Medical Professional Publications

Diagnostic Testing for Rumination Syndrome is Frequent, Expensive and Often Unhelpful

Columbus, OH — April 2017

The diagnostic criteria for pediatric rumination syndrome are seemingly straight-forward. According to the 2016 revised standards called “Rome IV,” a patient who fits in all of the following categories has rumination syndrome by definition:

  1. The patient experiences repeated regurgitation and re-chewing or expulsion of food that begins soon after ingestion of a meal and does not occur during sleep.
  2. The regurgitation is not preceded by retching.
  3. The symptoms cannot be fully explained by another medical condition after appropriate evaluation, and the patient has experienced the symptoms for at least two months.

Despite those well-defined criteria, a recent study from physician-researchers at Nationwide Children’s Hospital has found that patients referred to the hospital’s rumination syndrome inpatient treatment program have undergone many unnecessary and expensive diagnostic evaluations. Those may have resulted in delayed diagnosis – patients regularly experience symptoms for two or more years before a definitive determination – increasing anxiety for patients and their families.

“Sometimes patients have the same test two or three times, and these are not simple tests,” says Desale Yacob, MD, a member of the Division of Gastroenterology at Nationwide Children’s, medical director of the hospital’s Motility Center and senior author of the study. “The evaluations that are most important when diagnosing rumination syndrome, like many other functional gastrointestinal disorders, are complete medical histories, physical examination and detailed conversations with patients and their families.”

The study, published in The Journal of Pediatrics, considered 68 patients ultimately diagnosed with rumination syndrome who were referred to Nationwide Children’s. The average patient had 8.8 tests before diagnosis at an average cost of $19,795.

The most frequently performed tests were esophagogastroduodenoscopy, gastric emptying study, antroduodenal manometry and upper gastrointestinal series. A relatively small percentage of tests resulted in abnormal findings; since no test diagnoses rumination syndrome, however, even abnormal findings were not necessarily helpful and more likely to be insignificant. Antroduodenal and esophageal manometries can be helpful in confirming the diagnosis if confirmation is deemed to be essential.

Dr. Yacob, who is also an assistant professor of Clinical Pediatrics at The Ohio State University College of Medicine, says once a physician determines that a patient meets the symptom-based criteria for rumination syndrome, few other diagnoses should be on the differential list. Rumination syndrome also can be observed, and that can be important confirmation for a physician.

“If a patient says, ‘I eat, then I vomit within five minutes,’ give the patient something to eat,” Dr. Yacob explains. “If the patient eats, vomits and has no chest discomfort or sensation of something being stuck in the esophagus, and a detailed medical history indicates she meets the criteria, then a physician should give a diagnosis of rumination.”   

Still, an upper GI series is important to rule out anatomical abnormality and as a screening test for motility problems in the esophagus. If the clinical history suggests reflux or eosinophilic esophagitis, then esophagogastroduodenoscopy could be appropriate.

Tests beyond that have two primary drivers, says Dr. Yacob. First, many providers lack familiarity with or comfort in making a rumination diagnosis. Second, patients and parents want proof when presented with a condition they may never have heard of. Addressing the first issue can help solve the second issue as well, Dr. Yacob says; a clear and confident explanation of pathophysiology from the physician often helps convince families of the diagnosis.

Reference:
Alioto A, Di Lorenzo C, Montgomery ML, Yacob D.  High cost and low yield: the diagnostic evaluation of rumination syndrome in pediatrics. The Journal of Pediatrics. 2017 Feb 28. [Epub ahead of print]

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