Combined high-resolution manometry and impedance measurement as diagnostic tools in the rumination syndrome

Rumination syndrome is a functional gastroduodenal disorder of unknown etiology
characterized by persistent or recurrent regurgitation of recently ingested
food into the mouth, typically not preceded by retching and occurring without
nausea1-3.
Diagnosis is currently based on clinical features as defined by the Rome III
criteria1,4. Differentiating rumination syndrome from other pathology that can
present with similar complaints can be challenging. Gastro-esophageal reflux
disease can present with regurgitation symptoms, regurgitation can occur
secondary to gastroparesis, symptoms can be mistaken for aerophagia or
excessive belching and other functional disorders can also be mistaken for
rumination syndrome1. Rumination syndrome is currently a syndrome that can only
be diagnosed by clinical observation by a physician with expertise in
esophageal motility disorders. As there are only clinical criteria and no
objective tests to diagnose rumination, this syndrome is an underappreciated
condition in which patients are often misdiagnosed1. Patients often have
symptoms for several years and have consulted many different physicians before
rumination syndrome is diagnosed5.

A relatively new techniques is impedance recording which measures not only acid
reflux but also non-acid-reflux and gas-reflux. This offers the advantage of
differentiation between belching and regurgitation by differentiating gaseous
reflux from liquid reflux and also detect non-acidic regurgitation6. Two case
reports described the role of combined manometry/impedance in patients with
rumination syndrome. The authors observed an increase in intra-abdominal
pressure followed by an increase in intra-esophageal pressure in all channels
(common cavity) that was associated with esophageal reflux on impedance
monitoring7,8. Recently, Rommel et al were able to successfully differentiate
between belching-regurgitation and rumination syndrome using
manometry/impedance measurement by differentiating gas reflux from fluid reflux
with impedance measurement9.
A second relatively new technique is high resolution manometry which offers the
advantage of a more detailed measurement of the whole esophageal body including
measurement of the upper esophageal sphincter10.
Despite the fact that rumination syndrome shows typical patterns when measured
by combined (high-resolution) manometry and impedance7,8, only limited efforts
have yet been made to differentiate rumination syndrome from other pathology,
using these objective measurements. Interpretation of esophageal function tests
in patients suspected of rumination syndrome is therefore challenging due to
absence of objective criteria and can only be performed by an expert physician.
These shortcomings in current diagnostic tools for the rumination syndrome
contribute to under-appreciation and often a misdiagnosis of the syndrome.
Objective criteria are of clinical importance to allow correct and quick
recognition of the syndrome even by physicians with limited expertise in
esophageal motility disorders thereby contributing to early recognition and
proper treatment.

The aim of this study is to measure and describe differences in manometric and
impedance patterns in patients with an initial presentation of regurgitation
and/or vomiting with and without clinical diagnosis of rumination syndrome.
With these differences we will subsequently be able to create objective
criteria in the future that can help to distinguish rumination syndrome from
other, rather similar presenting disorders.

A prospective study using combined high-resolution manometry and impedance
measurements in which patients presenting with true rumination are compared to
patients with regurgitation and vomiting that do not have the rumination
syndrome.

Patients have to stop PPI or medication influencing GI-motility and have to
travel to the AMC. There are no known risks associated with these
investigations.