Treatment options for rumination syndrome: A systematic review

Table 1 Characteristics of studies included in analysis

Study	Site	Type of study	n	Fem (%)	Age (yr) (range)	Diagnostic criteria	Physiological tests done	Treatment	Description of treatment	Primary outcome	Main results	Proposed mechanism of action	Follow up period (mo)
Barba et al[8]	Spain	RCT, Placebo controlled	12	7 (58)	Median 42 (19-69)	Rome 3 rumination syndrome	EMG+ activity of abdomino-thoracic muscles, done PRE and POST	EMG+ guided biofeedback	Pre-meals, patients were trained to control the activity of the abdomino-thoracic muscles under visual control of EMG+ recordings displayed on a monitor. Specifically, they were instructed to voluntarily reduce the activity of intercostal and anterior abdominal muscles and to increase the activity of the diaphragm. After each biofeedback session, patients were instructed to perform the same exercises daily at home for 5 min before and after breakfast, lunch, and dinner. At the end of the treatment period, patients were encouraged to continue practicing these same exercises over time. 3 such sessions performed over 10 d	Reduction in rumination episodes measured over 10 d, patient reported	Regurgitation episodes decreased by 74 ± 6% in the biofeedback group (n = 12) but only by 1 ± 14% in the placebo group (n = 11; P < 0.001). Biofeedback significantly reduced the activity of the abdominothoracic muscles, whereas the placebo had no effect; Number of daily rumination episodes decreased to 7.7 ± 1.9 immediately after biofeedback, 3.0 ± 1.1 by 1 mo, 1.2 ± 0.5 by 3 mo, and 0.7 ± 0.4 by 6 mo (P < 0.001)	Modified basal postprandial muscular tone; Possibly increase awareness in patients to suppress rumination	6 mo
Pauwels et al[14]	Belgium	RCT, Placebo controlled	10	6 (60)	Mean 42 (18-61)	Rome 4 rumination syndrome and/or supragastric belching	Oesophageal HRiM+ done PRE and POST	Baclofen	5 mg tds first week then increased to 10 mg tds second week, followed by 1 wk washout period, before 2 wk crossover to alternative treatment	Number of symptoms of regurgitation via event marker on HRiM+ and overall treatment evaluation (OTE)	Median number of times that the “regurgitation” marker was pushed significantly lower in baclofen group compared to placebo [4 (0–14) vs 6 (0–19), P = 0.04] Patients reported significantly better OTE ratings after baclofen compared to placebo [mean score 1 (0–2) vs 0 (−1–1), P = 0.03]. On baclofen treatment, 63% of patients improved on Baclofen compared to 26% on placebo (P < 0.0001)	Increased LES+ pressure: Postprandial LES+ pressure significantly higher in the baclofen arm compared to placebo [17.79 (12.72–22.68) vs 13.06 (7.16–16.91) mm Hg (P = 0.0002)]. Borderline negative correlation between postprandial LES pressure and the number of rumination episodes in the baclofen condition (P = 0.056, r = −0.54). Reduced TLESR+: Postprandial TLESRs was significantly lower after baclofen compared to placebo [4 (1–8) vs 7 (3–12), P = 0.017].	No long term follows up
Barba et al[9]	Spain	Prospective cohort with controls	24	17 (71)	14-76	Rome 3 rumination syndrome	EMG+ activity, done PRE and POST treatment	EMG+ guided biofeedback	Pre-meals, patients were trained to control the activity of the abdomino-thoracic muscles under visual control of EMG+ recordings displayed on a monitor. Specifically, they were instructed to voluntarily reduce the activity of intercostal and anterior abdominal muscles and to increase the activity of the diaphragm. After each biofeedback session, patients were instructed to perform the same exercises daily at home for 5 min before and after breakfast, lunch, and dinner. At the end of the treatment period, patients were encouraged to continue practicing these same exercises over time. 3 such sessions performed over 10 d	Not defined	Post-biofeedback session, patients experienced a decrease in the number of regurgitation events (8 recorded vs 18 in the basal challenge test; P < 0.001). The improvement observed during the first biofeedback session was strengthened by the following biofeedback sessions. Regurgitation events had decreased by 70% (P < 0.001). By the end of the 3 biofeedback sessions, postprandial abdominal symptoms were reduced (1.6 score; P < 0.001 vs basal). Further reductions in the number of rumination events during the 6-mo observation period while controls had no changes	Modified basal postprandial muscular tone; Possibly increase awareness in patients to suppress rumination	6 mo
Halland et al[10]	United States	Prospective observational	16	9 (56)	Mean 37	Rome 3 rumination	Oesophageal HRiM+ done PRE, during and POST treatment	HRM+ guided biofeedback therapy	Behavioral therapy delivered by a single subspecialist gastroenterologist where he placed his hand on the patient’s abdomen and instructed patients in diaphragmatic breathing, which entails abdominal rather than chest motion. Patients were also instructed to observe the HRM+ monitor to observe the impact of DB on reduction in gastric pressurizations and regurgitation.	Not defined	Rumination episodes reduced from a median of 5 (2–10) to 1 (0–2) (P < 0.001) during, and 3 (1–5) after (P < 0.001 vs during) diaphragmatic breathing.	Diaphragmatic breathing increased EGJ pressure (P < 0.001) and restored a negative gastroesophageal pressure gradient [20 mmHg (80-7)] by reducing postprandial intragastric pressure. DB may also alter vagal acticity and reduce TLESR whilst increasing LES tone	Nil
O’Brien et al[2]	United States	Retrospective and Prospective observational	36	29 (81)	Mean 27	Not elaborated	All had oesophageal manometry, 20 had pH studies. Tests done PRE treatment	Various	6 prokinetics7 antacids3 behavioural therapy (e.g. biofeedback); 2 psychotherapy; 2 combined behavioural and psychotherapy	Not defined	12/16 patients reported subjected improvement, but not broken down to individual treatment options. No therapy deemed effective enough compared to another	N/A	Mean 25 (7-74)
Soykan et al[18]	United States	Retrospective and Prospective observational	10	6 (60)	Mean 28.5 (16-63)	Rome 2 for rumination syndrome	All had oesophageal manometry, electrogastrography, gastric emptying study. All done PRE treatment	Various	5 biofeedback;2 prokinetics;1 prokinetic and acid blockade; 1 leuprolide acetate and antacid; 1 no treatment	Not defined	all 5 undergoing biofeedback improved, 1 taking prokinetic improved	N/A	Mean 31.2 (6-72)
Vijayvargiya et al[12]	United States	Retrospective observational	57	54 (95)	Mean 30.3 (14-62)	Rome 3 for rumination syndrome and rectal evacuation disorder	11 oesophageal manometry, 45 gastric emptying, 3 pH studies, 6 barium oesophagogram, 12 SPECT+. All done PRE treatment	Diaphragmatic breathing	Via behavioural psychologist with instructions onf diaphragmatic breathing to abort or control regurgitation	Not defined	Not reported	N/A	N/A
Tucker et al[11]	United Kingdom	Prospective observational	46	34 (74)	18-68	HRM+ criteria (Rommel)	All had oesophageal HRM+ PRE treatment	Diaphragmatic breathing	All patients received a 20 min behavioural intervention immediately after HRM+ investigation. This included a description of the abnormal findings, cause of symptoms and explanation of the rationale for behavioural therapy. Behavioural instruction was focused on deep muscle relaxation and diaphragmatic breathing	Not defined	Complete improvement in rumination in 20/46 (43%). Partial improvement in 13 (28%)	N/A	Median 5 (3-11)
Lee et al[17]	South Korea	Prospective observational	21	8 (38.1%)	Mean 41.9	Modified Rome 2 for rumination ayndrome	All had oesophageal HRM+, pH study and gastric emptying tests PRE treatment	various	all given levosulpride 25 mg TDS+; supportive psychotherapy, education and reassurance given monthly, with 15 min sessions over a minimum of 6 mo via therapists experienced in eating disorders	Not defined	8 (38.1%) showed improvement, 47.6% unchanged while 3 (14.3%) worsened. Those who improved were statistically more likely to have undergone treatment for > 6 mo and less likely to have low mean LES+ pressure	N/A	Mean 19 (15-24)
Oelschlager et al[15]	United States	Prospective observational	5	4 (80%)	Mean 40.6 (18-61)	Rome 2 for rumination syndrome	All had oesophageal manometry and pH studies PRE treatment	Fundoplication	1 laparoscopic, 4 open Nissen fundoplication	Not defined	All had resolution of symptoms;3/5 had pathological acid exposure, 4/5 had hypotensive LES+, 3/5 had hiatal hernias	Restoration of LES+ dysfunction	Median 6 mo, 2 wk - 1 yr
Blondeau et al[13]	Belgium	Prospective observational	12	8 (67)	45 (18-89)	Clinical diagnosis	All had oesophageal HRiM+ PRE and POST treatment	Baclofen	10 mg TDS+ for a week	Not defined	Patients on baclofen recorded significantly fewer symptoms during the study [6 (2–22); P 0.01). The number of symptom markers for regurgitation was significantly reduced from 9 (0 –11) to 1 (0 –13) (P 0.01); The total number of flow events was significantly reduced from 473 to 282 (39.2%) during baclofen treatment (P 0.02)	Increase in LES+ function and reduction in TLESR+; Possible central mechanism of action to reduce sensitivity of stomach during distension and reduction of compulsive behaviour of straining; The number of TLESR+s during the postprandial period was significantly reduced from 15 (9-19) in baseline conditions to 7 (6-15) during baclofen treatment (P 0.03). The number of strains was reduced from 32 (17-48) in baseline conditions to 17 (2–70) during baclofen treatment (P 0.1).	No long term follows up
Johnson et al[16]	United States	Retrospective observational	5	3 (60)	Mean 26.8 (18-43)	Clinical diagnosis	1 barium oesophagogram; 1 gastric emptying test; all done PRE	Lifestyle changes	All advised to eat slowly, chew completely, avoid food triggers, regular exercises, weight reduction, stress management strategies	Not defined	All 5 had complete cessation of symptoms	Reduction in behavioural and cognitive processes that may develop and maintain symptoms; improvement in coping mechanisms for symptoms	Mean 34.4 (22-43)

EMG: Electromyography; HRiM: High resolution impedance manometry; LES: Lower esophageal sphincter; TLESR: Transient lower esophageal sphincter relaxation; TDS: Three times daily; HRM: High resolution manometry; SPECT: Single photon emission computed tomography.

Table 2 Summary of treatment options for rumination syndrome

Treatment	Strength of evidence	Treatment outcome
Diaphragmatic Breathing	RCT[8]	Regurgitation episodes decreased by 74% in the biofeedback group compared to 1% in placebo (P < 0.001)
	Prospective cohort with controls[9]	Regurgitation events decreased by 70% (P < 0.001).
	Prospective observational[10]	Median rumination episodes reduced from 5 (2–10) to 1 (0–2) (P < 0.001)
	Retrospective observational[12]	Not reported
	Prospective observational[11]	Complete improvement in rumination in 43%. Partial improvement in 28%
Baclofen	RCT[14]	Median regurgitation events lower with baclofen compared to placebo [4 (0–14) vs 6 (0–19), P = 0.04]
	Prospective observational[13]	Median regurgitation events significantly reduced from 9 (0-11) to 1 (0-13) (P 0.01)
Surgery	Prospective observational[15]	100% (5/5) resolution of symptoms
Psychotherapy	Prospective observational[17]	38.1% showed improvement. 47.6% unchanged.
	Retrospective observational[16]	100% (5/5) resolution of symptoms

Table 3 Suggested approach in treatment of rumination syndrome

Condition	Treatment
Initial treatment	Extensive explanation of condition and underlying mechanism together with reassurance of benign nature of condition[2,20]
	Diaphragmatic breathing by trained personnel (with EMG guidance or HRiM if available)
	If no response to diaphragmatic breathing after ensuring compliance, Baclofen 5-10 mg three times daily
For refractory cases	Consider alternative diagnosis (GERD, gastroparesis, functional dyspepsia, supragastric belching) and treat appropriately
	Since both DB and baclofen appear to be effective and work via different mechanisms, we postulate that a switching to the other therapy or a combination of these therapies could be useful in cases refractory to either treatments
	Address psychological illness, if present. Consider adjunctive psychological therapies to correct cognitive processes that may perpetuate symptoms

EMG: Electromyography; GERD: Gastroesophageal reflux disease; DB: Diaphragmatic breathing.