Recurrent regurgitation isn’t always a sign of reflux disease. Regurgitation that is persistent, involves partially digested or undigested food and requires no effort, retching or nausea to bring food up the wrong way, could be related to rumination syndrome. This often under-diagnosed condition can occur at any age in both men and women and is thought to be related to a problem with accommodation of food in the stomach immediately after eating. Regurgitation can begin during or soon after eating and can carry on for several hours after eating. Regurgitated food arrives into the mouth with subsequent spitting or re-chewing and swallowing, stopping only when the contents becomes acidic or unpleasant.

The similarities between reflux disease and rumination can make it difficult to differentiate the two; a 24h pH-study will frequently be positive in both cases. For this reason, it is important to choose a 24h test capable of evaluating the pattern of both acid and non-acid reflux occurring in the post-prandial period by combining pH-monitoring with impedance measurement. (Oesophageal Manometry & 24 hr pH/Imp.)

Behavioural therapy involving biofeedback can reduce symptoms in rumination syndrome, however it is imperative that the correct diagnosis is obtained first. Rumination can be demonstrated using high resolution manometry with impedance measurement (HRM-z). Abdominal contractions observed during and shortly after a test meal (usually a bowl of breakfast cereal) appear as coloured pressure bands easily understood by the patient. When these are associated with lower oesophageal sphincter (LOS) relaxation, the barrier between the stomach and oesophagus is compromised. This results in reflux of stomach contents visible on the impedance trace as demonstrated in the image (.

HRM with impedance gives us the ability to show patients the source of their problem directly as well as providing the tools required to change behaviour and improve symptoms. Using this combined approach, rumination can be subtyped to account for learned and spontaneous responses used to relieve symptoms (1). In addition to the typical ‘reflux rumination’ described above, rumination episodes may involve movement of air or foods, without complete passage into the stomach first. This is called ‘supra-gastric rumination’. Frequent belching associated with rumination can also occur as supra-gastric belching, where air is forcibly suctioned into the oesophagus. The impedance trace tells us whether this has been expelled or becomes trapped in the food pipe.

At The Functional Gut Clinic, we have successfully used biofeedback to reduce abdominal contractions and reflux episodes by combining visual feedback, behavioural therapy and patient education. Relaxation and breathing techniques taught with care, compassion and expertise reduce transient LOS relaxations creating a stronger barrier keeping meals where they belong (see image below).

A combined high resolution manometry with impedance colour-plot showing the effect on diaphragmatic breathing on reducing rumination behaviour and maintaining lower oesophageal sphincter integrity.