Supplement Abstracts Submitted for the 73rd Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
Purpose: Rumination is a behavioral disorder that is characterized by the effortless regurgitation of undigested food typically within minutes of starting a meal or completion of a meal often accompanied by both a sensation of belching and/or a voluntary contraction of abdominal muscles. Transient lower esophageal sphincter relaxation (TLESR) has been recognized as the predominant mechanism for gastroesophageal reflux. Primary treatment of TLESR is the gamma-aminobutyric acid-beta (GABA-beta) agonist, baclofen, which may decrease TLESR's and treat rumination.
Results: A 22-year-old U.S. Naval Academy Midshipman presented to the Gastroenterology Service with complaint of lifelong, mild, post-prandial heartburn as well as effortless regurgitation of fluid into the mouth which was exclusively diurnal. Occasionally, episodes were associated with extraesophageal manifestations to include hoarseness, cough, and dyspnea. Physical examination and initial labs were unremarkable. Baseline manometry and pH/Impedances studies were normal (LESp = 16 mmHg, normal esophageal peristalsis –67 mmHg, and normal 24-hr pH score off PPI's (11.6). The patient was placed on a PPI's which relieved refluxate acidity but not frequency of regurgitation episodes. The patient was then placed on baclofen 10 mg po tid 30–60 minutes prior to meals resulting in significant improvement of rumination. Repeat manometry/pH-Impedance studies showed a significant reduction in the number of regurgitant episodes post vs. pre baclofen (18 to 1) and number of proximal impedance reflux episodes (45 to 8). LESp (12 vs. 13.3 and distal reflux episodes remained similar (76 vs. 80). The patient also underwent biofeedback/hypnotherapy with similar results as baclofen.
Conclusion: Rumination is a behavioral disorder which is difficult to treat. Baclofen or self hypnotherapy should be considered in treating patients with rumination as PPI's lower acid but does not affect the primary mechanism of rumination.