Rumination syndrome: what it is, symptoms and breathing treatment

Guts UK explains that rumination syndrome is the chronic, repetitive, effortless regurgitation of recently swallowed food back into the mouth. The regurgitated food may then either be re-chewed and swallowed or spat out. It happens following an unintentional contraction of the abdominal muscles shortly after eating, which abruptly raises the pressure in the stomach enough to force open the valve in the lower oesophagus.

The Royal Hospital for Children in Glasgow describes it as a rare behavioural disorder in which recently eaten food is regurgitated from the stomach into the mouth because of an increase in pressure in the stomach, and says the food will not have an acidic taste like vomit as it is undigested.

Guts UK says people can experience symptoms for some time before diagnosis. Rumination is not usually accompanied by nausea, it is painless, and most people do not have heartburn or retching. It can be preceded by a feeling you are about to burp.

• Regurgitation of food within minutes after a meal, which can continue for 1 to 2 hours, with both liquids and solids.

• Food that tastes like what was just eaten rather than sour, bitter or acidic, and may even be pleasant.

• A conscious choice whether to swallow or expel the food.

• Regurgitation that usually stops when the food develops an acidic taste, and does not occur during sleep.

• Possible effects of regular rumination: dental damage, bad breath, weight loss and electrolyte imbalance.

• Avoiding social situations, sports, work or school because of the symptoms, in some people.

Guts UK says rumination syndrome is often mistaken for reflux, unexplained vomiting, bulimia, anorexia nervosa and gastroparesis. People sometimes describe their symptoms as vomiting, but it is not the same. Unlike acid reflux, the regurgitated food is not generally acidic.

Guts UK says symptoms are similar to other gut conditions, so other causes are ruled out first. Most people have an endoscopy (OGD) or a barium swallow to rule out structural or inflammatory causes. There are no blood tests that can diagnose it. The main way of diagnosing is a detailed clinical history and screening for the recognised symptoms.

Doctors use the Rome IV criteria. Guts UK says all of the following must be fulfilled for the last 3 months, with symptom onset at least 6 months before diagnosis: persistent or recurrent regurgitation of recently eaten food into the mouth with spitting or re-chewing and swallowing; regurgitation not preceded by retching; and no evidence of an inflammatory, structural, metabolic or cancerous process that explains the symptoms. A test called high-resolution impedance manometry can support the diagnosis and distinguish it from reflux.

Guts UK says that, because it is an acquired behavioural disorder, behavioural modification is the main treatment and has the most evidence in clinical trials. Diaphragmatic breathing is taught to break the habit and retrain the muscles so they compete with the urge to ruminate. If done correctly, it is not possible to tense the abdominal muscles during this breathing, so rumination cannot happen at the same time. The exercises need to be continued at home, in the middle and at the end of all meals and following every episode, until the pattern becomes natural. Biofeedback can sometimes be used to teach them.

The Royal Hospital for Children in Glasgow describes how to do it: place one hand on your upper chest and the other just below your rib cage, and breathe in slowly through your nose so that your stomach moves out against your hand. Sitting tall while eating also helps. It says breathing exercises work for most patients, and that if symptoms return the exercises may need to be continued.

Guts UK says medicines have a limited role. Proton pump inhibitors are sometimes offered, but there is little evidence they work. Baclofen has been shown in a clinical study to reduce regurgitation events, but it can cause drowsiness, so it is usually reserved for people who do not improve with diaphragmatic breathing. Mindfulness has been offered but there is not much evidence yet. Nissen fundoplication surgery is rarely used and is not supported by robust evidence, and doctors currently recommend avoiding surgery without structural abnormalities such as a hiatus hernia.

Guts UK says the cause is currently unknown. Some people report symptoms following an acute illness, surgery, stress or a major life event. About half of people with the condition have a diagnosis of anxiety or depression, though it is not known which comes first. The Royal Hospital for Children says symptoms often begin after illness or a stressful event and unintentionally turn into a habit, and that holding stress in the shoulders and stomach can make symptoms worse.

Guts UK says in children and adolescents without developmental difficulties it is more common in females, whereas in adults it occurs equally in men and women. The Royal Hospital for Children in Glasgow publishes information for patients, parents and carers, with a box-breathing exercise: breathe in through the nose for 3 seconds, hold for 2, breathe out through the mouth for 3, pause for 2, and repeat five times, ideally before, during and 10 minutes after eating.

Guts UK says that in the early stages after diagnosis nutrition, oral intake, weight and hydration should be monitored, and if there is weight loss or malnutrition, support from a dietetics team may be needed. It also says that if food is getting stuck in the oesophagus and it is painful and you are losing weight, you should contact your doctor, because pain is a red flag that needs investigation, particularly in people over 55, and rumination is not generally painful.

On the NHS, a GP can refer you to gastroenterology for tests such as endoscopy. Guts UK says diaphragmatic breathing instructions can be given by speech therapists, psychologists, gastroenterologists and other practitioners familiar with the technique, so it is worth asking your GP for a referral for breathing retraining. Private gastroenterology can also offer assessment and tests.