Rumination Syndrome

Background:

The word rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination is the voluntary or involuntary regurgitation and rechewing of partially digested food that is either reswallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.

In rumination, the regurgitant does not taste sour or bitter. The behavior must exist for at least 1 month, with evidence of normal functioning prior to onset. Rumination occurs within a few minutes postprandial and may last 1-2 hours. Though frequency may vary, rumination typically occurs daily and may persist for many months or years.

Pathophysiology:

While the pathophysiology of rumination remains unclear, a proposed mechanism suggests that gastric distention with food is followed by abdominal compression and relaxation of the lower esophageal sphincter; these actions allow stomach contents to be regurgitated and rechewed and then swallowed or expelled.

Several mechanisms for the relaxation of the lower esophageal sphincter have been offered, including (1) learned voluntary relaxation, (2) simultaneous relaxation with increased intra-abdominal pressure, and (3) an adaptation of the belch reflex (eg, swallowing air produces gastric distention that activates a vagal reflex to relax the lower esophageal sphincter transiently during belching). Rumination may cause the following:

• Halitosis
• Malnutrition
• Weight loss
• Growth failure
• Electrolyte imbalance
• Dehydration
• Gastric disorders
• Upper respiratory distress
• Dental problems
• Aspiration
• Choking
• Pneumonia
• Death

Frequency:

• In the US: No systematic studies have reported the prevalence of rumination; most of the information about this disorder is derived from small case series or single case reports. Rumination disorder has been reported in children and adults with mental retardation as well as in infants, children, and adults of normal intelligence. Among those with otherwise normal intelligence and development, rumination is most common in infants. The prevalence in adults of normal intellectual functioning is unknown because of the secretive nature of the condition and because physicians lack awareness of rumination among this population.
  Rumination is more common in individuals with severe and profound mental retardation than in those with mild or moderate mental retardation. Prevalence rates of 6-10% have been reported among the institutionalized population of individuals with mental retardation.
• Internationally: Rumination has been reported and researched in other countries (eg, Italy, Netherlands); however, frequency of occurrences in other countries is unclear.

Mortality/Morbidity:

Rumination is estimated to be the primary cause of death in 5-10% of individuals who ruminate. Mortality rates of 12-50% have been reported for institutionalized infants and older individuals.

Sex:

Rumination occurs in both males and females. A male predominance has been reported by 1 case series, although this finding may not be definitive.

Age:

Rumination onset in otherwise normally developing infants typically occurs during the first year of life; onset usually manifests at age 3-6 months. Rumination often remits spontaneously.

• For individuals with severe and profound mental retardation, onset of rumination may occur at any age; average age of onset is age 6 years.
• Rumination among adolescents and adults of normal intelligence is gaining increased recognition.

History:

• Symptoms may include the following:
  • Weight loss
  • Halitosis
  • Indigestion
  • Chronically raw and chapped lips
• Vomitus may be noted on the individual's chin, neck, and upper garments.
• Regurgitation typically begins within minutes of a meal and may last for several hours.
• Regurgitation occurs almost every day following most meals. Regurgitation generally is described as effortless and rarely is associated with forceful abdominal contractions or retching.

Physical:

• Regurgitation
• Vomiting not visible to others
• Unexplained weight loss, growth failure
• Symptoms of malnutrition
• Antecedent behaviors
  • Postural changes
  • Putting hands into mouth
  • Gentle gagging motion of the neck region
• May appear to derive satisfaction and sensory pleasure from mouthing the vomit rather than considering vomitus in the mouth disgusting
• Tooth decay and erosion
• Aspiration that may cause recurrent bronchitis or pneumonia, reflex laryngospasm, bronchospasm, and/or asthma
• Premalignant changes of the esophageal epithelium (ie, Barrett epithelium) that may occur with chronic rumination

Causes:

Although the etiology of rumination is unknown, multiple theories have been advanced to explain the disorder. These theories range from psychosocial factors to organic origins. Cultural, socioeconomic, organic, and psychodynamic factors have been implicated. The following causes have been postulated over the years:

• Adverse psychosocial environment
  • The most commonly cited environmental factor is an abnormal mother-infant relationship in which the infant seeks internal gratification in an understimulating environment or as a means to escape an overstimulating environment.
  • Onset and maintenance of rumination also has been associated with boredom, lack of occupation, chronic familial disharmony, and maternal psychopathology.
• Learning-based theories
  • Learning-based theories propose that rumination behaviors increase following positive reinforcement, such as pleasurable sensations produced by the rumination (eg, self-stimulation) or increased attention from others after rumination.
  • Rumination also may be maintained by negative reinforcement when an undesirable event (eg, anxiety) is removed.
• Organic factors: The role of medical/physical factors in rumination is unclear. Although an association between gastroesophageal reflux (GER) and the onset of rumination may exist, some researchers have proposed that a variety of esophageal or gastric disorders may cause rumination.
• Psychiatric disorders: Rumination in adults of average intelligence has been associated with psychiatric disorders (eg, depression, anxiety).
• Heredity: Although occurrences in families have been reported, no genetic association has been established.
• Other proposed physical causes include the following:
  • Dilatation of the lower end of the esophagus or of the stomach
  • Overaction of the sphincter muscles in the upper portions of the alimentary canal
  • Cardiospasm
  • Pylorospasm
  • Gastric hyperacidity
  • Achlorhydria
  • Movements of the tongue
  • Insufficient mastication
  • Pathologic conditioned reflex
  • Aerophagy (ie, air swallowing)
  • Finger or hand sucking