Systematic Review
Copyright ©The Author(s) 2019.
World J Meta-Anal. Jun 30, 2019; 7(6): 297-308
Published online Jun 30, 2019. doi: 10.13105/wjma.v7.i6.297
Table 1 Characteristics of studies included in analysis
StudySiteType of studynFem (%)Age (yr) (range)Diagnostic criteriaPhysiological tests doneTreatmentDescription of treatmentPrimary outcomeMain resultsProposed mechanism of actionFollow up period (mo)
Barba et al[8]SpainRCT, Placebo controlled127 (58)Median 42 (19-69)Rome 3 rumination syndromeEMG+ activity of abdomino-thoracic muscles, done PRE and POSTEMG+ guided biofeedbackPre-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 dReduction in rumination episodes measured over 10 d, patient reportedRegurgitation 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 rumination6 mo
Pauwels et al[14]BelgiumRCT, Placebo controlled106 (60)Mean 42 (18-61)Rome 4 rumination syndrome and/or supragastric belchingOesophageal HRiM+ done PRE and POSTBaclofen5 mg tds first week then increased to 10 mg tds second week, followed by 1 wk washout period, before 2 wk crossover to alternative treatmentNumber 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]SpainProspective cohort with controls2417 (71)14-76Rome 3 rumination syndromeEMG+ activity, done PRE and POST treatmentEMG+ guided biofeedbackPre-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 dNot definedPost-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 changesModified basal postprandial muscular tone; Possibly increase awareness in patients to suppress rumination6 mo
Halland et al[10]United StatesProspective observational169 (56)Mean 37Rome 3 ruminationOesophageal HRiM+ done PRE, during and POST treatmentHRM+ guided biofeedback therapyBehavioral 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 definedRumination 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 toneNil
O’Brien et al[2]United StatesRetrospective and Prospective observational3629 (81)Mean 27Not elaboratedAll had oesophageal manometry, 20 had pH studies. Tests done PRE treatmentVarious6 prokinetics7 antacids3 behavioural therapy (e.g. biofeedback); 2 psychotherapy; 2 combined behavioural and psychotherapyNot defined12/16 patients reported subjected improvement, but not broken down to individual treatment options. No therapy deemed effective enough compared to anotherN/AMean 25 (7-74)
Soykan et al[18]United StatesRetrospective and Prospective observational106 (60)Mean 28.5 (16-63)Rome 2 for rumination syndromeAll had oesophageal manometry, electrogastrography, gastric emptying study. All done PRE treatmentVarious5 biofeedback;2 prokinetics;1 prokinetic and acid blockade; 1 leuprolide acetate and antacid; 1 no treatmentNot definedall 5 undergoing biofeedback improved, 1 taking prokinetic improvedN/AMean 31.2 (6-72)
Vijayvargiya et al[12]United StatesRetrospective observational5754 (95)Mean 30.3 (14-62)Rome 3 for rumination syndrome and rectal evacuation disorder11 oesophageal manometry, 45 gastric emptying, 3 pH studies, 6 barium oesophagogram, 12 SPECT+. All done PRE treatmentDiaphragmatic breathingVia behavioural psychologist with instructions onf diaphragmatic breathing to abort or control regurgitationNot definedNot reportedN/AN/A
Tucker et al[11]United KingdomProspective observational4634 (74)18-68HRM+ criteria (Rommel)All had oesophageal HRM+ PRE treatmentDiaphragmatic breathingAll 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 breathingNot definedComplete improvement in rumination in 20/46 (43%). Partial improvement in 13 (28%)N/AMedian 5 (3-11)
Lee et al[17]South KoreaProspective observational218 (38.1%)Mean 41.9Modified Rome 2 for rumination ayndromeAll had oesophageal HRM+, pH study and gastric emptying tests PRE treatmentvariousall 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 disordersNot defined8 (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+ pressureN/AMean 19 (15-24)
Oelschlager et al[15]United StatesProspective observational54 (80%)Mean 40.6 (18-61)Rome 2 for rumination syndromeAll had oesophageal manometry and pH studies PRE treatmentFundoplication1 laparoscopic, 4 open Nissen fundoplicationNot definedAll had resolution of symptoms;3/5 had pathological acid exposure, 4/5 had hypotensive LES+, 3/5 had hiatal herniasRestoration of LES+ dysfunctionMedian 6 mo, 2 wk - 1 yr
Blondeau et al[13]BelgiumProspective observational128 (67)45 (18-89)Clinical diagnosisAll had oesophageal HRiM+ PRE and POST treatmentBaclofen10 mg TDS+ for a weekNot definedPatients 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 StatesRetrospective observational53 (60)Mean 26.8 (18-43)Clinical diagnosis1 barium oesophagogram; 1 gastric emptying test; all done PRELifestyle changesAll advised to eat slowly, chew completely, avoid food triggers, regular exercises, weight reduction, stress management strategiesNot definedAll 5 had complete cessation of symptomsReduction in behavioural and cognitive processes that may develop and maintain symptoms; improvement in coping mechanisms for symptomsMean 34.4 (22-43)
Table 2 Summary of treatment options for rumination syndrome
TreatmentStrength of evidenceTreatment outcome
Diaphragmatic BreathingRCT[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%
BaclofenRCT[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)
SurgeryProspective observational[15]100% (5/5) resolution of symptoms
PsychotherapyProspective 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
ConditionTreatment
Initial treatmentExtensive 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 casesConsider 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