Acid Reflux or Self-induced Vomiting or…?

Q. I have recently seen two people with bulimia nervosa, one in her teens and one in his mid-20s, who report the same problem involving vomiting after meals. They describe the vomiting as spontaneously occurring from 10 to 15 minutes after they eat. As they have described it, the food comes back up into the mouth and stops there. Often the patient reports chewing the food again, swallowing, and then “throwing up” the food. Is this due to gastric reflux, or even anxiety or is it an eating disorder symptom? (H.D., Fort Worth, TX)

A. The symptoms you have described suggest rumination disorder, which is now included in the DSM-5. It is uncommon, and is usually seen in younger children, and less often in teens and adults. Diagnostic uncertainty about GI reflux or self-induced vomiting, or avoidant restrictive food intake disorder (ARFID) can lead to unneeded tests and delays. And, in this instance, although the symptoms seem to point to reflux, one key pointing to rumination is the delay in symptoms and in vomiting. Usually the symptoms do not appear less than 15 minutes after eating. Regurgitation can then persist for 1 to 2 hours after finishing a meal.

A detailed history is the most important key to the correct diagnosis, but many patients struggle to differentiate between vomiting and regurgitation, according to Drs. Alexander Kusnik and Sarosh Vaqar of Unity Hospital, Rochester, NY (Stat Pearls Publishing, 2022). The correct diagnosis of rumination syndrome is often delayed. It appears that contraction of abdominal muscles is a key mechanism of rumination symptoms.

Kusnik and Vaqar suggest an involved workup evaluation of patients with suspected rumination syndrome, including a careful ED history, endoscopy or CT enterography, esophageal manometry, and EMG of the abdominal-thoracic muscles.

However, Murray and colleagues, in a recent review, suggest that in those with typical symptoms and no other known gastrointestinal problems, simply obtaining a careful history may suffice.

+After making the diagnosis, diaphragmatic breathing techniques are the standard treatment approach. Education is clearly also valuable. Once people understand that this condition can be treated without medications or invasive tests, most are relieved about their symptoms and the anxiety over this condition subsides.

—SC