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Rumination disorder—also called rumination syndrome—is an uncommon condition once thought to only occur in children.
It was largely unrecognized in adults until recently because the symptoms are generally mild and can be confused with other conditions (Talley, 2011). Researchers are now learning more about this uncommon disorder, its causes, and ways to treat it.
The term “rumination” can also refer to dwelling on recurring thoughts, but we’ll be addressing the gastrointestinal rumination disorder in this article.
What is rumination disorder?
Rumination means the bringing up of undigested food from the stomach back up into the mouth. It can be mistaken for vomiting, but it is a different condition. In vomiting, stomach contents are forcefully expelled. In contrast, regurgitation is an effortless reflex response where food and fluids come back up into the mouth, and you can choose to swallow again or spit them out (Talley, 2011).
While rumination is a normal part of digestion in some animals, such as cows, it’s not considered normal in humans. It can cause some health problems, but this syndrome can also occur in otherwise healthy people (Talley, 2011).
Rumination disorder is a chronic condition. An affected person will usually experience rumination for one to two hours after most meals (Talley, 2011).
What are the symptoms of rumination disorder?
The most common symptoms of rumination include (Papadopoulos, 2007):
- Effortless, repetitive regurgitation of gastric contents
- Contents that contain partially recognizable food material, usually of pleasant taste
- Regurgitation that starts shortly after a meal and continues for one to two hours
- Weight loss may occur, especially in adolescents
- Sometimes there is a sensation of belching that precedes the arrival of the food in the mouth
- Neither retching nor nausea is experienced while this is happening
- The person has the choice of re-chewing and swallowing or spitting out the regurgitation
Many individuals with rumination also present with other less specific symptoms such as nausea, heartburn, abdominal discomfort, diarrhea, and constipation. This can lead to many of them being misdiagnosed (Papadopoulos, 2007).
Rumination disorder can also occur with other eating disorders, such as anorexia nervosa (Balasundaram, 2021).
The key to diagnosing rumination is giving your provider a thorough history of your symptoms. Rumination disorder is frequently misdiagnosed as recurrent vomiting, partial paralysis of the stomach (called gastroparesis), an eating disorder, or gastroesophageal reflux disease (GERD) (Talley, 2011).
What causes rumination syndrome?
Researchers don’t yet know what causes rumination disorder. Most early studies suggested that this is an involuntary learned behavior. However, some emerging evidence suggests that lower esophageal sphincter changes may also be involved (Papadopoulos, 2007).
Some small studies have suggested that stress could be a factor for developing rumination. One study found that rumination appeared to start after an acute illness in eight out of 12 participants (Papadopoulos, 2007).
Another small study noted that nine out of 16 participants had a history of surgery and that 67% of them reported that their symptoms began after surgery. There did not seem to be a connection to the type of surgery, but it suggested that a stressful situation was present (Papadopoulos, 2007).
How do you diagnose rumination disorder?
Rumination syndrome is recognized as both a gastrointestinal disorder and as a feeding and eating disorder, according to two separate associations (Murray, 2019).
Functional gastrointestinal disorder
The Rome Foundation’s Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction, 4th edition (ROME-IV) identifies rumination disorder as a functional gastroduodenal disorder, based on the following criteria (Tack, 2011):
- Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or re-chewing and swallowing
- Regurgitation is not preceded by retching
- Regurgitation events usually not preceded by nausea
- Stops when the regurgitated material becomes acidic
- Regurgitated material contains recognizable food with a pleasant taste
Feeding and eating disorder
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) considers rumination disorder to be a feeding and eating disorder, based on the following criteria (National Eating Disorders Association, 2018):
- Repeated regurgitation of food for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
- The repeated regurgitation is not due to a medical condition (e.g., gastrointestinal condition).
- The person doesn’t instead have anorexia nervosa, bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorder.
- If occurring in the presence of another mental disorder (e.g., intellectual developmental disorder), it is severe enough to warrant independent clinical attention.
If you find yourself experiencing any of the symptoms listed above, you should contact your healthcare provider for a diagnosis and to help you alleviate your symptoms.
Can rumination syndrome cause health problems?
Rumination does not usually cause any severe, lasting effects. Some consequences of untreated rumination can occur, but they typically resolve when the rumination is treated. These include (Talley, 2011; Balasundaram, 2021):
- Irritation to the esophagus
- Weight loss
- Dental problems due to acidic stomach contents
The major consequence of rumination disorder is the distress it may cause the person experiencing it.
Individuals with rumination disorder may start to avoid foods, situations, or sensations associated with regurgitation. Others may avoid eating when around other people for fear of regurgitating in public or experiencing bad breath due to ruminating (Murray, 2019).
How do you treat rumination disorder?
Several different treatment strategies have been proposed for rumination disorder. These include biofeedback-guided diaphragmatic breathing, general relaxation, behavioral therapy, aversion training, and distraction technique (Balasundaram, 2021).
Some types of medication and surgery as a last resort have also been studied. Overall, because rumination disorder is so rare, studies have been small in size and number. More research is needed to determine which treatment is best (Murray, 2019).
The intervention for rumination syndrome with the most research behind it is diaphragmatic breathing. Diaphragmatic breathing operates as a way to counteract the habitual abdominal wall contraction usually seen in rumination by instead learning to relax the abdominal wall (Murray, 2019).
If you have difficulty learning diaphragmatic breathing, you might benefit from adding biofeedback guidance. This allows you to visualize the activity in the muscles and use it to help decrease the muscle contractions in the stomach area while increasing diaphragm activity (Murray, 2019).
An alternative treatment for some children with rumination is chewing gum, believe it or not. Some case studies have reported that chewing gum after meals led to a decrease in the number of rumination events in young children and adolescents (Tack, 2011).
There are no medications that are Food and Drug Administration (FDA) approved for treating rumination syndrome. Many medications have been studied, including baclofen, tricyclic antidepressants, H2 blockers, proton pump inhibitors (PPIs), prokinetics, and antiemetics. The only one supported as effective by a randomized controlled trial is baclofen, which fights muscle spasm. More research is still needed, though, to determine if it is more effective than other interventions (Murray, 2019).
In a small group of people that did not respond to any other treatments, a specific kind of surgery was found to be effective. This surgery is called Nissen fundoplication, a procedure usually used for persistent acid reflux. Although this surgery shows potentially good results, it’s typically only tried as a last resort due to the potential for side effects, such as retching, gas-bloat syndrome, or gastroparesis (Tack, 2011).
If you or a loved one are having trouble with rumination or other eating disorder symptoms, contact your healthcare provider. They can help you to confirm the diagnosis and access effective treatments to help you feel better.
- Balasundaram P, Santhanam P. (2021). Eating disorders. [Updated 2021 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK567717/
- Murray, H. B., Juarascio, A. S., Di Lorenzo, C., Drossman, D. A., & Thomas, J. J. (2019). Diagnosis and treatment of rumination syndrome: A critical review. The American Journal of Gastroenterology, 114(4), 562–578. doi:10.14309/ajg.0000000000000060. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492032/
- National Eating Disorders Association. (2018). Rumination disorder. Retrieved from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/rumination-disorder
- Papadopoulos, V., & Mimidis, K. (2007). The rumination syndrome in adults: a review of the pathophysiology, diagnosis and treatment. Journal of Postgraduate Medicine, 53(3), 203–206. doi: 10.4103/0022-3859.33868. Retrieved from https://pubmed.ncbi.nlm.nih.gov/17699999/
- Tack, J., Blondeau, K., Boecxstaens, V., & Rommel, N. (2011). Review article: the pathophysiology, differential diagnosis and management of rumination syndrome. Alimentary Pharmacology & Therapeutics, 33(7), 782–788. doi: 10.1111/j.1365-2036.2011.04584.x. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21303399/
- Talley N. J. (2011). Rumination syndrome. Gastroenterology & Hepatology, 7(2), 117–118. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061016/
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.