Rumination Clinical Presentation

Symptoms of rumination may include the following:

• Weight loss

• Halitosis

• Indigestion

• Chronically raw and chapped lips

Vomitus may be noted on the individual's chin, neck, and upper garments.

Regurgitation typically begins within minutes of a meal and may last for several hours. Regurgitation occurs almost every day following most meals.

Regurgitation is generally described as effortless and is rarely associated with forceful abdominal contractions or retching.

Infants with rumination display a characteristic position of straining and arching the back with the head held back, making sucking movements with their tongue. They may also exhibit irritability and hunger, as well as weight loss and failure to make expected weight gains. Malnutrition may occur. ^[2]

Physical findings in patients with rumination may include the following:

• Regurgitation

• Vomiting not visible to others

• Unexplained weight loss, growth failure

• Symptoms of malnutrition

• Antecedent behaviors including postural changes, putting hands into mouth, and gentle gagging motion of the neck region

• The patient may appear to derive satisfaction and sensory pleasure from mouthing the vomit rather than considering vomitus in the mouth disgusting

• Tooth decay and erosion

• Aspiration that may cause recurrent bronchitis or pneumonia, reflex laryngospasm, bronchospasm, and/or asthma

• Premalignant changes of the esophageal epithelium (ie, Barrett epithelium) that may occur with chronic rumination

Although the etiology of rumination is unknown, multiple theories have been advanced to explain the disorder. These theories range from psychosocial factors to organic origins. Cultural, socioeconomic, organic, and psychodynamic factors have been implicated. The following causes have been postulated over the years.

Adverse psychosocial environment

The most commonly cited environmental factor is an abnormal mother-infant relationship in which the infant seeks internal gratification in an understimulating environment or as a means to escape an overstimulating environment.

Onset and maintenance of rumination has also been associated with boredom, lack of occupation, chronic familial disharmony, and maternal psychopathology.

Learning-based theories

Learning-based theories propose that rumination behaviors increase following positive reinforcement, such as pleasurable sensations produced by the rumination (eg, self-stimulation) or increased attention from others after rumination.

Rumination may also be maintained by negative reinforcement when an undesirable event (eg, anxiety) is removed.

Organic factors: The role of medical/physical factors in rumination is unclear. Although an association between gastroesophageal reflux (GER) and the onset of rumination may exist, some researchers have proposed that various esophageal or gastric disorders may cause rumination.

Psychiatric disorders: Rumination in adults of average intelligence has been associated with psychiatric disorders (eg, depression, anxiety).

Heredity: Although occurrences in families have been reported, no genetic association has been established.

Other proposed physical causes of rumination include the following:

• Dilatation of the lower end of the esophagus or of the stomach

• Overaction of the sphincter muscles in the upper portions of the alimentary canal

• Cardiospasm

• Pylorospasm

• Gastric hyperacidity

• Achlorhydria

• Movements of the tongue

• Insufficient mastication

• Pathologic conditioned reflex

• Aerophagy (ie, air swallowing)

• Finger or hand sucking