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RUMINATION SYNDROME, BELCHING, AEROPHAGIA.pptx
- 6. Introduction • When translated into English, the Latin word ruminor means to chew over again. This word has been used to describe the behaviour of a class of herbivorous mammals who, due to the indigestibility of the foods they eat, require that food is regurgitated and rechewed before being reswallowed to aid its breakdown and subsequent digestion. In certain herbivorous animals, rumination is, therefore, a normal, voluntary activity whereby gastric contents are brought up and rechewed as often as needed to optimise digestion. By contrast, rumination in humans, which was first described in 1618, is pathological as omnivores have no need of chewing the cud and
- 7. Introduction • In humans, rumination is thought to be an acquired behavioural disorder. It is often unconscious and can occur in both children and adults.Although individuals with learning difficulties or eating disorders can suffer from rumination syndrome, it can and indeed often occurs in otherwise healthy individuals.
- 9. Incidence • Depending on whether children or adults are being studied, the prevalence of rumination syndrome ranges from 0.1% to 4% in children and 0.8% to 8% in adults. In a recent Rome Foundation global epidemiological study, rumination syndrome was found to have an overall worldwide prevalence of 2.8% with women having a slightly higher prevalence (3.1%) than men (2.5%). A higher prevalence of rumination syndrome has been noted in those with eating disorders (20%) and those with fibromyalgia (8%).
- 10. Rumination syndrome • Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen.
- 11. • Rumination syndrome is a functional gastrointestinal disorder of unknown etiology characterized by effortless, often repetitive, regurgitation of recently ingested food into the mouth. • The regurgitated material can either be chewed and re-swallowed or expectorated by the patient.
- 12. • There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation, as there is with typical vomiting, and the regurgitated food is undigested. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities
- 14. Clinical features • Diagnostic criteria for rumination syndrome feature in the literature from three sources. First, the Rome IV diagnostic criteria for gastroduodenal disorders, the International Classification of Diseases or the Diagnostic and Statistical Manual for mental Disorders (table 1).
- 30. Complications • When severe, rumination syndrome can lead to malnutrition and dehydration which, in turn, can lead to electrolyte imbalances and the occurrence of refeeding syndrome when nutrition improves. Malnutrition and dehydration arise due to either a possible reduced desire to eat or drink so as to avoid episodes of regurgitation or spitting of food and fluids, reducing nutritional intake below what is required for good health. • Additional complications in children and adults include failure to thrive, dental erosions, an increased likelihood of aspiration, halitosis and stigma due to the rumination itself or
- 31. Differential diagnoses • While there is a long list of potential differentials for patients presenting with recurrent episodes of regurgitation, a few key conditions need to be excluded if, after a history is obtained, there remains a degree of uncertainty (table 2). GORD, achalasia, gastric outlet obstruction and gastroparesis can present with recurrent regurgitation although often with other symptoms including nausea and dysphagia. From a mental health standpoint, bulimia nervosa can mimic rumination syndrome, and an early psychiatric opinion should be sought if there is a suspicion of an eating disorder.
- 34. Investigations • The gold standard investigation for rumination syndrome, in cases where a history is insufficient to make a firm diagnosis, is high-resolution oesophageal manometry (HROM) with concurrent impedance monitoring. The manometric aspect of the investigation enables visualisation of the abrupt rise in gastric pressure and subsequent postprandial relaxation of the LOS, while the concurrent impedance monitoring demonstrates the regurgitated material.
- 35. • Gastric pressures increase by ≥30 mm Hg followed by cranial movement of gastric contents. HROM involves a manometry catheter, containing >30 pressure sensors interspersed at 1 cm intervals, being inserted transnasally before patients are asked to either lie supine (classically) or sit upright. The catheter is positioned so that its tip is roughly 5 cm below the LOS. Some advanced oesophageal high-resolution manometry systems have in-built combined oesophageal impedance capability which is ideal for the
- 36. • In the absence of a system with combined impedance/manometry, a second catheter in the opposite nostril for concurrent pH/impedance recording is often required. During a test for suspected rumination, patients are often instructed to consume a ‘test meal’ such as a cereal, and during the stationary manometry study monitoring is usually extended for up to 3 hours postprandially. During the test, oesophageal pressure and impedance traces can be visualised providing visual cues to demonstrate observed abnormalities to patients (figure 3A). This can help improve understanding and acceptance of the diagnosis. Episodes of rumination often occur sporadically, and can be influenced by an individual’s social setting or level of distraction. As a result, longer studies with ambulatory 24- hour HROM, despite not being widely available, may have the potential to improve the diagnostic yield.
- 42. Figure 1. • Muscular mechanism of rumination by electromyography. (A) Rumination (light blue arrow) occurs as a result of abdominal compression (orange arrow), coupled with chest expansion (green arrow). (B) Electromyography showing increased intercostal activity and abdominal wall activation during rumination events (blue box).
- 43. Figure 1 Clinical Gastroenterology and Hepatology 2018 161549-1555DOI: (10.1016/j.cgh.2018.05.049) Copyright © 2018 AGA Institute Terms and Conditions
- 44. Figure 2(A). • Rumination shown on gastroduodenal manometry; R waves are marked with asterisks and coincide with regurgitation. (B) High-resolution impedance manometry; impedance detected rumination events noted with stars. (C) Electromyography shows activation of intercostal and abdominal wall muscles during rumination.
- 45. Figure 2 Clinical Gastroenterology and Hepatology 2018 161549-1555DOI: (10.1016/j.cgh.2018.05.049)
- 46. Figure 3. • Diaphragmatic breathing. (A) The patient slowly inhales through the nose while protruding the abdomen and keeping the chest stationary. (B) The patient slowly exhales via the mouth and allows the abdomen to retract.
- 47. Treatment • Provide education and reassurance • Diaphragmatic breathing = First line therapy – Can do with biofeedback therapy with high resolution manometry or Electromyography(EMG).
- 48. Figure 3 Clinical Gastroenterology and Hepatology 2018 161549-1555DOI: (10.1016/j.cgh.2018.05.049)
- 49. Figure 4. • Approach to the patient with postprandial regurgitation or vomiting. A suggested approach to patients who report postprandial symptoms and vomiting is outlined, including a key, but not an exhaustive, differential diagnosis. CNS, central nervous system; EGJOO, esophagogastric junction outflow obstruction; GERD, gastroesophageal reflux disease; IRP, integrated relaxation pressure.
- 52. Figure 4 Clinical Gastroenterology and Hepatology 2018 161549-1555DOI: (10.1016/j.cgh.2018.05.049)
- 54. Key messages • Rumination syndrome should be considered in any patient who presents with recurrent regurgitation without associated retching or significant nausea. • Behavioural therapies including diaphragmatic breathing and biofeedback are effective treatments for rumination syndrome and have the largest evidence bases. • Following treatment, most patients have large reductions in their frequency of
- 67. Belching • Belching is defined as the eructation of gas through the mouth; • bloating is gaseous abdominal distention; and • flatulence is the passage of intestinal gas through the rectum.
- 68. Belching • Belching is not a symptom of organic disease. The only cause of belching is the swallowing of air (aerophagia). Air is swallowed or, more accurately, sucked into the stomach and released in the form of a belch. Air swallowing may occur with eating or drinking; more air is swallowed with liquids than with solids.
- 69. Belching • Aerophagia also occurs as a conscious or, more often, an unconscious nervous habit unassociated with food ingestion. It can also be associated with mouth breathing, gum chewing, orthodontic appliances, and poorly fitting dentures.
- 70. Belching • Chronic, repetitive, unintentional belching is usually caused by repetitive inhalation of air and its regurgitation from the stomach or esophagus in the form of a belch. Some patients who demonstrate these findings consciously or unconsciously relax the upper esophageal sphincter during inspiration. Belching occurs in patients with dyspepsia and may be an uncommon sign of gastroesophageal reflux. It cannot be used to differentiate between them.
- 71. Types of Belching • Two Types of Belching: • Gastric Belching and • Supragastric Belching
- 89. Nature of Patient • Excessive belchers tend to be nervous, anxious, and tense. Belching is often normal in infants, although excessive belching may be the result of excessive air swallowing during feeding. If the seal of the infant’s lips is inadequate around the real or artificial nipple, air may be ingested during nursing. This may be exaggerated if during feeding the child is held in a position that is too horizontal.
- 90. Nature of Patient • Some patients with gastric or biliary disorders develop a habit of trying to relieve abdominal discomfort by swallowing (sometimes unconsciously) air and belching it up again; they believe that this provides some relief from their abdominal discomfort.
- 91. Nature of Patient • If associated pathology can be confidently ruled out, patients must be reassured that nothing serious is wrong. It may help to describe how a patient with a laryngectomy can be trained to swallow air; accordingly, a patient with a belching problem can be untrained. Simply instructing some patients not to belch when they feel the urge to do so may gradually stop their habit of swallowing air and belching it back. Antifoaming agents have not been particularly helpful. Instead, patients should be instructed to avoid chewing gum, eating quickly, smoking, and drinking carbonated beverages.
- 92. Associated Symptoms • The most common associated symptom is abdominal distention, representing gas in the stomach. Most swallowed air that is not belched up is reabsorbed in the small intestine. Usually, intestinal gas is derived by fermentation of intestinal contents. Some patients who swallow large amounts of air may experience or perceive abdominal discomfort until they belch. An urge to belch accompanied by chest pain on belching is a rare finding that may indicate an inferior wall myocardial infarction.
- 93. Precipitating and Aggravating Factors • The most common precipitating factor is air swallowing and subsequent relaxation of the esophageal sphincter to produce a belch. Nervous concern about belching can initiate a vicious circle of unconscious air swallowing and more belching. For some individuals, a supine position prevents swallowed gastric air from escaping into the esophagus, and an upright position facilitates belching. Emotional stress increases the likelihood of air swallowing. Ingestion of carbonated beverages, gum chewing, and poorly fitting dentures may also aggravate belching.
- 94. Diagnostic Studies • Although belching is invariably caused by swallowing air, this fact does not rule out coexisting unrelated pathology. If other symptoms warrant further tests, cholecystography, upper gastrointestinal (GI) studies, and chest radiography should be considered.
- 95. • Figure 1. Combined high-resolution manometry and impedance monitoring showing a supragastric belch. Because of a contraction of the diaphragm, the esophagogastric junction (EGJ) moves distally and a decrease in pressure in the esophagus is observed. Subsequently, relaxation of the UES allows the influx of air from the pharynx into the esophagus seen on the impedance tracing (arrow). The supragastric belch is characterized by an increase in impedance, starting in the proximal impedance channel, and progressing to the most distal impedance channel and followed by a return to baseline, starting in the most distal channel and progressing to the proximal channel. The movement of air out of the esophagus in a retrograde direction is caused by straining, as can be seen as a simultaneous increase in pressure in esophageal and gastric channels.Clinical Gastroenterology and Hepatology , 6-12DOI: ( /j.cgh )Copyright © 2013 AGA Institute Terms and Conditions
- 97. Figure 2. • Abdominal radiograph of a patient with aerophagia showing a large volume of intestinal and colonic air; there are some signs of constipation as well but no air-fluid levels. Impedance monitoring showed massive air swallowing. • Clinical Gastroenterology and Hepatology , 6-12DOI: ( /j.cgh )Copyright © 2013 AGA Institute Terms and Conditions
- 99. Less Common Diagnostic Considerations • Oral eructation of intestinal gas rarely occurs. In patients with this condition, the odor is offensive, resembling that of methane or hydrogen sulfide. It suggests fermentation in stagnating gastric contents secondary to gastroparesis, vagotomy, or pyloric obstruction from an ulcer or tumor.
- 100. Effect of Baclofen 10mg TID on Reflux
- 101. Aerophagia • Aerophagia is a functional gastrointestinal disorder characterized by repetitive air swallowing, abdominal distension, belching and flatulence
- 102. Functional aerophagia • Functional aerophagia (FA) involves excessive air swallowing causing progressive abdominal distension. The typical clinical presentation is a non-distended abdomen in the morning, progressive abdominal distension during the day, visible, often audible, air swallowing and excessive flatus.
- 103. Pathologic aerophagia • When FA is associated with various gastrointestinal symptoms, such as burping, abdominal pain, flatulence and belching, this condition is de fined as pathologic aerophagia. • Pathologic aerophagia is present in 8.8% of the mentally retarded population.
- 104. Identification of a patient with aerophagia based on the Rome III Criteria for FGIDs
- 105. Clinical evaluation of patients with aerophagia
- 107. • FA in patient 1. • Abdominal distension represents the most satisfactory criterion for diagnosis; it can be observed especially in the second part of the day.
- 109. • FA in patient 1. • Gaseous distension of the large bowel and rectum without signs of obstruction can be observed on orthostatic abdominal radiograph.
- 111. Thankyou