Belching Disorders and Rumination Syndrome: A Literature Review.

BACKGROUND: Belching disorders and rumination syndrome (RS) are disorders of gut-brain interaction (DGBIs) in Rome IV. Belching disorders are composed of excessive gastric belching (GB) and supragastric belching (SGB). Excessive GB is related to physiological phenomenon whereas excessive SGB and RS are behavioral disorders. SUMMARY: A recent large internet survey found that prevalence of belching disorders and RS were 1% and 2.8%, respectively. It has been recognized that not a few patients with two behavioral disorders, excessive SGB and RS, could be misdiagnosed as proton pump inhibitors (PPI)-refractory gastroesophageal reflux disease (GERD). In patients with reflux symptoms, distinguishing these conditions is essential because they need psychological treatment (i.e., cognitive behavioral therapy (CBT) rather than acid suppressants. Clinicians should take a medical history meticulously first to identify possible excessive SGB and/or RS. High-resolution impedance manometry and/or 24-h impedance-pH monitoring can offer an objective diagnosis of the disorders. Several therapeutic options are available for excessive SGB and RS. The first-line therapy should be CBT using diaphragmatic breathing that can stop the behaviors involving complex muscle contraction (e.g., abdominal straining) to generate SGB or rumination. Overlap with eating disorders and/or other DGBIs such as functional dyspepsia can make management of the behavioral disorders challenging since such coexisting conditions often require additional treatments. KEY MESSAGES: Excessive SGB and RS are not unusual conditions. It is important to raise awareness of the behavioral disorders for appropriate management.

Rumination syndrome: Critical review. / Síndrome de rumiación, revisión crítica.

Rumination syndrome is a functional disorder characterized by the involuntary regurgitation of recently swallowed food from the stomach into the mouth, from where it can be re-chewed or expelled. Clinically, it is characterized by repeated episodes of effortless food regurgitation. The most usual complaint is frequent vomiting. The physical mechanism that generates regurgitation events is dependent on an involuntary process that alters abdominal and thoracic pressures accompanied by a permissive oesophageal-gastric junction. The diagnosis of rumination syndrome is clinical, highlighting the importance of performing an exhaustive anamnesis on the characteristics of the symptoms. Complementary tests are used to corroborate the diagnosis or rule out organic pathology. Treatment is focused on behavioural therapies as the first line, reserving pharmacological and surgical therapies for refractory cases.

Chronic vomiting in children: A prospective study reveals rumination syndrome is an important etiology that is underdiagnosed and untreated.

BACKGROUND: The diagnosis of rumination syndrome is frequently overlooked, and under-recognized; children are subjected to unnecessary testing and inappropriate treatment for a condition which can be diagnosed clinically and managed easily. In the first ever systematic exploration of this condition from India, we present a prospective study on children with chronic vomiting in which rumination emerged as the predominant cause. METHODS: This was a prospective study in which all consecutive children (5-18 years) presenting with chronic or recurrent vomiting of at least 2-month duration were enrolled. Clinical history was assessed by a physician-administered questionnaire. All subjects underwent standard testing followed by additional investigations as required. The ROME III criteria were used. RESULTS: Fifty children (28 boys, age 12.2 + 3 years) were enrolled. Diagnosis was rumination syndrome 30, cyclical vomiting 8, functional vomiting 6, intestinal tuberculosis 4, intestinal malrotation 1, and superior mesenteric artery syndrome 1. Children with rumination syndrome had a relapsing and remitting (12, 40%) or a chronically symptomatic course (18, 60%). These children received incorrect diagnoses (26, 87%) or no diagnosis (3, 10%) and extensive investigation before referral. Before referral, children with rumination syndrome were treated with a median of four drugs (range 1 to 9); two underwent surgery (appendectomy) for their symptoms while one child was subjected to electroconvulsive therapy. Overall, resolution after treatment was seen in 26 (87%) with a relapse in 8 (27%) children. CONCLUSION: The diagnosis of rumination syndrome is delayed and these children are often inappropriately treated. Therapy in the form of diaphragmatic breathing has a good success rate.

Can youth at high risk of illness progression be identified by measures of rumination and sleep-wake disturbance.

AIM: Clinical staging models offer a useful framework for understanding illness trajectories, where individuals are located on a continuum of illness progression from stage 0 (at-risk but asymptomatic) to stage 4 (end-stage disease). Importantly, clinical staging allows investigation of risk factors for illness progression with the potential to target trans-diagnostic mechanisms at an early stage, especially in help-seeking youth who often present with sub-threshold syndromes. While depressive symptoms, rumination and sleep-wake disturbances may worsen syndrome outcomes, the role of these related phenomena has yet to be examined as risk factors for trans-diagnostic illness progression in at-risk youth. METHODS: This study is a prospective follow-up of 248 individuals aged 12 to 25 years presenting to headspace services with sub-threshold syndromes (stage 1) classified under the clinical staging model to determine transition to threshold syndromes (stage 2). Factor analysis of depression, rumination and sleep-wake patterns was used to identify key dimensions and any associations between factors and transition to stage 2 at follow-up. RESULTS: At 1 year, 9% of cases met criteria for stage 2 (n = 22). One of three identified factors, namely the factor reflecting the commonalities shared between rumination and sleep-wake disturbance, significantly differentiated cases that transitioned to stage 2 vs those that did not demonstrate transition. Items loading onto this factor, labelled Anergia, included depression severity and aspects of rumination and sleep-wake disturbance that were characterized as introceptive. CONCLUSIONS: Common dimensions between rumination and sleep-wake disturbance present a detectable trans-diagnostic marker of illness progression in youth, and may represent a target for early intervention.