repetitive effortless vomiting is termed as rumination syndrome and is common in infants and mentally retarded individuals .
it is associated with considerable morbidity in children who frequently miss the school , have history of multiple hospitalizations , and also suffer significant psychiatric morbidity .
unfortunately , before reaching a correct diagnosis , a number of patients undergo unnecessary invasive testing and surgical treatments .
symptoms are often confused with that of gastric motility disorders and diagnosis is often delayed due to poor awareness regarding adult rumination syndrome among physicians .
here we are presenting a case that posed diagnostic confusion as already mentioned and showed improvement soon after the correct diagnosis was made .
the main factors that helped in remission of symptoms were supportive psychotherapy and the firm attitude of the physician .
a 26-year - old lady presented with her husband and mother with the complaints of recurrent and intractable vomiting since past 2 years .
the vomiting was regular , occurring throughout the day , and it used to increase after meals . for the past 6 months , she was not able to hold even the liquid diet to the extent that few sips of water were sufficient to induce vomiting . along with vomiting
, she also complained of episodic loss of consciousness , which she used to regain after 1 - 2 h. these episodes of unconsciousness specifically occurred when she was under some stress . besides this
, she was not having any other complaint , e.g. , abdomen pain , fullness in the stomach after having meals , diarrhea or constipation , or swallowing difficulties .
her history did not suggest any cardiac problem , focal neurological deficits , or convulsions . at the time of presentation , she was pregnant ( second trimester ) with normal fetal growth .
her family history was unremarkable except that she had strained relations with her parents - in - law .
though her husband was very supportive but for almost 1 year she was staying at her mother 's house due to this illness . since the onset of illness
she underwent extensive laboratory investigations including upper gastro - intestinal endoscopy , barium meal , and mri brain but any of the tests did not reveal any finding that could explain the symptoms .
results of her liver and kidney function tests were within normal limits since the onset of illness . in the past
, she was treated with a number of drugs including antidepressants , antipsychotics , promethazine , proton - pump inhibitors , and prokinetics for optimal periods without any relief .
her husband also took her for a vacation when suggested by a physician , but it also did not improve the situation .
looking at such a long history , multiple consultations , and extensive laboratory work - up , she was interviewed in the presence of her husband .
then it became clear that her vomiting was effortless ; in other words , she used to stand in front of a wash basin and without putting any finger or anything else in the mouth , used to expel all the food ( liquid or solid ) that she had .
the vomiting act was not associated with lacrimation , salivation , cramping of the abdomen , cessation of respiration followed by hyperventilation , and the  gag sound  that is otherwise common during true vomiting .
it always took her about half an hour to expel the food . to make the information clearer
, she was made to drink a glassful of water and her vomiting was observed which confirmed the information provided by her husband .
her general physical examination showed pale conjunctiva but we did not find any signs of induced vomiting .
however , she was not meeting all criteria for the major depressive disorder according to dsm - iv tr .
looking at the concern of her family members and her pregnancy , she was hospitalized and reassured .
when she did not improve even after 2 days , in view of her pregnancy , oral feeding from a naso - gastric tube was started . to our surprise
, she improved within few hours and started taking liquids orally without  vomiting  them .
she also insisted on the removal of the naso - gastric tube , but due to our concerns for the maintenance of feeding , it was kept for 2 days .
she kept on taking liquid diet orally as well as through the tube and the symptoms did not recur .
now her tube was removed and she was insisted to have solid food . for the next 2 days , she even had solid food without  vomiting  anything ; at this juncture , supportive psychotherapy was started .
she was discharged after 3 days with the advice to attend regular supportive psychotherapy sessions .
the diagnosis often poses a challenge to the physicians , especially when encountered in adults with normal intelligence and is often confused with gastroparesis and gastroesophageal reflux . in these adults , it is commonly associated with psychiatric morbidity in themselves or in their family members .
one common psychiatric problem is personality disturbances with high scores on hypochondriasis and depression sub - scales .
previous literature suggests that these patients often show multiple physician consultations and diagnosis is often delayed by years , and the food is usually expelled within few minutes of having it .
could find manometric abnormality only in one - third of patients while levine et al .
the present case , gastroscopy , barium meal and mr scan of head were done before presenting to us .
however , none of them showed any abnormality . in view of the available literature and her pregnancy
the treatment of adult rumination syndrome consists of reassurance , behavior therapy , psychotherapy , and relaxation therapies .
these may improve a number of patients while others suffer persistence of symptoms.[36 ] nissen fundoplication has been reported to provide complete relief in the symptoms in one report .
this patient was also shown to a number of physicians and was given all kinds of medical treatment including gastrokinetics , antacids , antidepressants , and benzodiazepines without any improvement .
the relief was obtained with reassurance , supportive psychotherapy , and our firm attitude to take care of the patient 's health . in conclusion , adult rumination syndrome may be more prevalent than it appears and adequate knowledge of this syndrome among the physicians is necessary to reach to a diagnosis and early intervention .
in addition , further studies are required to assess therapeutic benefits of various modalities in this entity .
 rumination syndrome is known to exist in infants and mentally retarded adults since long time . in past few years 
 , some reports appeared that showed its existence in adult patients also . 
 it is frequently confused with the intractable vomiting in adults and misdiagnosis leads to delay in appropriate management . 
 we are here describing the case of a female patient with rumination syndrome where specific points in the history delineated the presence of this illness and helped in appropriate management . 
 the patient became symptom free soon after the diagnosis was reached . 
INTRODUCTION
CASE REPORT
DISCUSSION