Background: Rumination is a subconscious but a volitional, behavioral disorder.
Contraction of the abdominal muscles results in an increase of abdominal pressure and a
subsequent regurgitation of recently ingested food, followed by rechewing, reswallowing
or spitting (1). The diagnosis is based on the Rome IV criteria for functional
gastrointestinal disorders and esophageal high-resolution manometry (1, 2). Behavioral
therapy consisting of diaphragmatic breathing exercises has proven efficient in these
patients (3, 4). Psychophysical physiotherapy was effective in a published patient case
(5).
Aim: The study aim is to diagnose patients with rumination syndrome defined by the Rome
IV criteria and to treat them with behavioral therapy. The primary aim is a reduction of
two points ore more in the rumination frequency measured by the Rome IV questionnaire for
adult functional gastrointestinal diseases (6). Secondary aims are improved esophageal
high-resolution manometry, health-related quality of life, and functional capacity and
reduced anxiety and depression scores.
Patients: 20 Finnish speaking, 15-70 years old patients with rumination symptoms
fulfilling the Rome IV criteria will be enrolled in this open study. Before referral to
Helsinki University Central Hospital, gastroscopy, esophageal high-resolution manometry
and esophageal 24-hour pH and impedance monitoring are required. Adolescents of 15 to 17
years old are referred to the childrens' gastroenterologist and adults 18 years or older
are referred to the gastroenterologist. The inclusion criteria consist of rumination
symtoms fulfilling the Rome IV criteria but esophageal high-resolution manometry may be
negative because rumination cannot be always provoked during the study.The exclusion
criteria comprise eating disorder, BMI <14, pregnancy, cognitive or other disorder that
disallows behavioral therapy
Methods: Symptoms will be evaluated by the Rome IV questionnaire for adult functional
gastrointestinal diseases in all patients. Health-related quality of life will be
evaluated by 15D, a 15-dimensional measure of health-related quality of life, depression
by Beck Depression Inventory (BDI), anxiety by the Beck Anxiety Inventory (BAI), and
functional capacity by WHODAS 2.0, World Health Organization disability assesment
schedule 2.0 in the patients 18 years or older (7-10). In the patients 15-17 years old,
health-related qualiy of life will be evaluated by 16D, a sixteen-dimensional
health-related measure for adolescents (11). All questionnaires will be carried out at
the onset of the study and at the 6-month control. Esophageal high-resolution manometry
will be performed at the 6-month control.
After the baseline visit to the gastroenterologist, patients will be sent to the speech
therapist for five, one-hour sessions consisting of diaphragmatic breathing exercises and
to a psychophysical physiotherapist for two one-hours sessions aiming at body-awareness
to sense tensed thoracic and abdominal muscles and to relax them through guided
exercises. Patients will continue these exercises at home during meals. All patient l
visit the psychologist and dietician once to rule out eating disorders and other
psychopathological conditions and will be referred to the psychiatrist when necessary.
Esophageal high-resolution manometry will be performed at the 6-month control.