Getting to the source of the problem
Bobbi’s first appointment at Children’s Mercy was a telehealth visit with John Rosen, MD, a pediatric gastroenterologist. As Dr. Rosen listened to Bobbi’s symptoms and reviewed her test results, Heather said he suggested Bobbi might have a rare condition called rumination disorder, not acid reflux.
Rumination disorder causes the backward flow of recently eaten food from the stomach to the mouth. The food is then re-chewed and swallowed or spat out. This typically happens immediately to 15 to 30 minutes after eating.
Rumination often occurs without retching or gagging. It may be proceeded by a feeling of pressure, the need to belch, nausea, or discomfort. Some people with rumination disorder experience bloating, heartburn, diarrhea, constipation, abdominal pain, headaches, dizziness, or sleeping difficulties.
Initially, it may be triggered by emotional distress, viral illness or physical injury. In many cases, no underlying trigger can be identified. The main treatment for rumination disorder is behavioral therapy. This may involve habit reversal strategies, relaxation, diaphragmatic breathing and biofeedback.
Dr. Rosen recommended diaphragmatic breathing as a first-line treatment for Bobbi and taught her how to use it during her telehealth visit. But at the next appointment, Bobbi said the breathing technique wasn’t helping relieve her symptoms. She was still spitting her food up and felt full after eating a small amount. That’s when Dr. Rosen prescribed an additional therapy called cyproheptadine, a medication to decrease the feeling of fullness, reduce stomach pain and potentially improve appetite.
When the medication didn’t help, Dr. Rosen referred Bobbi to the hospital’s new Rumination Disorder Clinic where she saw Jennifer Schurman, PhD, Associate Division Director of Integrative Care and Innovation; Chief, Section of GI Psychology; Director, Gastroenterology Research; and Co-Director, Abdominal Pain Program.
Dr. Schurman has been instrumental in developing the Children’s Mercy Gastroenterology Division’s unique biopsychosocial approach to care, addressing physiological and behavioral factors that may impact a patient’s gastrointestinal health.
The new Rumination Disorder Clinic is the only one in the region specializing in helping patients like Bobbi by offering a multidisciplinary approach to care, starting with a medical evaluation. Once any medical issues have been addressed, patients begin working on behavioral issues.
After talking with Bobbi, Dr. Schurman suspected stress might have triggered the disorder years earlier, but she had learned to suppress it. As she got older and faced even more stressful situations, the habit resurfaced, causing her to start spitting her food up again.
“Rumination disorder is probably more common than we think,” Dr. Schurman said. “When there is no medical cause for the problem, we focus on changing the habit or behavior.”
And that’s just what Dr. Schurman helped Bobbi do. At her first visit, Dr. Schurman explained that at some point, Bobbi’s esophagus had learned to push food up in response to stress, and that she needed to retrain those muscles to push food down instead.
She taught Bobbi breathing exercises to help her relax, and recommended she do them daily. Dr. Schurman also explained that even though it didn’t make Bobbi feel good, she needed to swallow her food, not spit it out. And, she suggested Bobbi try sucking on hard candy or a mint the first 30 minutes after eating, causing her to continuously swallow, another strategy to help retrain her esophagus.
During her first in-person visit, Dr. Schurman used biofeedback to determine how Bobbi responds to stress. Biofeedback therapy is a safe, painless technique where patients are trained to improve their health using signals from their own bodies.
Electronic biofeedback sensors were connected to Bobbi’s forehead and fingers to provide computerized information about muscle tension, hand temperature, and hand moisture levels. The biofeedback machine acted as a kind of sixth sense, allowing her to see or hear activity inside her body.
Dr. Schurman used the information gained from the biofeedback sessions to teach Bobbi additional skills to reduce stress, balance her nervous system, and reduce or eliminate physical symptoms.
“Bobbi was committed to changing this habit, and was a very compliant patient, making her treatment all the more effective,” Dr. Schurman said.