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The most commonly used and effective therapy for rumination syndrome is diaphragmatic breathing performed postprandially. Mechanistically, diaphragmatic breathing when performed during fed manometry has been shown to lower gastric pressure and increase LES pressure. The latter is accomplished presumably through increasing tone in the crural diaphragm. With maintenance of the normal positive pressure gradient between the LES and the stomach, the reflux of gastric content is prevented. Diaphragmatic breathing can be taught directly, with manometry using visualization of the gastric pressures for biofeedback [10] or with abdominal EMG [11] using the reduction of electrical activity in the musculature for biofeedback. Diaphragmatic breathing videos are readily available on the internet and regularly taught in disciplines such as yoga, meditation, martial arts, and singing. The concept behind this type of breathing is to extend the abdominal wall to enable inhalation rather than expansion of the chest cavity. With an increase in abdominal volume, pressure decreases (Boyle’s Law) in the abdominal cavity and, therefore, the stomach. This technique is easily taught bedside by asking the patient to place one hand on the chest and the other on the abdomen (Figure 4.2). With proper diaphragmatic breathing, the hand on the chest will stay still and the hand on the abdomen will rise. In addition to changing the symmetry of breathing, patients are asked to inhale and exhale slowly as part of the process. Slow breathing increases concentration and reduces the time available for contraction of the abdominal musculature. This can be taught initially in the supine or sitting position. Optimally, patients can perform diaphragmatic breathing in the office after consumption of a meal to assess and demonstrate effectiveness of the administered treatment. Nevertheless, several treatment sessions are often needed [3].

Table 4.3 Treatment of rumination syndrome.

Diaphragmatic breathing

Cognitive therapy/biofeedback/stress reduction

Medical therapy

Baclofen 10 mg three times daily before meals

Buspirone 5–10 mg three times daily before meals

The long‐term efficacy of this type of breathing in controlling symptoms of rumination is not well reported, though acute administration has been shown to be effective in controlling rumination symptoms. In one study, 85% of patients were cured or improved at a one‐year follow‐up [3].

Figure 4.2 Teaching diaphragmatic breathing.