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Persistent Postprandial Regurgitation vs Rumination in Patients With Refractory Gastroesophageal Reflux Disease Symptoms

Identification of a Distinct Rumination Pattern Using Ambulatory Impedance-pH Monitoring

Nakagawa, Kenichiro MD, PhD1,2; Sawada, Akinari MD, PhD1; Hoshikawa, Yoshimasa MD, PhD1; Nikaki, Kornilia MD1; Sonmez, Shirley MRS1; Woodland, Philip MD, PhD1; Yazaki, Etsuro PhD1; Sifrim, Daniel MD, PhD1

American Journal of Gastroenterology: August 2019 - Volume 114 - Issue 8 - p 1248–1255
doi: 10.14309/ajg.0000000000000295

OBJECTIVES: Up to 20% of patients with refractory gastroesophageal reflux disease (GERD) might have postprandial rumination. The aim of this study was to distinguish persistent GERD-related postprandial regurgitation from rumination in patients with refractory GERD undergoing ambulatory multichannel intraluminal impedance–pH (MII-pH) monitoring.

METHODS: We first characterized 24-hour and postprandial MII-pH patterns in 28 consecutive patients with confirmed rumination syndrome (positive clinical and high-resolution manometry/impedance). We compared such MII-pH patterns with those from 30 patients with typical GERD symptoms (10 nonerosive reflux disease, 10 hyperactive esophagus, and 10 functional heartburn) and 27 healthy controls. Using ROC curves, we selected the best MII-pH parameters to prepare an MII-pH rumination score. We prospectively tested the performance of the new MII-pH rumination score in 26 consecutive patients with refractory GERD (predominant regurgitation).

RESULTS: Compared with GERD controls, patients with rumination were more often females, younger, and had significantly more postprandial early nonacid reflux episodes with high proximal extent. Postprandial reflux in ruminators had a distinct nadir pH profile over time (from nonacid to acid). Despite increased reflux events, baseline impedance in ruminators was similar to that in healthy subjects. Ruminators marked postprandial symptoms earlier and much more often than patients with GERD. An MII-pH–based rumination score (using postprandial nonacid reflux/hour and Symptom Index) diagnosed rumination in 46% of patients with refractory GERD and persistent regurgitation (sensitivity 91.7% and specificity 78.6%).

DISCUSSION: Postprandial rumination is very common in refractory GERD with persistent regurgitation. A simple MII-pH score detects rumination in these patients with high sensitivity and specificity.

1Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom;

2Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Correspondence: Daniel Sifrim, MD, PhD. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at

Received February 06, 2019

Accepted May 03, 2019

Online date: June 26, 2019

© The American College of Gastroenterology 2019. All Rights Reserved.
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