ALA ABDEL JALIL, HARLEEN CHELA^, TASNIM ALAWAWDEH, FATIMA ABDELJALEEL, DONALD CASTELL 

¹Gastroenterology & Hepatology, Cleveland Clinic Foundation

²Gastroenterology & Hepatology, University of Missouri-Columbia

³School of Health Professions, University of Missouri-Columbia

⁴Internal Medicine, Al-Najah University

⁵Gastroenterology & Hepatology, Medical University of South Carolina 

Corresponding Author: Ala Abdel Jalil, MD FACP, Gastroenterology & Hepatology, Cleveland Clinic Foundation, Cleveland, OH 9500 Euclid Ave, Cleveland OH 44195, Email: abdela2@ccf.org 

Citation: Ala AJ, Harleen C, Tasnim A, Fatima A, Donald C, (2021) D Rumination Syndrome: The Forgotten Offender. Int J Gastroenterol Hepatol Endosc, 1(1);1-3. 

Copyright: © 2021, Ala AJ, Harleen C, Tasnim A, Fatima A, Donald C. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. 

ABSTRACT

Rumination syndrome is a condition that is underdiagnosed and not well understood. It's a repetitive and effortless habit but becomes a subconscious process that affects children and adults that are developmentally challenged as well as healthy patients of all ages. It carries social stigmata and impacts one's health. We describe a case of a middle-aged woman suffering from this for majority of her life and once successfully diagnosed, she underwent biofeedback therapy and diaphragmatic breathing technique with remarkable improvement in her quality of life. 

KEYWORDS:

Motility, Esophagus, Manometry, Rumination

CASE REPORT

A 68-year-old female with past medical history significant for Gastroesophageal Reflux Disease (GERD) and diabetes mellitus, who presented to the esophageal motility clinic with chief complaint of chronic regurgitation for more than 48 years, of food immediately after she eats, causing her a lot of social distress. She would have to re-chew the regurgitated food and this could last for up to 2 hours. In addition, she was complaining of postprandial heartburn and cough, but she denied dysphagia, chest pain or weight loss. As a result, her social and functional status was significantly impaired as she worked as a tour guide. She had an extensive evaluation in the past with unremarkable upper endoscopy, barium esophagram, gastric emptying study and a normal high-resolution esophageal manometry. Examination was unremarkable except for moderate obesity and severe dental caries. Esophageal manometry revealed an unremarkable study with normal contraction amplitude seen for liquid and viscous swallows, complete bolus transit and normal LES profile. 24-hour pH-impedance reflux monitoring testing while on acid suppression revealed poor gastric acid control and a slightly abnormal upright acid exposure (1.6%) suggestive of retrograde movement of the gastric contents. However, it did reveal a normal recumbent esophageal acid exposure. A total of 94 reflux episodes were seen (50 non-acid, 44 acid related) during the study. A symptom index (SI) showed positive association for cough (SI = 21/23) and a negative association for indigestion (SI = 0/2). Baclofen 10 mg TID was tried for 1 month, however there was only a minimal response. The patient was asked to bring a meal that provokes her regurgitation symptoms to the laboratory. The high-resolution manometry-impedance catheter was advanced to 5-cm below the lower esophageal sphincter to have it situated within the gastric cardia to measure intra-gastric pressure. Over the 1-hour study, total of 39 episodes of regurgitation were observed (Figure 1). The episodes were preceded by an increase in intra-gastric pressure (>30 mmHg), and followed immediately by a normal swallow to clear up the regurgitated food. These events were typical for rumination syndrome, and the patient was complaining of cough shortly after the rumination events. The patient underwent Biofeedback therapy where she was shown the occurrence of rumination episodes and was explained the mechanism behind it, including the involuntary increase in gastric pressure followed by opening of the lower esophageal sphincter and increase in the intra-esophageal pressure to the same extent as the stomach (common-cavity phenomenon). Diaphragmatic breathing (DB) technique was then used as adjunctive modality for treatment. Initially, patient was instructed to perform DB for 3 different 5-minutes segments when encountering the rumination symptoms while eating and also at bedtime. Within few months she had impressive improvement in quality of social life (70-80% as per patient) and encountered significant relief of symptoms starting 1 month of DB therapy. A Likert scale was used to quantify patient’s symptoms improvement, where she had considerable improvement in regurgitation, heartburn, belching, acidic taste in the mouth and bloating sensation especially with the combined use of biofeedback and diaphragmatic breathing technique (Figure 2). Repeat manometry after ingestion of a meal, 5-months later, showed only 9 episodes of rumination (4.3 folds decrease in rumination events). 14 cough symptoms were reported during the repeat manometry-impedance testing, but none was associated with rumination episodes.

ACKNOWLEDGEMENTS

None

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