Objective Manometric Criteria for the Rumination Syndrome
Objective Manometric Criteria for the Rumination Syndrome
Three different mechanisms of rumination were observed during the stationary measurements. The first mechanism was characterized by an abdominal pressure increase that preceded the retrograde flow (Figure 2a). The peak pressure of the abdominal pressure increase occurred after the initial drop in impedance and during the retrograde flow. Furthermore, the intraluminal esophageal pressure increased during the retrograde flow and concurrent relaxation of the UES was observed. Thereafter, the gastric content in the esophageal body was cleared by a swallow. This mechanism was labeled as primary rumination, as the abdominal pressure increase resulted in the retrograde flow of gastric content. Primary rumination occurred in 100% of the rumination patients and was the predominant mechanism in 8/12 patients (Table 3).
(Enlarge Image)
Figure 2.
The rumination variants as measured by combined high-resolution manometry and pH-impedance monitoring. (a) Primary rumination: an increase in gastric pressure is followed by the flow of gastric content. Peak gastric pressure is observed during the flow of gastric content. Pressure in the esophageal lumen increases during the retrograde flow of gastric content and subsequent relaxation of the upper esophageal sphincter is observed. (b) Secondary rumination: similar to primary rumination but preceded by a spontaneous gastroesophageal reflux event. (c) Supragastric belch-associated rumination: initially, a movement of the diaphragm in aboral direction and a sub-atmospheric pressure in the esophageal lumen is observed. Relaxation of the UES is observed during the onset of inflow of air. The inflow of air is indicated by an antegrade rise in impedance. Thereafter, the esophageal air is immediately expulsed during which an increase in gastric pressure is observed. Subsequent flow of gastric content into the esophagus is observed during the increase in gastric pressure. The latter can be observed as a drop in impedance from baseline immediately after the supragastric belch.
The second mechanism was similar to a primary rumination event but the increase in abdominal pressure occured after the onset of a reflux event (Figure 2b). This mechanism was labeled as secondary rumination, as the abdominal pressure increase was secondary to reflux. Secondary rumination occurred in 45% of patients and was the predominant mechanism in 1/12 patients.
The onset of the third mechanism of rumination was characterized by the typical pattern of a supragastric belch during which an aboral movement of the diaphragm creates a sub-atmospheric pressure in the esophageal body and concurrent UES relaxation occurs (Figure 2c). The latter allows inflow of air into the esophageal body, which could be observed with impedance monitoring as a rise in impedance level in aboral direction. The inflow of air was followed by an immediate expulsion of the esophageal air (<1 s), which could be observed in the impedance signals as a return to baseline impedance level. The abdominal pressure increase during supragastric belch-associated rumination occurred during the expulsion of air and preceded the retrograde flow of gastric content. Subsequently, the esophageal pressure increased during the retrograde flow and concurrent relation of the UES was observed. This mechanism was considered as supragastric belch-associated rumination, as the abdominal pressure increase occurred during the expulsion of air. Supragastric belch-associated rumination occurred in 36% of the patients and was the predominant mechanism in 3/12 patients.
Ambulatory manometry and pH-impedance monitoring was refused by three rumination patients and could not be analyzed in one patient due to a technical failure. Ambulatory pH-impedance data was available for 9 of 12 GERD patients. Rumination patients exhibited a larger percentage of reflux episodes reaching the proximal esophagus compared with patients with GERD ( Table 4). However, other parameters of ambulatory pH-impedance monitoring were similar between the groups.
All three mechanisms of rumination could also be identified using combined ambulatory manometry and pH-impedance monitoring and similar pressure patterns were observed (Figure 3). Similar to stationary manometry, all rumination patients exhibited proximal reflux events, which were associated with a pressure peak >30 mm Hg during the ambulatory measurement. Moreover, 57 (34–80) % of the proximal reflux episodes per patient coincided with a gastric pressure increase of >30 mm Hg.
(Enlarge Image)
Figure 3.
Rumination variants as measured by combined ambulatory manometry and pH-impedance monitoring. I: Primary rumination. II: Secondary rumination. III: Supragastric belch-associated rumination.
Repetitive rumination episodes were observed in 50% of the rumination patients (Figure 4). During an episode of repetitive rumination, the rumination events occurred shortly (<1 min) after one another. Repetitive rumination could occur as repetitive primary rumination and as repetitive supragastric belch-associated rumination but not as repetitive secondary rumination.
(Enlarge Image)
Figure 4.
Repetitive primary rumination episodes as measured by combined ambulatory manometry and pH-impedance monitoring.
Rumination Mechanisms
Three different mechanisms of rumination were observed during the stationary measurements. The first mechanism was characterized by an abdominal pressure increase that preceded the retrograde flow (Figure 2a). The peak pressure of the abdominal pressure increase occurred after the initial drop in impedance and during the retrograde flow. Furthermore, the intraluminal esophageal pressure increased during the retrograde flow and concurrent relaxation of the UES was observed. Thereafter, the gastric content in the esophageal body was cleared by a swallow. This mechanism was labeled as primary rumination, as the abdominal pressure increase resulted in the retrograde flow of gastric content. Primary rumination occurred in 100% of the rumination patients and was the predominant mechanism in 8/12 patients (Table 3).
(Enlarge Image)
Figure 2.
The rumination variants as measured by combined high-resolution manometry and pH-impedance monitoring. (a) Primary rumination: an increase in gastric pressure is followed by the flow of gastric content. Peak gastric pressure is observed during the flow of gastric content. Pressure in the esophageal lumen increases during the retrograde flow of gastric content and subsequent relaxation of the upper esophageal sphincter is observed. (b) Secondary rumination: similar to primary rumination but preceded by a spontaneous gastroesophageal reflux event. (c) Supragastric belch-associated rumination: initially, a movement of the diaphragm in aboral direction and a sub-atmospheric pressure in the esophageal lumen is observed. Relaxation of the UES is observed during the onset of inflow of air. The inflow of air is indicated by an antegrade rise in impedance. Thereafter, the esophageal air is immediately expulsed during which an increase in gastric pressure is observed. Subsequent flow of gastric content into the esophagus is observed during the increase in gastric pressure. The latter can be observed as a drop in impedance from baseline immediately after the supragastric belch.
The second mechanism was similar to a primary rumination event but the increase in abdominal pressure occured after the onset of a reflux event (Figure 2b). This mechanism was labeled as secondary rumination, as the abdominal pressure increase was secondary to reflux. Secondary rumination occurred in 45% of patients and was the predominant mechanism in 1/12 patients.
The onset of the third mechanism of rumination was characterized by the typical pattern of a supragastric belch during which an aboral movement of the diaphragm creates a sub-atmospheric pressure in the esophageal body and concurrent UES relaxation occurs (Figure 2c). The latter allows inflow of air into the esophageal body, which could be observed with impedance monitoring as a rise in impedance level in aboral direction. The inflow of air was followed by an immediate expulsion of the esophageal air (<1 s), which could be observed in the impedance signals as a return to baseline impedance level. The abdominal pressure increase during supragastric belch-associated rumination occurred during the expulsion of air and preceded the retrograde flow of gastric content. Subsequently, the esophageal pressure increased during the retrograde flow and concurrent relation of the UES was observed. This mechanism was considered as supragastric belch-associated rumination, as the abdominal pressure increase occurred during the expulsion of air. Supragastric belch-associated rumination occurred in 36% of the patients and was the predominant mechanism in 3/12 patients.
Combined Ambulatory Manometry and pH-impedance Monitoring
Ambulatory manometry and pH-impedance monitoring was refused by three rumination patients and could not be analyzed in one patient due to a technical failure. Ambulatory pH-impedance data was available for 9 of 12 GERD patients. Rumination patients exhibited a larger percentage of reflux episodes reaching the proximal esophagus compared with patients with GERD ( Table 4). However, other parameters of ambulatory pH-impedance monitoring were similar between the groups.
All three mechanisms of rumination could also be identified using combined ambulatory manometry and pH-impedance monitoring and similar pressure patterns were observed (Figure 3). Similar to stationary manometry, all rumination patients exhibited proximal reflux events, which were associated with a pressure peak >30 mm Hg during the ambulatory measurement. Moreover, 57 (34–80) % of the proximal reflux episodes per patient coincided with a gastric pressure increase of >30 mm Hg.
(Enlarge Image)
Figure 3.
Rumination variants as measured by combined ambulatory manometry and pH-impedance monitoring. I: Primary rumination. II: Secondary rumination. III: Supragastric belch-associated rumination.
Repetitive rumination episodes were observed in 50% of the rumination patients (Figure 4). During an episode of repetitive rumination, the rumination events occurred shortly (<1 min) after one another. Repetitive rumination could occur as repetitive primary rumination and as repetitive supragastric belch-associated rumination but not as repetitive secondary rumination.
(Enlarge Image)
Figure 4.
Repetitive primary rumination episodes as measured by combined ambulatory manometry and pH-impedance monitoring.
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