20.7 Rumination Disorder

Etiology and Diagnosis of Rumination

Rumination syndrome can mimic gastrointestinal disorders and is often misdiagnosed (Taclob et al., 2022). Clients can present with symptoms of heartburn or abdominal pain that is also seen with gastrointestinal disorders, and report “vomiting.” (Kusnik & Vaqar, 2023). Obtaining a detailed history is essential to determining if the client has an eating disorder. For example, it will be helpful to know if the client is experiencing vomiting versus regurgitation where the action is effortless. DSM-5 criteria also requires that the symptoms occur over one month and not be from a medical condition, so evaluation and testing may be needed to rule out gastrointestinal causes. Rumination syndrome can affect individuals of all ages with an estimated prevalence between 0.8 percent and 10.6 percent (Murray et al., 2019). There are also higher incidences of rumination disorder seen in individuals with intellectual disorders such as developmental delays (APA, 2023b). The recommended diagnostic tests used to evaluate possible rumination syndrome include the following:

• Gastric emptying studies: These studies measure the time it takes for food to move in the gastrointestinal tract and can help rule out conditions like reflux or gastroparesis.
• Electromyography (EMG): This test measures electrical signals in the abdominal muscles and can help determine a rumination diagnosis.
• High-resolution esophageal manometry (HRIM): This test measures gastric pressure and can be used to evaluate for rumination syndrome.
• Endoscopy: A scope is inserted into the gastrointestinal tract and can be used to visualize any possible mechanical obstructions.
• High-resolution impedance-pH manometry: The study measures pressure and pH and is used to confirm rumination syndrome and determine if it is primary or secondary. With primary rumination, there is reflux followed by abdominal pressure increase, whereas the opposite is seen in secondary rumination (Kusnik & Vaqar, 2023).

There is limited information regarding the development of rumination disorder (Schweizer et al., 2018). Temperament and parenting factors have been associated with rumination syndrome. Individuals with temperaments that include high negative emotions such as fear, anger, and sadness are at higher risk for developing rumination disorder; a persistent focus on negative emotions is seen with rumination (Schweizer et al., 2018). Parenting styles also may have an effect on the development of rumination disorder. The highest levels of rumination disorder have been found in clients with overcontrolling parents and those who have negative parenting behaviors like hostility (Schweizer et al., 2018). Other developmental factors, such as having developmental delays seen with intellectual disorders, have also been associated with rumination disorder. The act of regurgitating is thought to be self-soothing or self-stimulating for infants along with individuals with intellectual disabilities, and that may factor into the development of rumination syndrome (APA, 2023b).

Treatment

Rumination syndrome is a treatable condition and is considered an acquired habit that can be reversed (Kusnik & Vaqar, 2023). The most effective treatments for rumination syndrome are behavioral therapies that include diaphragmatic breathing and biofeedback (Sasegbon et al., 2022). Diaphragmatic breathing is a technique that involves having the client breathe by expanding and contracting their abdomen versus chest breathing (Sasegbon et al., 2022). This technique interferes with abdominal contractions that may lead to regurgitation, especially after a meal (Sasegbon et al., 2022). Biofeedback is an advanced behavioral therapy that may be used to improve diaphragmatic breathing. It involves using electromyography to guide diaphragmatic breathing by helping to decrease chest breathing and increase abdominal breathing (Murray et al., 2019). Other behavioral therapies that have shown promise include general relaxation and distractions like gum chewing. Cognitive behavioral therapy for rumination disorder may also be effective (Kusnik & Vaqar, 2023).

Medications are not typically used to manage rumination disorders unless they are treating underlying conditions. Behavioral therapies are considered first-line, but baclofen is a medication that has been used for clients who do not respond to behavioral interventions (Murray et al., 2019). Baclofen is an antispasmodic medication that has been found to reduce the frequency of regurgitation in clients with rumination syndrome (Murray et al., 2019). Its mechanism of action involves stopping the relaxation of the lower esophageal sphincter by increasing the pressure in that area. The counteractivity produced by baclofen has been effective in decreasing episodes of regurgitation (Kusnik & Vaqar, 2023).

Nursing Considerations

Nurses have vital roles in managing clients with rumination disorder. They can help manage medical complications like dehydration by administering fluids and electrolyte replacements. They can provide education on rumination disorder and help clients and their families understand the condition. They can also implement behavioral therapies and collaborate with other professionals involved in the plan of care, such as medical providers and behavioral therapists.

Education on rumination syndrome should occur with the client and family. They should be educated on symptoms to look for related to medical complications and when to seek prompt care. Symptoms like notable weight loss and signs of dehydration could indicate severe nutritional or electrolyte deficiencies that require treatment. Because dental erosions are a common complication seen with rumination disorder, encourage oral hygiene.

Clients should also be educated on behavioral techniques used to manage rumination syndrome, like diaphragmatic breathing. Abdominal breathing is different from chest breathing, so it will be helpful to demonstrate this technique for clients and families when providing education. Recommend that clients start practicing diaphragmatic breathing for five to ten minutes while lying flat with their knees bent until they become comfortable with the technique. Once they are comfortable, they can perform this technique while sitting to suppress the urge to regurgitate (Sasegbon et al., 2022). Education can include providing links to John Hopkins and Mayo Clinic, which offer resources regarding eating disorders, including rumination disorder.