:cat2: My husband has a very rare eating disorder called rumination syndrome. I can't begin to tell everyone how it has affected our relationship other than to say that it has totally killed the intimacy. He has had it all his life but kept it from me for almost 2 years until after we were married. He is refusing to get treatment however much it is affecting our marriage and how it must be affecting his health. I recently separated from him because I am tired of dealing with this issue that never goes away. Is there anyone else out there either dealing with the same issue or has the disorder themselves? It could help me decide what to do regarding my marriage.
- Thread starter lswife
- Start date
For anyone unfamiliar with Rumination Syndrome, here is some background:
About Rumination Syndrome
A syndrome is a group of symptoms that are characteristic of a particular disorder. Rumination syndrome is characterized by effortless and repeated regurgitation of small amounts of food from the stomach. The food is then partially or completely rechewed, reswallowed, or expelled. People with rumination syndrome typically do not experience heartburn, abdominal pain or nausea when the regurgitation occurs. (See symptoms.)
Rumination syndrome is relatively common in infants and mentally handicapped persons, but also occurs in children, adolescents and adults with normal intelligence.
Individuals with rumination syndrome are often not accurately diagnosed, in part because many physicians are not familiar with this disorder and in part because patients are often reticient to describe their symptoms. Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) , and upper gastrointestinal motility disorders such as gastroparesis or chronic intestinal pseudo-obstruction.
Mayo Clinic doctors, in a review of adolescents and adults of normal intelligence treated for rumination syndrome, found that patients had seen an average of five physicians and had symptoms for two to three years before they were correctly diagnosed and treated. PubMed Reference
Without treatment, rumination syndrome can adversely affect a patient's quality of life and health, causing work or school absences, unhealthy weight loss, malnutrition, dental erosion, halitosis (bad breath), electrolyte abnormalities and significant functional disability.
Source: Mayo Clinic.com
Cheryl,
Why do you suppose your husband is resisting treatment? Could it be he is unaware that his behaviour is a defined medical disorder, and he is not the only one doing these things?
Denial and lack of awareness is a frequent result in conditions and disorders not commonly seen or diagnosed by the medical community.
What do you see as your options at this time?
About Rumination Syndrome
A syndrome is a group of symptoms that are characteristic of a particular disorder. Rumination syndrome is characterized by effortless and repeated regurgitation of small amounts of food from the stomach. The food is then partially or completely rechewed, reswallowed, or expelled. People with rumination syndrome typically do not experience heartburn, abdominal pain or nausea when the regurgitation occurs. (See symptoms.)
Rumination syndrome is relatively common in infants and mentally handicapped persons, but also occurs in children, adolescents and adults with normal intelligence.
Individuals with rumination syndrome are often not accurately diagnosed, in part because many physicians are not familiar with this disorder and in part because patients are often reticient to describe their symptoms. Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease (GERD) , and upper gastrointestinal motility disorders such as gastroparesis or chronic intestinal pseudo-obstruction.
Mayo Clinic doctors, in a review of adolescents and adults of normal intelligence treated for rumination syndrome, found that patients had seen an average of five physicians and had symptoms for two to three years before they were correctly diagnosed and treated. PubMed Reference
Without treatment, rumination syndrome can adversely affect a patient's quality of life and health, causing work or school absences, unhealthy weight loss, malnutrition, dental erosion, halitosis (bad breath), electrolyte abnormalities and significant functional disability.
Source: Mayo Clinic.com
Cheryl,
Why do you suppose your husband is resisting treatment? Could it be he is unaware that his behaviour is a defined medical disorder, and he is not the only one doing these things?
Denial and lack of awareness is a frequent result in conditions and disorders not commonly seen or diagnosed by the medical community.
What do you see as your options at this time?
Rumination Syndrome: Case Study
Rumination Syndrome: An Emerging Case Scenario
Navneet Attri MD; M Ravipati MD; Preeti Agrawal MD; Christine Healy; A Feller MD
South Med J. 2008;101(4):432-435.
Abstract
This article describes the case of a 19-year-old woman presenting with repetitive episodes of effortless vomiting, which started within 3 weeks of her naval boot camp training. She underwent a battery of costly investigations before the diagnosis of rumination syndrome could be made. One of the reasons for her delayed diagnosis is that many physicians are unaware of, or are reluctant to make the diagnosis of rumination syndrome. The purpose of this article is to make the general physician aware of the possibility of rumination syndrome in adolescents and adults of normal intelligence, even though it was initially considered only in infants and mentally retarded individuals. The key to diagnosis is a thorough patient history. Reassurance and behavioral therapy is the mainstay of treatment, with a reported success of >80%.
Introduction
Rumination syndrome is a clinical diagnosis based on presenting symptoms with the absence of structural disease. Individuals with rumination syndrome are often misdiagnosed or undergo extensive, costly, and invasive testing before diagnosis.[1] Rumination syndrome is characterized by regurgitation of recently ingested food into the pharynx; the food is then either ejected or rechewed and reswallowed. This syndrome occurs most often in infants and persons with mental retardation, but is still underdiagnosed in adults with normal intelligence.
Case Report
A 19-year-old white woman was referred by the Navy to North Chicago Veteran Affairs after 3 months of vomiting. She had been in boot camp for nearly 3 weeks when she started vomiting; she initially suffered two to three episodes a day, progressing to multiple episodes a day over the few days before her arrival at the hospital. The vomiting typically occurred 5 to 15 minutes after eating, was not forceful, and had no associated nausea or retching. The patient did not vomit during her sleep. The vomitus was described as nonbilious and nonbloody, and was usually tasteless but sometimes tasted sour. Her appetite was good; in fact, she was hungry all the time. She had initially lost 20 pounds when she started boot camp but gained about 5 pounds within the 2 weeks before her stay at the hospital. She had been seen by several physicians during this period, undergoing an esophagogastroduodenal endoscopy and a colonoscopy, both of which were essentially normal. Her hepatoiminodiacetic acid (HIDA) scan revealed gallbladder dyskinesia. She was scheduled for gallbladder surgery within a fortnight. She was a nonsmoker, a nonalcoholic, and she denied drug use. Her family history was unremarkable. Psychiatric history revealed a suicide attempt at age 14 by making cuts on her arms when her parents got divorced. Outpatient medications included ondansetron, metoclopramide, omeprazole, and promethazine, and she had been taking oral contraceptives for 2 years. She denied any food or drug allergies. A review of her symptoms was unremarkable except for constipation and irregular menstrual cycles for 2 months, and her physical examination was unremarkable. She appeared well nourished, with no signs of nutritional deficiency. Dentition was good, and her hands had no evidence of erosions.
The patient's labs were within normal limits, and her serum potassium was 3.8. A pregnancy test was negative. Computed tomography of her head and abdomen were normal. An x-ray of her abdomen, as well as upper gastrointestinal and small bowel barium follow-through, were all normal. In addition, her thyroid stimulating hormone level was normal, with a prealbumin of 26.1, an albumin of 3.8, an erythrocyte sedimentation rate of 11, and a C-reactive protein at <0.2. Her antinuclear antibody was positive, with a titer of 1:640, homogenous pattern. The subsequent workup for connective tissue antibodies was normal. An esophageal manometry study showed normal amplitude and pressures in the upper esophagus, the body and the lower esophagus. Gastric emptying studies were done in both solid and liquid phases at 0, 2, and 4 hours. The result of the gastric emptying liquid phase was 134.9 minutes (normal 8-16 min). The gastric emptying solid phase was 148.72 minutes, which is markedly prolonged (normal 45-60 min).
Finally, a diagnosis of rumination syndrome was made. The abnormal gastric emptying studies were attributed to food going back and forth in the stomach, or between the stomach and esophagus. She was taught diaphragmatic breathing and received positive reinforcement from the behavioral psychologist, with marked improvement in her symptoms.
Discussion
The first case reports of rumination syndrome are from the early 17th century. Many famous people in history have had this syndrome; the most notable was a physician, Edouard Brown-Sequard, who acquired the condition as a result of experiments he performed on himself. He would swallow sponges tied to a string to evaluate the acid response of the stomach to various foodstuffs. He learned to regurgitate the sponge to analyze its contents, and eventually developed habitual regurgitation with his meals.[2]
Rumination syndrome is encountered most commonly in infancy and in mentally handicapped children and adults, and in males more than females. Its incidence has been reported to be about 6 to 10% of mentally challenged patients in institutions.[3] The prevalence in adults of normal intelligence is unknown because many physicians are unaware of this condition. It may remain undiagnosed for many months or years, and the patients often undergo unnecessary, expensive, and invasive tests.[3] Of the cases that have come to light, female preponderance has been observed in adolescents; the average age at diagnosis is 15 ? 0.3 years.[1] A genetic association has not been established.[4]
The pathophysiology of rumination remains unclear. The physiologic mechanism points to the forward extension of the head to open the upper esophageal sphincter, and a contraction of the abdominal rectus abdominis muscle to force the gastric contents into the mouth.[5] It has been demonstrated that the lower esophageal sphincter relaxation occurs at a lower pressure of gastric distension in patients with rumination syndrome as compared with controls.[6] Rumination may be the consequence of a learned voluntary relaxation of the lower esophageal sphincter or diaphragmatic crura, allowing increased postprandial intragastric hydrostatic pressure and normal phasic and tonic contractions of the proximal stomach. This increase in pressure overcomes the resistance to regurgitation usually provided by the antireflux mechanisms at the esophagogastric junction.[7]
Rumination is believed to be a learned adaptation of the belch reflex.[3] The duration of the transient lower esophageal sphincter relaxations during gastric reflux or belching is much longer (by about 12 s) than that associated with deglutition, (about 2-4 s) which seems to be long enough to allow particulate food to be retropulsed from the stomach to the pharynx.[8] Also, during a belch or swallow, lowered pressure in the lower esophageal sphincter creates a common cavity between the stomach and the esophagus. It is also postulated that the gastric distension activates a vagal reflex to transiently relax the lower esophageal sphincter during belching.[8]
Psychiatric aspects probably also play a part in this syndrome.[9,10] In fact, 67% of the patients in a study[11] were found to have experienced a stressful situation, like the loss of a family member or a professional setback, before the onset of symptoms. Psychological disturbances, including depression, anxiety, obsessive-compulsive behavior, and other disorders are reported in up to one-third of affected individuals.[12] In children, rumination may represent a self-stimulating positive behavior resulting from a poor mother-infant relationship.[13] Alternatively, the behavior may be learned as a conditioned response, maintained by the reward of increased parental attention or the positive feedback associated with the taste of regurgitated food.[14] Whether these apply to intellectually intact adults is not clear.
An association between rumination and bulimia nervosa has been previously described; 20% of patients with bulimia were found to ruminate in one study.[3] Ruminators with bulimia tend to expel rather than reswallow food, like ruminators without bulimia, and may self-induce vomiting by digital stimulation of the hypopharynx. In patients with bulimia, rumination may be a learned behavior for controlling their weight.
Diagnosis
First, it should be noted that an accurate clinical history is the key to the correct diagnosis. The Rome III Consensus Criteria for Rumination Syndrome in Adolescents must all be met at least once per week for at least 2 months before diagnosis.[15] According to these criteria, the patient must experience:
Scintigraphic studies of gastric emptying may show delayed gastric emptying, probably as a result of regurgitation and reswallowing of food, which is then delivered intermittently or later to the distal stomach for digestion and mixing.[1]
Manometric recordings demonstrate the occurrence of synchronous pressure spikes, termed R waves, at all levels in the stomach and small intestine in about 40% of the patients with rumination, which correlates with a generalized increase in the intraabdominal pressure that occurs during a rumination event.[1] But the test may be normal in 55% of patients,[1] thus, abnormal results should be interpreted carefully in the setting of rumination.
When the patient is alert and awake, 24-hour esophageal pH monitoring may demonstrate acidic pH in the esophagus postprandially.[1] In gastroesophageal reflux disease, on the other hand, the episodes occur nocturnally and are aggravated by a supine position.[1]
Rumination is mostly confused with gastroparesis and gastroesophageal reflux disease.[4] This syndrome is different from gastroparesis, because regurgitation is effortless and occurs within 15 to 30 minutes after a meal. Even liquids can be regurgitated within minutes of intake.[11] On the other hand, patients with gastroparesis vomit later in the postprandial period, usually more than an hour after a meal, and the symptoms may not occur daily. The concomitant presence of nausea and heartburn may make the presentation look like gastroesophageal reflux disease, but as mentioned above, the symptoms of gastroesophageal reflux disease occur predominantly at night and/or when the patient is supine. Thus the presence of heartburn, nausea, abdominal pain and weight loss in certain subsets of patients does not rule out rumination syndrome.[4] Though the clinical presentation is obvious, 24-hour esophageal monitoring and gastric studies may be necessary in these patients.[11]
Treatment
Medications for rumination disease, including acid blocking agents, prokinetic medications, antiemetics, anticholinergics, anxiolytics, and antidepressants, are not well studied. Their role in improving symptoms in patients with rumination syndrome is unclear.[12] Stress and psychological aspects in rumination syndrome have to be addressed. Nissen fundoplication has been tried but has led to complications like retching, bloating, and gastroparesis.[16]
Nonaversive behavioral therapy is the cornerstone to treatment; it involves habit reversal by using several strategies, like strong encouragement not to vomit, biofeedback relaxation, and diaphragmatic breathing.[3,9] The patient is asked to sit or lay in a relaxed position. One hand is placed on the upper chest and one hand on the abdomen just below the rib cage at the bottom of the sternum. Patients are initially instructed to take a deep inspiratory breath by only moving the abdomen and keeping the chest motionless. The goal is to keep the hand on the chest motionless, while the hand on the abdomen rises and falls with each breath. Patients should be encouraged to practice diaphragmatic breathing midway through the meal if regurgitation occurs during the meal, or after meals for three different 5-minute periods of inactivity, with 10 minutes in between periods. However, if this method is unsuccessful, further instruction and reinforcement of diaphragmatic breathing should be sought from a behavioral psychologist.[16]
In general, rumination syndrome is a benign condition.[10] The challenge lies in awareness of this entity, careful history taking, early recognition of the clinical features of rumination, and referral for behavioral treatment to reduce adverse consequences. Outcomes in children and adolescents who have received behavioral therapy have been reported as having a >80% success rate.[1]
References
Sidebar: Key Points
Rumination Syndrome: An Emerging Case Scenario
Navneet Attri MD; M Ravipati MD; Preeti Agrawal MD; Christine Healy; A Feller MD
South Med J. 2008;101(4):432-435.
Abstract
This article describes the case of a 19-year-old woman presenting with repetitive episodes of effortless vomiting, which started within 3 weeks of her naval boot camp training. She underwent a battery of costly investigations before the diagnosis of rumination syndrome could be made. One of the reasons for her delayed diagnosis is that many physicians are unaware of, or are reluctant to make the diagnosis of rumination syndrome. The purpose of this article is to make the general physician aware of the possibility of rumination syndrome in adolescents and adults of normal intelligence, even though it was initially considered only in infants and mentally retarded individuals. The key to diagnosis is a thorough patient history. Reassurance and behavioral therapy is the mainstay of treatment, with a reported success of >80%.
Introduction
Rumination syndrome is a clinical diagnosis based on presenting symptoms with the absence of structural disease. Individuals with rumination syndrome are often misdiagnosed or undergo extensive, costly, and invasive testing before diagnosis.[1] Rumination syndrome is characterized by regurgitation of recently ingested food into the pharynx; the food is then either ejected or rechewed and reswallowed. This syndrome occurs most often in infants and persons with mental retardation, but is still underdiagnosed in adults with normal intelligence.
Case Report
A 19-year-old white woman was referred by the Navy to North Chicago Veteran Affairs after 3 months of vomiting. She had been in boot camp for nearly 3 weeks when she started vomiting; she initially suffered two to three episodes a day, progressing to multiple episodes a day over the few days before her arrival at the hospital. The vomiting typically occurred 5 to 15 minutes after eating, was not forceful, and had no associated nausea or retching. The patient did not vomit during her sleep. The vomitus was described as nonbilious and nonbloody, and was usually tasteless but sometimes tasted sour. Her appetite was good; in fact, she was hungry all the time. She had initially lost 20 pounds when she started boot camp but gained about 5 pounds within the 2 weeks before her stay at the hospital. She had been seen by several physicians during this period, undergoing an esophagogastroduodenal endoscopy and a colonoscopy, both of which were essentially normal. Her hepatoiminodiacetic acid (HIDA) scan revealed gallbladder dyskinesia. She was scheduled for gallbladder surgery within a fortnight. She was a nonsmoker, a nonalcoholic, and she denied drug use. Her family history was unremarkable. Psychiatric history revealed a suicide attempt at age 14 by making cuts on her arms when her parents got divorced. Outpatient medications included ondansetron, metoclopramide, omeprazole, and promethazine, and she had been taking oral contraceptives for 2 years. She denied any food or drug allergies. A review of her symptoms was unremarkable except for constipation and irregular menstrual cycles for 2 months, and her physical examination was unremarkable. She appeared well nourished, with no signs of nutritional deficiency. Dentition was good, and her hands had no evidence of erosions.
The patient's labs were within normal limits, and her serum potassium was 3.8. A pregnancy test was negative. Computed tomography of her head and abdomen were normal. An x-ray of her abdomen, as well as upper gastrointestinal and small bowel barium follow-through, were all normal. In addition, her thyroid stimulating hormone level was normal, with a prealbumin of 26.1, an albumin of 3.8, an erythrocyte sedimentation rate of 11, and a C-reactive protein at <0.2. Her antinuclear antibody was positive, with a titer of 1:640, homogenous pattern. The subsequent workup for connective tissue antibodies was normal. An esophageal manometry study showed normal amplitude and pressures in the upper esophagus, the body and the lower esophagus. Gastric emptying studies were done in both solid and liquid phases at 0, 2, and 4 hours. The result of the gastric emptying liquid phase was 134.9 minutes (normal 8-16 min). The gastric emptying solid phase was 148.72 minutes, which is markedly prolonged (normal 45-60 min).
Finally, a diagnosis of rumination syndrome was made. The abnormal gastric emptying studies were attributed to food going back and forth in the stomach, or between the stomach and esophagus. She was taught diaphragmatic breathing and received positive reinforcement from the behavioral psychologist, with marked improvement in her symptoms.
Discussion
The first case reports of rumination syndrome are from the early 17th century. Many famous people in history have had this syndrome; the most notable was a physician, Edouard Brown-Sequard, who acquired the condition as a result of experiments he performed on himself. He would swallow sponges tied to a string to evaluate the acid response of the stomach to various foodstuffs. He learned to regurgitate the sponge to analyze its contents, and eventually developed habitual regurgitation with his meals.[2]
Rumination syndrome is encountered most commonly in infancy and in mentally handicapped children and adults, and in males more than females. Its incidence has been reported to be about 6 to 10% of mentally challenged patients in institutions.[3] The prevalence in adults of normal intelligence is unknown because many physicians are unaware of this condition. It may remain undiagnosed for many months or years, and the patients often undergo unnecessary, expensive, and invasive tests.[3] Of the cases that have come to light, female preponderance has been observed in adolescents; the average age at diagnosis is 15 ? 0.3 years.[1] A genetic association has not been established.[4]
The pathophysiology of rumination remains unclear. The physiologic mechanism points to the forward extension of the head to open the upper esophageal sphincter, and a contraction of the abdominal rectus abdominis muscle to force the gastric contents into the mouth.[5] It has been demonstrated that the lower esophageal sphincter relaxation occurs at a lower pressure of gastric distension in patients with rumination syndrome as compared with controls.[6] Rumination may be the consequence of a learned voluntary relaxation of the lower esophageal sphincter or diaphragmatic crura, allowing increased postprandial intragastric hydrostatic pressure and normal phasic and tonic contractions of the proximal stomach. This increase in pressure overcomes the resistance to regurgitation usually provided by the antireflux mechanisms at the esophagogastric junction.[7]
Rumination is believed to be a learned adaptation of the belch reflex.[3] The duration of the transient lower esophageal sphincter relaxations during gastric reflux or belching is much longer (by about 12 s) than that associated with deglutition, (about 2-4 s) which seems to be long enough to allow particulate food to be retropulsed from the stomach to the pharynx.[8] Also, during a belch or swallow, lowered pressure in the lower esophageal sphincter creates a common cavity between the stomach and the esophagus. It is also postulated that the gastric distension activates a vagal reflex to transiently relax the lower esophageal sphincter during belching.[8]
Psychiatric aspects probably also play a part in this syndrome.[9,10] In fact, 67% of the patients in a study[11] were found to have experienced a stressful situation, like the loss of a family member or a professional setback, before the onset of symptoms. Psychological disturbances, including depression, anxiety, obsessive-compulsive behavior, and other disorders are reported in up to one-third of affected individuals.[12] In children, rumination may represent a self-stimulating positive behavior resulting from a poor mother-infant relationship.[13] Alternatively, the behavior may be learned as a conditioned response, maintained by the reward of increased parental attention or the positive feedback associated with the taste of regurgitated food.[14] Whether these apply to intellectually intact adults is not clear.
An association between rumination and bulimia nervosa has been previously described; 20% of patients with bulimia were found to ruminate in one study.[3] Ruminators with bulimia tend to expel rather than reswallow food, like ruminators without bulimia, and may self-induce vomiting by digital stimulation of the hypopharynx. In patients with bulimia, rumination may be a learned behavior for controlling their weight.
Diagnosis
First, it should be noted that an accurate clinical history is the key to the correct diagnosis. The Rome III Consensus Criteria for Rumination Syndrome in Adolescents must all be met at least once per week for at least 2 months before diagnosis.[15] According to these criteria, the patient must experience:
- Repeated painless regurgitation and rechewing or expulsion of the food that:
- Begins soon after ingestion of a meal (contrasting with a typical history of vomiting during the later postprandial period in patients with gastroparesis)
- Does not occur during sleep;
- Does not respond to standard treatment for gastroesophageal reflux;
- Includes no retching;
- Includes no evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the patient's symptoms.
Scintigraphic studies of gastric emptying may show delayed gastric emptying, probably as a result of regurgitation and reswallowing of food, which is then delivered intermittently or later to the distal stomach for digestion and mixing.[1]
Manometric recordings demonstrate the occurrence of synchronous pressure spikes, termed R waves, at all levels in the stomach and small intestine in about 40% of the patients with rumination, which correlates with a generalized increase in the intraabdominal pressure that occurs during a rumination event.[1] But the test may be normal in 55% of patients,[1] thus, abnormal results should be interpreted carefully in the setting of rumination.
When the patient is alert and awake, 24-hour esophageal pH monitoring may demonstrate acidic pH in the esophagus postprandially.[1] In gastroesophageal reflux disease, on the other hand, the episodes occur nocturnally and are aggravated by a supine position.[1]
Rumination is mostly confused with gastroparesis and gastroesophageal reflux disease.[4] This syndrome is different from gastroparesis, because regurgitation is effortless and occurs within 15 to 30 minutes after a meal. Even liquids can be regurgitated within minutes of intake.[11] On the other hand, patients with gastroparesis vomit later in the postprandial period, usually more than an hour after a meal, and the symptoms may not occur daily. The concomitant presence of nausea and heartburn may make the presentation look like gastroesophageal reflux disease, but as mentioned above, the symptoms of gastroesophageal reflux disease occur predominantly at night and/or when the patient is supine. Thus the presence of heartburn, nausea, abdominal pain and weight loss in certain subsets of patients does not rule out rumination syndrome.[4] Though the clinical presentation is obvious, 24-hour esophageal monitoring and gastric studies may be necessary in these patients.[11]
Treatment
Medications for rumination disease, including acid blocking agents, prokinetic medications, antiemetics, anticholinergics, anxiolytics, and antidepressants, are not well studied. Their role in improving symptoms in patients with rumination syndrome is unclear.[12] Stress and psychological aspects in rumination syndrome have to be addressed. Nissen fundoplication has been tried but has led to complications like retching, bloating, and gastroparesis.[16]
Nonaversive behavioral therapy is the cornerstone to treatment; it involves habit reversal by using several strategies, like strong encouragement not to vomit, biofeedback relaxation, and diaphragmatic breathing.[3,9] The patient is asked to sit or lay in a relaxed position. One hand is placed on the upper chest and one hand on the abdomen just below the rib cage at the bottom of the sternum. Patients are initially instructed to take a deep inspiratory breath by only moving the abdomen and keeping the chest motionless. The goal is to keep the hand on the chest motionless, while the hand on the abdomen rises and falls with each breath. Patients should be encouraged to practice diaphragmatic breathing midway through the meal if regurgitation occurs during the meal, or after meals for three different 5-minute periods of inactivity, with 10 minutes in between periods. However, if this method is unsuccessful, further instruction and reinforcement of diaphragmatic breathing should be sought from a behavioral psychologist.[16]
In general, rumination syndrome is a benign condition.[10] The challenge lies in awareness of this entity, careful history taking, early recognition of the clinical features of rumination, and referral for behavioral treatment to reduce adverse consequences. Outcomes in children and adolescents who have received behavioral therapy have been reported as having a >80% success rate.[1]
References
- Chial HJ, Camilleri M, Williams DE, et al. Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Paediatrics 2003;111:158-162.
- Kanner L. Historical notes on rumination in man. Med Life 1936;43:27-60.
- Malcolm A, Thumshirn MB, Camilleri M. Rumination syndrome. Mayo Clinic Proc 1997;72:646-652.
- O'Brien BD, Bruce BK, Camilleri M. The rumination syndrome. Clinical features rather than manometric diagnosis. Gastroenterology 1995;108:1024-1029.
- Shay SS, Johnson LF, Wong RKH. Rumination, heartburn and daytime gastroesophageal reflux. J Clin Gastroenterol 1986;8:115-126.
- Thumshirn M, Camilleri M, Hanson RB, et al. Gastric mechanosensory and lower esophageal sphincter function in rumination syndrome. Am J Physiol Gastrointest Liver Physiol. 1998;275:G314-G321.
- Smout AJ, Breumelhof R. Voluntary induction of transient lower esophageal sphincter relaxations in an adult patient with the rumination syndrome. Am J Gastroenterol 1990;85:1621-1625.
- Wyman JB, Dent J, Heddle R, et al. Control of belching by the lower esophageal sphincter. Gut 1990;31:639-646.
- Johnson WG, Corrigan SA, Crusco AH, et al. Behavioral assessment and treatment of postprandial regurgitation. J Clin Gastroenterol 1987;9:679-684.
- Levine DF, Wingate DL, Pfeffer JM, et al. Habitual rumination: a benign disorder? BMJ 1983;287:255-256.
- Soykan I, Chen J, Bradley KJ, et al. The rumination syndrome. Dig Dis Sci 1997;42(9):1866-1872.
- Laheij RJ, De Koning RW, Horrevorts AM. Predominant symptom behavior in patients with persistent dyspepsia during treatment. Clin Gastroenterol 2004;38:490-495.
- Stein ML, Rausen AR, Blau A. Psychotherapy of an infant with rumination. JAMA 1959;171:2309-2312.
- Wolf MM, Birnbrauer J, Lawler J, et al. The Operant Extinction, Reinstatement and Re-extinction of Vomiting Behavior in a Retarded Child, in Ulrich R, Statnik T, Mabry J (eds): Control of Human Behavior: From Cure to Prevention. Glenview Illinois: Scott, Foresman, 1970, vol 2.
- Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology 2006;130:1466-1479.
- Chitkara D, Tilburg MV, Whitehead W, et al. Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol 2006;101:2449-2452.
Sidebar: Key Points
- Rumination syndrome may remain undiagnosed for months or years because many doctors are unaware of this syndrome.
- Patients often undergo unnecessary, expensive and invasive tests.
- The key to diagnosis is a thorough patient history.
- Reassurance and behavioral therapy is the mainstay of treatment, with a reported success of >80%.
:canadian:Hi Steve, The only "treatment" my husband is seeking so far is by getting and endoscopy done to see what kind of damage has been done to his esophagus. As far as my husband is concerned he does not have a problem and that it does not bother him. He thinks that the problem lies in me in that I won't accept his disorder. He however does know that other people have this condition and that he is not the only one. My husband is 61 years old and has had this condition all of his life. The probability of him changing this behavior after ruminating for so long could be very low. We live in a very small community in NW BC Canada and there are no treatment facilities anywhere near by, plus the medical community here know very little about this disorder.
My options are unknown at this point other than to change my own life because my husband is unwilling to change for the better. If he would things would be so much different. All I can say that for me it is very difficult living with someone who has an eating disorder. This is why I joined this forum, I would like to get some feed back and support from other people who have experienced this. I feel so all alone in this.
Cheryl
My options are unknown at this point other than to change my own life because my husband is unwilling to change for the better. If he would things would be so much different. All I can say that for me it is very difficult living with someone who has an eating disorder. This is why I joined this forum, I would like to get some feed back and support from other people who have experienced this. I feel so all alone in this.
Cheryl
I didn't know anything about rumination syndrome (prior to reading TSOW's posts), but I tend to be pessimistic about the efficacy of influencing people who continue to refuse treatment for their disorders -- not just mental disorders, but physical disorders as well like diabetes. So when you stated the following, I became even more pessimistic, especially since he, apparently, hasn't turned around at all after the separation:
Cheryl,
It sounds like your husband has been diagnosed, which is why the endoscopy is being performed to evaluate possible esphogeal damage.
Is the gastro-enterologist aware of your husband's disorder, and if so, can your husband be referred for further evaluation?
Are there any mental health professionals serving your area who might be able to help?
Being sixty one is not necessarily an insurmountable obstacle for receiving counseling and treatment, although he would need to come to terms with his disorder, and to understand how the disorder is affecting your relationship.
May I ask how long have you been married, and how did he keep this from you for two years?
Are you seeking support with the hope of reconciling and getting back together? If you choose to remain separated, do you have the resources to remain independent?
It sounds like your husband has been diagnosed, which is why the endoscopy is being performed to evaluate possible esphogeal damage.
Is the gastro-enterologist aware of your husband's disorder, and if so, can your husband be referred for further evaluation?
Are there any mental health professionals serving your area who might be able to help?
Being sixty one is not necessarily an insurmountable obstacle for receiving counseling and treatment, although he would need to come to terms with his disorder, and to understand how the disorder is affecting your relationship.
May I ask how long have you been married, and how did he keep this from you for two years?
Are you seeking support with the hope of reconciling and getting back together? If you choose to remain separated, do you have the resources to remain independent?
lswife said:
Does he agree that the disorder is treatable? If no, does he think other people with the disorder can be treated?
:canadian:Hi Daniel, Thanks for your insight. Yes I do agree with you about your comment to my quote. I believe that anyone who hides their true selves from people until after they have gotten the other person to commit to them say as in marriage has no intentions of changing.
This has been very difficult for me as his wife to deal with over the years as no tactics such as separation and others such ones on my part (how to deal with the issue) have influenced him in any way.
It tried other ways over the years to deal with this issue by trying to ignore the issue (believing and hoping that maybe it would just go away), focusing on raising our 2 children, becoming a long distance runner (running away from the issue) eating too much, sometimes drinking too much and also spending too much money. Of course none of these ways to deal with my husbands eating disorder never worked. The issue was always there.
So for me the separation this time will be permanent and for this I will need support from the separation and divorce threads which I will post in sometime in the future.
Even though my husband knows that he has a medically described eating disorder and there are treatments for it and the fact that he is going for an endoscopy has not stopped him from continuing his rumination. I don't know if he believes that he can be "cured". He has not had the endoscopy yet and has been told to tell the gastro-enterologist about his condition. As far as mental health services, I have already been to a therapist who knew nothing about this kind of eating disorder. My husband however has not seen a mental health professional yet, I think that he will only go if I decide to work on our marriage.
I have been married to this man for almost 26 years, now I know that some of you may be scratching your heads wondering why would I have put up with this for so long. Like I said in my previous posts I have tried to deal with it in my own manner without much success. I have stayed with my husband for our children's sakes. I feel like I have been an enabler all this time because the issue has never been resolved and that I stuck around for all the wrong reasons. This is not the first time we have separated over this.
I am not seeking reconciliation and we have enough assets to live comfortably. I am not employed however and haven't been for over 8 years (I have had 3 jobs over the course of our marriage) but as I am 12 years younger than my husband I feel that I am still employable and as a matter of fact I am looking for work presently.
Hi Steve, to answer your question as to how he hid it from me for 2 years is this, he would disappear after a meal to the bathroom or in the garage to work on something. When we first were going out he always kept his mouth clean. I never clued in until one day when he didn't realize I was in the house and saw him doing his regurgitation. I asked him what the h**l was he doing. He said that an old man taught him how to do it and that he was trying it out. How bizarre is that? Anyway silly me I gave him the benefit of the doubt and believed that he would never try that again. Boy was I wrong! He has been doing this all of his life. So after 61 years of this there has been alot of residual damage to his teeth (enamel erosion) and his tongue has a permanent sour taste. To him he doesn't notice this because this is so much a part of him. As you can imagine this has greatly affected our intimate life so much that we have become very distant emotionally and physically. We have had many years of this "unhappiness".
This has been very difficult for me as his wife to deal with over the years as no tactics such as separation and others such ones on my part (how to deal with the issue) have influenced him in any way.
It tried other ways over the years to deal with this issue by trying to ignore the issue (believing and hoping that maybe it would just go away), focusing on raising our 2 children, becoming a long distance runner (running away from the issue) eating too much, sometimes drinking too much and also spending too much money. Of course none of these ways to deal with my husbands eating disorder never worked. The issue was always there.
So for me the separation this time will be permanent and for this I will need support from the separation and divorce threads which I will post in sometime in the future.
Even though my husband knows that he has a medically described eating disorder and there are treatments for it and the fact that he is going for an endoscopy has not stopped him from continuing his rumination. I don't know if he believes that he can be "cured". He has not had the endoscopy yet and has been told to tell the gastro-enterologist about his condition. As far as mental health services, I have already been to a therapist who knew nothing about this kind of eating disorder. My husband however has not seen a mental health professional yet, I think that he will only go if I decide to work on our marriage.
I have been married to this man for almost 26 years, now I know that some of you may be scratching your heads wondering why would I have put up with this for so long. Like I said in my previous posts I have tried to deal with it in my own manner without much success. I have stayed with my husband for our children's sakes. I feel like I have been an enabler all this time because the issue has never been resolved and that I stuck around for all the wrong reasons. This is not the first time we have separated over this.
I am not seeking reconciliation and we have enough assets to live comfortably. I am not employed however and haven't been for over 8 years (I have had 3 jobs over the course of our marriage) but as I am 12 years younger than my husband I feel that I am still employable and as a matter of fact I am looking for work presently.
Hi Steve, to answer your question as to how he hid it from me for 2 years is this, he would disappear after a meal to the bathroom or in the garage to work on something. When we first were going out he always kept his mouth clean. I never clued in until one day when he didn't realize I was in the house and saw him doing his regurgitation. I asked him what the h**l was he doing. He said that an old man taught him how to do it and that he was trying it out. How bizarre is that? Anyway silly me I gave him the benefit of the doubt and believed that he would never try that again. Boy was I wrong! He has been doing this all of his life. So after 61 years of this there has been alot of residual damage to his teeth (enamel erosion) and his tongue has a permanent sour taste. To him he doesn't notice this because this is so much a part of him. As you can imagine this has greatly affected our intimate life so much that we have become very distant emotionally and physically. We have had many years of this "unhappiness".
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Sorry to hear about the difficult time you have had all this time. You are to be commended for taking charge of your own life at this time, and we'll be pleased to continue a conversation with you on this difficult journey.
How do your two children feel about this situation, Cheryl?
How do your two children feel about this situation, Cheryl?
:canadian:My two children are coping with the separation just fine. Our son who is 25 years old (still living in the family home) is adjusting well as can be expected and our daughter who is 23 living in a big city center for about 5 years now is also alright with the separation. Both of our children are not that close to their father. They are closer to me especially my daughter. They know about their fathers eating disorder and have seen the effects that has had on their parents relationship.. My son is very quiet and withdrawn basically an introvert, my daughter throughout her teenage years was very rebellious (I guess typical for a teenager) but I think that seeing how her parents relationship was compounded that. She is more outgoing, gregarious and an extrovert.
This is a very difficult situation I am in and not an easy one to go through. I am torn because I have had a long history with my husband and we are each others best friends.
He asked me tonight if there was a chance of reconciliation, I couldn't answer him, to me there has been so much time and damage that has been lost and done that I don't know how and if there is anything left to salvage. He is tired of waiting for things to change between us and I am tired of putting up with the eating disorder.
:canadian:For anybody who is wondering what does lswife stand for, it means long suffering wife. That is how I feel.
This is a very difficult situation I am in and not an easy one to go through. I am torn because I have had a long history with my husband and we are each others best friends.
He asked me tonight if there was a chance of reconciliation, I couldn't answer him, to me there has been so much time and damage that has been lost and done that I don't know how and if there is anything left to salvage. He is tired of waiting for things to change between us and I am tired of putting up with the eating disorder.
:canadian:For anybody who is wondering what does lswife stand for, it means long suffering wife. That is how I feel.
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Cat Dancer
MVP
My heart goes out to you. I struggle with eating disorders myself and I'm ashamed to admit I've never really thought about the consequences my actions have on my spouse. I try to hide my problems from him, but I'm sure he can tell some of what I'm going through.
I wish you the best as you go through this difficult time. I hope whatever is best will work out for you and I'm sorry you've had to go through so much.
I wish you the best as you go through this difficult time. I hope whatever is best will work out for you and I'm sorry you've had to go through so much.
:canadian
ear Cat Dancer, I appreciate your honesty and candor, for me honesty is the best policy and if you truly love your spouse you will get through anything. For me my spouse and I never got off the ground running. He hid his problem from me from the get go until I accidentally found out and then our whole world fell apart. This is nothing I ever imagined that I would have had to face in my life nor have I ever been prepared for. He insisted on keeping his disorder like it was a long lost friend that he couldn't let go off no matter how it was affecting our relationship. Maybe you can understand that... I don't know.
If I have any advice for you is this.... don't let a minute go by without facing your problem and getting through it with or without the support of your spouse. If you don't have the support of your spouse, do it for yourself. Don't let many years go by with regret and resentment.
ear Cat Dancer, I appreciate your honesty and candor, for me honesty is the best policy and if you truly love your spouse you will get through anything. For me my spouse and I never got off the ground running. He hid his problem from me from the get go until I accidentally found out and then our whole world fell apart. This is nothing I ever imagined that I would have had to face in my life nor have I ever been prepared for. He insisted on keeping his disorder like it was a long lost friend that he couldn't let go off no matter how it was affecting our relationship. Maybe you can understand that... I don't know.If I have any advice for you is this.... don't let a minute go by without facing your problem and getting through it with or without the support of your spouse. If you don't have the support of your spouse, do it for yourself. Don't let many years go by with regret and resentment.
Cat Dancer
MVP
Thank you for sharing what you have and giving me another perspective. I hate that you are going through so much. It definitely makes me determined to recover so that I won't put anyone through any pain and suffering like you're going through.
:hug:
I do understand the long, lost friend that's so hard to let go of. I don't know why it feels that way, but it does. Eating disorders are very insidious. Still, that's no excuse for not seeking help, I think.
:hug:
I do understand the long, lost friend that's so hard to let go of. I don't know why it feels that way, but it does. Eating disorders are very insidious. Still, that's no excuse for not seeking help, I think.
:canadian:Hi Cat Dancer, Thanks also for giving your perspective on how some one who has an eating disorder feels. I understand now more somewhat on how it is difficult to thing to live with. I am happy that you are more willing to go on your own road to recovery. However I must state that you shouldn't let too much time go by before you get healthy, life is too short to live with misery, shame and unhappiness.
:support:
For my husband and I however it is much too late, he never did anything about his eating disorder all the time we were married however much I begged, pleaded, complained etc....You get the picture. Now that he is faced with the reality of losing me, he says that he will seek treatment if I stay with him. I think that he should go seek help for himself. He should have done this a long time ago.
It is much too late for help in our marriage. There has been too much damage over the years done to the relationship. Please don't let the same thing happen to you.
:support:
For my husband and I however it is much too late, he never did anything about his eating disorder all the time we were married however much I begged, pleaded, complained etc....You get the picture. Now that he is faced with the reality of losing me, he says that he will seek treatment if I stay with him. I think that he should go seek help for himself. He should have done this a long time ago.
It is much too late for help in our marriage. There has been too much damage over the years done to the relationship. Please don't let the same thing happen to you.
Depending on what you want for your own life, if reconciliation is an option, then you might consider that your husband begin therapy on his own and demonstrate a commitment to his therapy along with a willingness to change his behaviour, if that is indeed possible, as a pre condition to reconciliation.
The risk of the alternative is that you commit to reconciliation and his commitment to seeking therapy is a ploy to get you back, based on the way you have described his history.
If a plan for therapy and treatment is considered, it would be in your mutual interest to determine what to expect from treatment. This would necessitate a conversation with the therapist, who should have clinical experience in treating this particular disorder.
You may find that someone with clinical experience in this disorder may require travel to a major clinical center.
I don't know how much of this disorder is involuntary and how much is physiological, and at your husband's age, given his lifelong association with the disorder, what the expectation should be.
It's obvious you have a great deal to take into consideration, and at this point there are many factors that appear to be unknown.
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