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Rumination

by Norton J. Greenberger, MD

Rumination is the (usually involuntary) regurgitation of small amounts of food from the stomach (most often 15 to 30 min after eating) that are rechewed and, in most cases, again swallowed. Patients do not complain of nausea or abdominal pain.

Rumination is commonly observed in infants. The incidence in adults is unknown, because it is rarely reported by patients themselves.

Etiology

Patients with achalasia or a Zenker diverticulum may regurgitate undigested food without nausea. In the majority of patients who do not have these obstructive esophageal conditions, the pathophysiology is poorly understood. The reverse peristalsis in ruminants has not been reported in humans. The disorder is probably a learned, maladaptive habit and may be part of an eating disorder. The person learns to open the lower esophageal sphincter and propel gastric contents into the esophagus and throat by increasing gastric pressure via rhythmic contraction and relaxation of the diaphragm.

Symptoms and Signs

Nausea, pain, and dysphagia do not occur. During periods of stress, the patient may be less careful about concealing rumination. Seeing the act for the first time, others may refer the patient to a physician. Rarely, patients regurgitate and expel enough food to lose weight.

Diagnosis

  • Clinical evaluation

  • Sometimes endoscopy, esophageal motility studies, or both

Rumination is usually diagnosed through observation. A psychosocial history may disclose underlying emotional stress. Endoscopy or an upper GI series is necessary to exclude disorders causing mechanical obstruction or a Zenker diverticulum. Esophageal manometry and tests to assess gastric emptying and antral-duodenal motility may be used to identify a motility disturbance.

Treatment

  • Behavioral techniques

Treatment is supportive. Drug therapy generally does not help. Motivated patients may respond to behavioral techniques (eg, relaxation, biofeedback, training in diaphragmatic breathing [using the diaphragm instead of chest muscles to breathe]). Psychiatric consultation may be helpful.

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