasia, although these patients present with dysphagia which is not seen in rumination syndrome. The epidemiology of rumination syndrome is limited because many providers are not aware of this diagnosis and is therefore rarely recognized. Although early observations were mostly described in infants and developmentally disabled patients, it is now recognized in healthy patients of normal intellect and of all ages.5 Psychological disturbances have been postulated to play a role around symptom onset of rumination, and therefore a psychiatric evaluation should be considered in patients with a suspected eating disorder.4,7
The pathogenesis of rumination syndrome is not well understood. The hallmark feature is a coordinated combination of lower esophageal relaxation and increased intra-abdominal pressure coupled with negative intrathoracic pressure.6,7 This subsequently leads to the reversal of the esophagogastric pressure gradient allowing food to come back up the esophagus and into the mouth. Diagnostic findings on manometry include reflux events associated with an increase in gastric pressures > 30 mm Hg caused by voluntary yet unintentional contraction of the abdominal wall muscles. Although postprandial high resolution impedance pH manometry can support a diagnosis, this test is not required to make diagnosis.5 A thorough history and physical examination are key to diagnosing rumination syndrome. Brisk contraction of the abdominis rectus muscle prior to regurgitation can be appreciated on exam. Rumination syndrome has been recognized as its own unique category under functional gastrointestinal disorders and should be diagnosed based on the Rome IV criteria outlined in Table 1.1
Treatment for rumination syndrome consists of reassurance and behavioral therapies including diaphragmatic breathing exercises during and after meals to target abdominal wall contraction and prevent the urge to regurgitate.2,3 This technique allows for habit reversal, and has been proven to be effective in most patients.7 There are no known effective medications in the treatment of rumination syndrome.
Our case was unique in that our patient had a Nissen fundoplication procedure as an infant and was therefore unable to regurgitate or vomit any food. Attempts to regurgitate food only led to severe epigastric pain and nausea which led to fear of eating resulting in significant weight loss. To our knowledge, this is the first case of rumination syndrome in a patient with a prior fundoplication. Interestingly, in a case series of five patients with rumination syndrome whose symptoms had been resistant to medical and psychiatric interventions, Oelschlager et al. reported complete elimination of symptoms in all five patients after performing a Nissen fundoplication.2 However, this was a very small sample size and fundoplication is not a recommended treatment for rumination syndrome.
CONCLUSION
Rumination syndrome is a behavioral disorder characterized by the subconscious regurgitation of recently ingested food into the mouth. It is widely unrecognized due to the limited awareness of this condition. Patients with prior fundoplication anatomy may further mask this diagnosis due to their inability to bring up undigested food. A thorough history and physical exam are key in diagnosing rumination syndrome with brisk contractions of the rectus abdominis muscles on exam prior to regurgitation. The mainstay of treatment includes diaphragmatic breathing with behavioral therapy.
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