Rumination disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mark Warren, M.D., M.P.H.; Fellow, Academy of Eating Disorders [2]; Kiran Singh, M.D. [3]

Synonyms and keywords: Childhood rumination disorder; merycism, rumination syndrome

Overview

Rumination is an eating disorder characterized by having the contents of the stomach drawn back up into the mouth, chewed for a second time, and swallowed again. In some animals, known as ruminants, this is a natural and healthy part of digestion and is not considered an eating disorder. However, in other species (including humans), such behavior is atypical and potentially dangerous as the esophagus can be damaged by frequent exposure to stomach acids. Rumination is also associated with eating disorders such as anorexia nervosa, and can be the result of one's apprehension and nervousness after eating a normal meal. For those with purging behaviors, rumination can take place when the option of getting rid of a meal via throwing up is not available (thus, one might feel worried and visibly upset). Rumination has also been reported in developmentally normal children and adults who experience regurgitation of previously swallowed food, without disgust, nausea or an acidic taste. The food is either chewed and reswallowed or spat out. Remission of these episodes is seen in some cases while others persist. Many claim this as a pleasurable habit.

Differential Diagnosis

Rumination syndrome should be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]

Disorder Clinical features Laboratory findings
Chronic nausea Vomiting Diarrhea Retching Lethargy Social withdrawal Photophobia Epigastric pain/burning Lanugo hair Hypogonadism Russel's sign Body mass index (normal range: 18.5 to 24.9) Complete blood count (CBC) Electrolyte imabalance Lipase and amylase levels Gastric scintigraphy Ambulatory esophageal pH and impedance testing
Gastroparesis ✔ (within 1 hour of eating) - - - - - -
  • Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)
  • Periodic measurement of radiolabeled solid meal:  
    • Grade 1 (mild), 11%-20% retention at 4 h
    • Grade 2 (moderate), 21%-35% retention at 4 h
    • Grade 3 (severe), 36%-50% retention at 4 h
    • Grade 4 (very severe), > 50% retention at 4 h
  • Impedance testing (antroduodenal manometery): Loss of normal fasting migratory motor complexes (MMCs) and reduced postprandial antral contractions and, in some cases pylorospasm
Anorexia nervosa - - - -
  • Increased
Bulimia nervosa - - - Normal
  • Increased
Rumination syndrome ✔ (Regurgitation more common- within minutes of meal intake) - - - -
  • Normal
  • Normal
  • Esophageal pH: Fall in esophageal pH immediately after reguritation (occurs while patient is awake and erect; this is in contrast to GERD, where reflux occurs diurnally and supine position)
Functional dyspepsia - - - - - - - Normal
  • Normal
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome - - - - - - -
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis - - - - - Normal
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction ✔ (within 1 hour of eating) - - - - - - - -
  • Esophageal pH: Increased
  • Esophageal manometery:   High manoraetric score

Other differntials

Other differentials of rumination disorder include the following:

Epidemiology and Demographics

Prevalence

Risk Factors

  • Lack of stimulation
  • Neglect
  • Problems in the parent-child relationship
  • Stressful life situations[33]

Natural History, Complications and Prognosis

Rumination disorder typically occurs within the first 3-12 months of age and can lead to the child becoming malnourished.

While rumination disorder may begin in childhood or infancy, adults may also have this chronic disorder, for which there is presently no known cure nor cause. While those diagnosed with this condition in childhood may 'grow out of it', it is by no means a medical fact that they are bound to do so by adolescence or adulthood.

Remission of these episodes is seen in some cases while others persist.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Rumination Disorder[33]

  • A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

AND

AND

  • C. The eating disturbance does not occur exclusively during the course of anorexia nervosa,bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.

AND

D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability, Intellectual developmental disorder or another neuro developmental disorder),they are sufficiently severe to warrant additional clinical attention.

Specify if:

  • In remission: After full criteria for rumination disorder were previously met, the criteria have not been met for a sustained period of time.

References

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