Rumination Syndrome Dr. T Zangen Case vignette-1 18 yo F - - PowerPoint PPT Presentation

Rumination Syndrome

• Dr. T Zangen

Case vignette-1

• 18 yo F

Persisting expulsion of food immediately after ingestion of any kind or amount of solid or semisolid food, lasting for 2 years. Past medical hystory:

• Celiac Disease , on gluten free diet for 10 y
• Chronic back and hip pain for years, medical

treatment by pain clinic ( celebrex, lyrica)

• Current sole medication : Omepradex

Case vignette -2

• Persisting expulsion of food immediately after

ingestion of any kind or amount of solid or semisolid food, lasting for 2 years.

• Symptoms of dyspepsia and vomiting started 3 years

ago following an acute gastroenteritis

• Vomiting worsened after cholecystectomy (for

gallbladder sludge) complicated by weight loss

• Few episodes of fecal load and constipation

Case vignette -3

• Tolerates well clear liquids an coconut water
• No abdominal pain, heartburn, fever, diarrhea,

abdominal distention, headache

Workup-1

• Endoscopic examinations-normal (numerous)
• Radiology: abdominal CT scan, MRE, MRI-brain, -normal
• Metabolic, Endocrine, Allergy tests-normal
• Neurologic and neuro-genetic consult: normal EMG-N,

MNGIE- excluded, mitochondrial disease excluded.

• Autonomic nervous system workup- normal
• Psychiatric assessment- normal, eating disorder excluded
• Blood biochemistry- normal, blood counts normal except

some neutropenia

Workup-2

• Gastric transit study (for gastroparhesis): solid

emptying a little more rapid than normal range.

• Esophageal manometry (without impedance): normal,

regular 10 swallows, without a meal.

• No antroduodenal manometry performed

Diagnosis by Neurogastroenterogists

• Intractable vomiting
• Functional vomiting with gastric hypersesitivity

Rumination syndrome???

Treatment

• Medications:

No improvement: Pregabalin, Amitriptylin, Quetiapine, Mitrazapine Some improvement: Ondansetron, Omepradex, Sertaline

• Elimination diet- failed
• Diaphragmatic breathing exercises, biofeedback, hypnosis-

didn’t work

• Gastric pacemaker placement- eliminated nausea but no

improvement in vomiting

• NJ tube feeding, PEG\PEJ feeding improved nutrition and

weight gain (multiple tube dislodging )

• Formal jejunostomy planned

Discussion

• Would you do an antrodoudenal manometry

to confirm the diagnosis of Rumination syndrome? Additional tests?

• What is the entity of “Functional vomiting

with gastric hypersensitivity”?

• What in your experience are the treatment
• ptions in this case ?

Dear Dr Zengen, I wanted to update you on Daniella’s progress.

• Emend (aprepitant) 165 mg daily
• This drug is currently being trialled for treating

gastroparesis in the US

• After 10 days, she started to notice an impact
• Progressively she was able to eat larger quantities
• Today she can eat a normal meal albeit consumed

slowly and in a relatively small quantity.

• She has not used the feeding tube for over a
• week. She has gained weight

• B3b. Functional Vomiting

Diagnostic criteria * Must include all of the following: 1.On average one or more episodes of vomiting per week

• 2. Absence of criteria for an eating disorder, rumination,
• r major psychiatric disease according to DSM-IV
• 3. Absence of self-induced vomiting and chronic

cannabinoid use and absence of abnormalities in the central nervous system or metabolic diseases to explain the recurrent vomiting * Criteria fulfilled for the last 3 months with symptom

• nset at least 6 months prior to diagnosis

• H1a. Adolescent Rumination Syndrome

Diagnostic criteria* Must include all of the following:

• 1. Repeated painless regurgitation and rechewing or expulsion of

food that

• a. begin soon after ingestion of a meal
• b. do not occur during sleep
• c. do not respond to standard treatment for gastroesophageal

reflux

• 2. No retching
• 3. No evidence of an inflammatory, anatomic, metabolic, or

neoplastic process

• that explains the subject’s symptoms
• * Criteria fulfilled for the last 3 months with symptom onset at least

6 months prior to diagnosis

• B4. Rumination Syndrome in Adults

Diagnostic criteria Must include both of the following:

• 1. Persistent or recurrent regurgitation of recently ingested

food into the mouth with subsequent spitting or remastication and swallowing

• 2. Regurgitation is not preceded by retching

Supportive criteria

• 1. Regurgitation events are usually not preceded by nausea
• 2. Cessation of the process when the regurgitated material

becomes acidic

• 3. Regurgitant contains recognizable food with a pleasant

taste