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Clinical Atlas Prestige · Evidence-first

Psych VivasGeneral adult psychiatry — feeding and eating disorders

Psych Vivas · General adult psychiatry — feeding and eating disorders

Pica and rumination disorder — structured clinical viva

Fellowship viva on adult rumination disorder: discrimination, diaphragmatic breathing, biofeedback RCT, baclofen RCT positioning, GI interface.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. A 34-year-old software engineer has had effortless post-meal regurgitation for 18 months. He rechews and reswallows most of the time to avoid embarrassment at work. He has no fear of weight gain, no binge eating, and no body checking. Multiple PPIs and a normal endoscopy have not helped. BMI 21.1 kg/m². He asks whether this is 'just anxiety' and whether a tablet can fix it. Discuss diagnosis versus GORD and BN, mechanism, first-line behavioural treatment, role of biofeedback and baclofen, and when to re-involve gastroenterology.

Interpretation

Reveal interpretation

This is adult rumination disorder (rumination syndrome): chronic effortless meal-linked regurgitation with rechewing/reswallowing, failed acid suppression, normal endoscopy, and absent BN body-image drive. Anxiety may coexist as a consequence or comorbidity but does not redefine the physiology.[1][5]

Versus GORD. Heartburn-predominant acid disease often responds at least partially to PPI; rumination is mechanical effortless regurgitation soon after meals, often with reswallowing. Endoscopy may be normal in both — history is decisive.[1][5]

Versus BN. No binge, no fat phobia, no shape overvaluation — do not force BN therapy targets. If those emerge later, dual formulate.[1]

Mechanism and treatment. Abdominothoracic strain → raised gastric pressure → LES relaxation → effortless regurgitation. First-line: education + diaphragmatic breathing competing with the strain pattern; evidence supports mechanism and clinical use.[1][2] Biofeedback has RCT support for reducing episodes.[3] Baclofen 10 mg orally three times daily has RCT support in refractory disease as adjunct — discuss side effects and specialist framing; not a magic sole tablet that replaces behavioural work.[4]

GI re-involvement. Red flags, diagnostic uncertainty, or refractory course → consider high-resolution manometry with impedance and joint management.[1][5] PARDI can structure feeding-disorder assessment when presentations are mixed with ARFID/pica features.[6]

Key points

Effortless, meal-linked, often reswallowed

That triad points to rumination, not classic vomiting.[1][5]

Breathing first

Diaphragmatic breathing is first-line, not PPI escalation alone.[1][2]

Baclofen is adjunct RCT evidence

10 mg TDS oral in Pauwels crossover RCT — specialist, not sole first-line.[4]

Name biofeedback evidence

Barba RCT supports biofeedback for rumination.[3]
[1] [2] [4]

References

  1. [1]Halland M, Pandolfino J, Barba E Diagnosis and Treatment of Rumination Syndrome Clin Gastroenterol Hepatol, 2018.PMID 29902642
  2. [2]Halland M, Parthasarathy G, Bharucha AE, Katzka DA Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action Neurogastroenterol Motil, 2016.PMID 26661735
  3. [3]Barba E, Accarino A, Soldevilla A, Malagelada JR, Azpiroz F Randomized, Placebo-Controlled Trial of Biofeedback for the Treatment of Rumination Am J Gastroenterol, 2016.PMID 27185077
  4. [4]Pauwels A, Broers C, Van Houtte B, et al. A Randomized Double-Blind, Placebo-Controlled, Cross-Over Study Using Baclofen in the Treatment of Rumination Syndrome Am J Gastroenterol, 2018.PMID 29206813
  5. [5]Absah I, Rishi A, Talley NJ, Katzka D, Halland M Rumination syndrome: pathophysiology, diagnosis, and treatment Neurogastroenterol Motil, 2017.PMID 27766723
  6. [6]Bryant-Waugh R, Micali N, Cooke L, et al. Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22 Int J Eat Disord, 2019.PMID 30312485