Prevalence, symptoms and risk factor profile of rumination syndrome and functional dyspepsia: a population-based study

Abstract

Background: Rumination syndrome is a functional gastroduodenal disorder characterised by effortless regurgitation of recently ingested food. Emerging evidence reports duodenal eosinophilic inflammation in a subset, suggesting a shared pathophysiology with functional dyspepsia (FD).

Aim: To assess the clinical features of rumination syndrome and FD in a community-based study.

Methods: We mailed a survey assessing gastrointestinal symptoms, diet and psychological symptoms to 9835 residents of Olmsted County, MN, USA in 2017-2018; diagnostic codes were obtained from linked clinical records. The two disorders were assessed as mutually exclusive in 'pure' forms with a separate overlap group, all compared to a control group not meeting criteria for either. Prevalence of associations, and univariate and independent associations with predictors were assessed by logistic regression.

Results: Prevalence of rumination syndrome and FD were 5.8% and 7.1%, respectively; the overlap was 3.83-times more likely than expected by chance. Independent predictors for rumination (odds ratio (OR), 95% confidence interval (CI)) were female gender (1.79, 1.21-2.63), smoking (1.89, 1.28-2.78), gluten-free diet (1.58, 1.14-2.19), allergic rhinitis (1.45, 1.01-2.08) and depression (1.10, 1.05-1.16). FD was independently associated with female gender, depression, non-coeliac wheat sensitivity, migraine, irritable bowel syndrome and somatic symptoms. A similar reported efficacy (≥54%) of low fat or dairy-free diets was found with both disorders (P = 0.53 and P = 1.00, respectively). The strongest independent associations with overlapping FD and rumination syndrome were a history of rheumatoid arthritis (3.93, 1.28-12.06) and asthma (3.02, 1.44-6.34).

Conclusion: Rumination syndrome overlaps with FD with a shared risk factor profile, suggesting a common pathophysiology.

Figure 1.

The prevalence and overlap of rumination syndrome with functional dyspepsia (FD) and its subtypes

Figure 2.

The prevalence of rumination syndrome (rumination syndrome) and functional dyspepsia (FD), the odds ratio compared to the age bracket 25–29, and the corresponding total number of survey respondents in each age brackets.

Figure 3.

(A) The prevalence of different bothersome (occurring 25% of the time or more) intestinal symptoms in individuals with rumination syndrome, functional dyspepsia and those with overlapping diagnosis in comparison to controls, and comparing the FD subtypes to controls (B). Note: p-value over bar: compared to controls. PDS: Postprandial distress syndrome, EPS: Epigastric pain syndrome.

Figure 3.

(A) The prevalence of different bothersome (occurring 25% of the time or more) intestinal symptoms in individuals with rumination syndrome, functional dyspepsia and those with overlapping diagnosis in comparison to controls, and comparing the FD subtypes to controls (B). Note: p-value over bar: compared to controls. PDS: Postprandial distress syndrome, EPS: Epigastric pain syndrome.

Figure 4.

(A) The prevalence of those with frequent (occurring daily or several times a week) and/or severely bothersome (4 or 5 on Likert scale) non-gastro-intestinal symptoms in individuals with rumination syndrome and functional dyspepsia and those with overlapping diagnosis in comparison to controls, and comparing the FD subtypes to controls (B). Note: p-value over bar: compared to controls. PDS: Postprandial distress syndrome, EPS: Epigastric pain syndrome.

Figure 4.

(A) The prevalence of those with frequent (occurring daily or several times a week) and/or severely bothersome (4 or 5 on Likert scale) non-gastro-intestinal symptoms in individuals with rumination syndrome and functional dyspepsia and those with overlapping diagnosis in comparison to controls, and comparing the FD subtypes to controls (B). Note: p-value over bar: compared to controls. PDS: Postprandial distress syndrome, EPS: Epigastric pain syndrome.

Figure 5.

A comparative prevalence of rumination syndrome using different versions of ROME criteria in our sample. Notes: (i) The frequency of rumination is defined as 2–3/month in ROME III and 1/week in ROME IV. (ii) The exact wording of food regurgitation is slightly different between different versions, and ROME IV uniquely includes re-swallowing without necessarily rechewing or spitting out (1, 4, 68). (iii): In our study, we have asked if the regurgitant is sour, in ROME II the question is “does it stop when it becomes sour”.

Figure 6.

Self-reported dietary avoidance data in rumination syndrome, functional dyspepsia compared to controls, among the components of the 6-food elimination diet. (p-value: compared to controls)