Neurogastroenterol Motil. 2021 Jun;33(6):e14068. doi: 10.1111/nmo.14068. Epub 2020 Dec 22.

The gastro-sphincteric pressure gradient: A new parameter to diagnose a rumination episode.

Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society

Hannelore Geysen, Siebe Michielsen, Nathalie Rommel, Tim Vanuytsel, Jan Tack, Ans Pauwels

PMID: 33350555 DOI: 10.1111/nmo.14068

Abstract

BACKGROUND: Rumination is defined as the repetitive, effortless regurgitation of recently ingested food into the mouth. These episodes are preceded by a rise in intragastric pressure (IGP) and mainly occur postprandially. IGP peaks >30 mmHg have been proposed as a cutoff to differentiate rumination from reflux events. In clinical practice, we observed that this cutoff, which does not consider esophagogastric junction (EGJ) resistance, is not always reached.

METHODS: We studied 27 patients with rumination syndrome [age: 43.6, 59% female] and 28 gastro-esophageal reflux disease patients [age: 45.9, 54% female]. For each rumination episode, reflux event, transient lower esophageal sphincter relaxation (TLESR), or straining without regurgitation, the following parameters were registered: maximal IGP, IGP, and EGJ pressure preceding the respective episodes. We also quantified the gastro-sphincteric pressure gradient (GSPG) prior to the respective episodes.

KEY RESULTS: Five reflux episodes were characterized by a maximal IGP >30 mmHg. In 28% of the rumination episodes, the IGP peak did not exceed 30 mmHg. Median GSPG was positive for rumination episodes and significantly higher compared with TLESRs, reflux episodes, and straining without regurgitation (7 [3-13] vs. 0 [-1-0] vs. 0 [-1-0] vs. -9 [-13--2]; p < 0.0001).

CONCLUSIONS & INTERFERENCES: Applying the proposed cutoff of 30 mmHg, 28% of the rumination episodes were missed. We found that the GSPG differentiates between rumination (positive GSPG), TLESRs and reflux events (GSPG around 0), and straining without regurgitation (negative GSPG). We propose a GSPG value ≥2 mmHg to distinguish rumination from reflux episodes, TLESRs, and straining without regurgitation.

© 2020 John Wiley & Sons Ltd.

Keywords: gastro-sphincteric pressure gradient; reflux events; rumination episodes

References

1. Stanghellini V, Chan FKL, Hasler WL, et al. Gastroduodenal disorders. Gastroenterology. 2016;150(6):1380-1392. - PubMed
2. Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Pediatrics. 2003;111(1):158-162. - PubMed
3. Rommel N, Tack J, Arts J, Caenepeel P, Bisschops R, Sifrim D. Rumination or belching - regurgitation? Differential diagnosis using oesophageal impedance - manometry. Neurogastroenterol Motil. 2009;2010(22):97-104. - PubMed
4. Vakil N, Van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-1920. - PubMed
5. Locke GR, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997;112(5):1448-1456. - PubMed
6. Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Functional esophageal disorders. Gastroenterology. 2016;150(6):1368-1379. - PubMed
7. Ronkainen J, Aro P, Storskrubb T, et al. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report. Scand J Gastroenterol. 2005;40(3):275-285. - PubMed
8. Jaspersen D, Kulig M, Labenz J, et al. Prevalence of extra-oesophageal manifestations in gastro-oesophageal reflux disease: analysis based on the ProGERD study. Aliment Pharmacol Ther. 2003;17(12):1515-1520. - PubMed
9. Yadlapati R, Tye M, Roman S, Kahrilas PJ, Ritter K, Pandolfino JE. Postprandial high-resolution impedance manometry identifies mechanisms of nonresponse to proton pump inhibitors. Clin Gastroenterol Hepatol. 2018;16:211-218. - PubMed
10. Blondeau K, Boeckxstaens V, Rommel N, Tack JF. Added value of combined high resolution manometry-impedance recordings in patients with postprandial belching or regurgitation. Gastroenterology. 2011;140(5):S-229. - PubMed
11. Kessing BF, Bredenoord AJ, Smout AJPM. Objective manometric criteria for the rumination syndrome. Gastroenterology. 2014;109(1):52-59. - PubMed
12. Rommel N, Tack J, Sifirim D. Improved diagnosis of rumination using impedance-manometry. Gastroenterology. 2007;132(4):A594. - PubMed
13. Nebel OT, Castell DO. Lower esophageal sphincter pressure changes after food ingestion. Gastroenterology. 1972;63(5):778-783. - PubMed
14. Roman S, Holloway R, Keller J, et al. Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry. Neurogastroenterol Motil. 2017;29(2):1-9. - PubMed
15. Tack J, Blondeau K, Boeckxstaens V, Rommel N. Review article: the pathophysiology, differential diagnosis and management of rumination syndrome. Aliment Pharmacol Ther. 2011;33(7):782-788. - PubMed
16. Kwiatek MA, Menne D, Steingoetter A, et al. Effect of meal volume and calorie load on postprandial gastric function and emptying: studies under physiological conditions by combined fiber-optic pressure measurement and MRI. Am J Physiol Gastrointest Liver Physiol. 2009;297:G894-G901. - PubMed

Publication Types

• Journal Article
• Research Support, Non-U.S. Gov't