MD

Objectives: Rumination syndrome (RS) is a clinical diagnosis characterized by repeated, unintentional regurgitation of undigested food and re-swallowing or spitting out food within 30 minutes of meal ingestion. Intragastric meal distribution (IMD) has been defined recently in an attempt to provide information on fundic accommodation (FA) in normal and abnormal subjects, and has been found to be impaired in patients with functional dyspepsia. Our objective was to define whether meal distribution plays a role in patients with RS by means of: 1) FA analysis, and 2) proximal emptying (PE) in the initial 30 minutes and time to proximal half-emptying (t½) compared to healthy subjects.

Methods: Twenty-two patients with RS referred to a tertiary academic center underwent gastric emptying scintigraphy (GES) with a standardized solid meal. Normal gastric emptying (NGE) was defined as equal or less than 10% retention at 4 hours and delayed gastric emptying (DGE) as greater than 10% retention. Proximal stomach regions of interest (ROIs), created automatically from the individual anterior total-stomach ROIs, were fixed at 50% of the maximum gastric body-axis length (Figure). IMD was calculated in the anterior immediate image after meal consumption as the ratio of the activity present in the proximal stomach region to the activity present in the total stomach. A study in 19 healthy volunteers by our research group, found an average IMD of 0.67±0.14 (range 0.49-0.93), compared to the established abnormal cutoff ratio of less than 0.568 (for larger proximal regions that extend to 50% of the total-stomach long axis). We also evaluated the decay-corrected PE generated from the proximal ROIs. The mean PE at 30 minutes in our normal population was 26.1±12.5%. The average proximal t½ was 65.9±17.7 minutes. Unpaired one-tail t-tests were used to compare the proximal parameters of the volunteers and the RS NGE and DGE subgroups.

Results: From a total of 22 patients with RS, 14 (64%) had NGE. The mean IMD ratio on immediate images was 0.68±0.18 (NS compared to the volunteer group). The mean PE at 30 minutes was 23%±18% (NS); three (21%) had proximal retention greater than the 90th percentile of the volunteer group).The mean t½ was 81.2±43.5 minutes (p=0.09), with 5 patients having t½ longer than the 90th percentile of the volunteer group. The 8 patients with RS and DGE had a mean IMD ratio on immediate images of 0.62±0.26 (NS). The mean PE at 30 minutes was 14%±15%, less than that of the volunteer group (p=0.024). Proximal t½ averaged 144.6±108.9 minutes, significantly longer than that of the volunteer group (p=0.002). The difference in mean IMD in the NGE and DGE subgroups was not statistically significant (p=0.24), nor was the difference in mean PE at 30 minutes (p=0.15). Mean proximal t½ was significantly different between the RS NGE and RS DGE subgroups (p=0.033).

Conclusions: 1) Patients with RS can present with either NGE or DGE. 2) Intragastric meal distribution on immediate images was normal in both NGE and DGE subgroups; mean proximal emptying at 30 minutes (the usual time duration when RS regurgitation is occurring) did not differ from that of healthy volunteers in NGE. 3) Mean proximal t½ was prolonged in the DGE subgroup compared to healthy volunteers. 4) We conclude that treatment goals for RS should not be focused on improving fundic function .

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