S4480 Rumination Syndrome Presenting as Dysphagia: A Case Highlighting the Role of High-Resolution Manometry With Impedance

Introduction: Rumination syndrome (RS) is an underrecognized functional gastrointestinal (GI) disorder that can symptomatically mimic other conditions, including dysphagia, regurgitation, and vomiting. We present the case of a patient who initially appeared to have dysphagia but was ultimately diagnosed with rumination syndrome following extensive evaluation. The patient was successfully treated with diaphragmatic breathing therapy. Case Description: A 55-year-old woman presented for dysphagia to solids and liquids for greater than 6 months, described as sensation of food getting stuck in mid chest. She also reported regurgitation, often after meals and occasionally delayed for up to 3 hours following eating. Initial endoscopy revealed mild distal esophageal ring stenosis with biopsy showing lymphocytic esophagitis. She was initiated on a proton pump inhibitor with minimal symptomatic relief. Subsequent esophagram showed evidence of esophageal dysmotility, though high-resolution manometry was normal, ruling out motility disorders. Due to severe symptom burden, repeat esophagogastroduodenoscopy was performed with empiric balloon dilation despite minimal stenosis, which yielded no symptomatic benefit. Notably, repeat biopsies showed no evidence of lymphocytic esophagitis. Due to suspicion for RS, high resolution manometry with 24 hour pH and impedance was done, which showed several prominent retrograde reflux events followed by antegrade flow, consistent with RS. She was initiated on baclofen, GI-focused psychotherapy, and diaphragmatic breathing exercises with near-complete symptom resolution. At 6-month follow-up, she remained asymptomatic off all pharmacotherapy. Discussion: This case highlights the importance of considering RS in patients presenting with apparent dysphagia, particularly when symptoms involve effortless regurgitation of undigested food shortly after eating. It also showcases the potential role of high-resolution manometry with impedance to help confirm diagnosis of RS. This case further illustrates the importance of diligent evaluation without anchoring-bias, as seen by the histologic resolution of lymphocytic esophagitis, despite persistent symptoms. Finally, it reinforces the effectiveness of behavioral therapy in managing rumination syndrome and value of multidisciplinary approach to treatment in these patients.