Mysterious Case With a Simple Cause
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Welcome back to another installment of GI Common Concerns—Computer Consult.
In my last Computer Consult, I gave you a tip on physical diagnosis that saves a lot of time, energy, and expense when evaluating abdominal pain: the Carnett sign.
This time I want to chat with you about the very simple and unique therapeutic intervention of diaphragmatic breathing to treat rumination syndrome.
Recently, I saw a patient whose case got me thinking about this. She was sent to me because they were so frustrated that no one could figure out why she was having refractory reflux.
She had a classic history, with repetitive regurgitation of food, frequently beginning within a couple of minutes of her meal. Following regurgitation, she'd sometimes spit out her food and sometimes chew it back up and simply reswallow it. It was never associated outside of a meal and never with heartburn. There was nothing that related to her early satiety or any type of obstructive symptoms. She was treated with a variety of medications, including countless doses of proton-pump inhibitors and H2-receptor antagonists at bedtime. She went through every paradigm of reflux therapy, which was not directed appropriately because what she had was not reflux disease but instead classic rumination syndrome.
This had been going on for years. There was no shocking precipitating event, which you'll sometimes get in patients with rumination syndrome. Instead, this was really an effortless regurgitation that recurred repetitively and always associated with meals.
Rumination's Physiologic Causes
When considering what to do for rumination syndrome, first you need to understand the physiologic changes that lead to it. Dr Steve Shay and his colleagues at Walter Reed Medical Center in Bethesda, Maryland, taught me a lot about this back in the mid-1980s. They defined what happens with rumination, where patients will move their neck forward and get an abdominal wall contraction that then overcomes the lower esophageal sphincter. As you would normally with something like a belch, you would relax both the lower and upper esophageal sphincter, resulting in regurgitation of food back up into the mouth. This is rumination syndrome's classical definition.
Of note, other investigators have shown that the abdominal distention pressure to induce that lower esophageal sphincter relaxation, which we see with transient lower esophageal sphincter relaxation in gastroesophageal reflux disease, is lower than what you would see with commonly occurring gas distention for a postprandial reflux event. This is a lower distention pressure with a hypersensitivity for relaxation of the lower esophageal sphincter.
Treating Rumination With a Simple Breathing Technique
What do you do for patients with rumination syndrome?
Most of us don't have technicians and physiotherapists to whom we can send these patients. For a variety of reasons, they're often lost in the system and left to continue to seek effective treatment for long periods of time, as was the case with my patient.
The technique that I use for these patients, which I'd like to describe to you here, is called diaphragmatic breathing. It addresses the abdominal wall compression that induces some of the precipitating events for rumination. It's a technique that patients who know yoga will identify with very quickly.
I tell these patients that I want to do some breathing exercises with them where they put one hand on their chest and the other on their belly button. This allows them to get an abdominal reach with the open fist and a chest wall reach with their upper arm. Then I ask them to take a deep breath, which allows for the shoulders to go up and to have thoracic expansion. The chest rises, and you feel the hand move as a response to that. You can see it as I breathe in here. This is something you can do with your patients.
Now tell your patients to keep their hand on their chest wall so that it doesn't move, and then have them do what I call "belly breathing." They can take a deep breath, trying to expand their abdomen but doing it in such a way that their chest wall, or their hand upon it, doesn't move at all. The abdomen expands out as they're breathing down, using this "belly breathing" technique. This is a concept that requires practice. I ask them to do this over about 3 seconds, with slow pursed lip breathing on the same exit breath. So the technique goes: belly breathing in, hand on the upper chest not moving, and then belly breathing out.
I ask my patients with rumination syndrome to do this about 5 minutes into their meal. I also ask them to practice this several times before they get to their meal and to do it repetitively during the course of any rumination symptom onset, as well as briefly following a meal, given that rumination episodes are always meal related.
I ask them to practice for 5 minutes, break, do it again for 5 minutes, break, and do it again for 5 minutes. The practice is meant to ultimately create desensitization of the abdominal wall contraction precipitating this upward pressure to the lower esophageal sphincter, with rumination syndrome evolving as a consequence.
This is a technique that is not often taught to us in medical school. I was certainly never taught this there but was instead fortunate enough to see the group at Walter Reed practice it firsthand. It's another arrow you can put in your quiver to teach patients so that they can practice it.
I've used this technique now on several patients with refractory and relapsing singultus or hiccups. I've had a couple of patients who have begun to get repetitive hiccups, and I always start them with granulated sugar and a little dose of vinegar on top and then go immediately to diaphragmatic breathing. I saw a patient today who has had to go into the emergency department to intermittently receive intravenous Thorazine® (chlorpromazine) for this condition. He has actually done very well with this technique, responding quite nicely despite his episodic refractory singultus. Again, this is something patients can use as an interruption to whatever becomes a challenging relapse.
It also has utility for belching. I've used this technique on several patients for belching. Though it doesn't work for everybody, it is effective for some. A lot of this has to do with aerophagia, but again they can do this to get an interruption in their belching.
Therefore, diaphragmatic breathing has several applications. Just remember the easy steps to this technique: hand on chest; hand on abdomen; without moving the upper hand, breathe into the belly for 3 seconds; and then blow out slowly.
This is something we're not taught to use in medical school, but it's a fantastic opportunity to make a meaningful intervention. In patients with rumination syndrome, its value is without question and, in my experience, has been phenomenal. For these other conditions, it's not a cure-all, but I think you'll find some benefit.
I'm Dr David Johnson. Hopefully this tip will give you a leg up the next time you have such a patient. Thanks again for listening.
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Cite this: Breathe Easy: Rumination Syndrome Can Have a Simple Fix - Medscape - Sep 28, 2016.