Baclofen improves symptoms and postprandial flow events in patients with rumination and supragastric belching/aerophagia

Introduction In patients with clinically suspected rumination, esophageal impedance-manometry identifies episodes of rumination (involuntary straining with intragastric pressure rises overcoming lower esophageal sphincter (LES) pressure) and aerophagia/supragastric belching. Treatment options are limited and focus on behavioural therapy. The gabab agonist baclofen, which increases LES pressure and decreases the swallowing rate, has a potential for clinical benefit in this conditions. Our aim was to evaluate the effect of baclofen in these patients. Methods Combined high resolution manometry-impedance recordings (HRM-IM) were performed in 9 patients [4 men, mean age 45 (19-88) years] with clinically suspected rumination or supragastric belching. After 30 minutes of recordings, patients received a standard 1000kcal solid meal after which recordings were continued during 1h. Patients were asked to register symptom occurrence with an event marker. After the study, all patients were treated with baclofen 10mg t.i.d., and after 1 week a second HRM-IM study was performed. Analysis The number of symptoms registered by the patient was compared before and after treatment as well as the number and type of individual flow events. We identified the events during HRM-IM recording and events were classified as rumination, reflux, supragastric belching or aerophagia. Results Four patients had predominant pattern of rumination, 3 of supragastric belching, 1 of aerophagia and 1 of reflux. Overall, 317 symptom markers were recorded in baseline conditions (215 for belching and 102 for regurgitation). After baclofen treatment the number of symptoms was significantly reduced to 166 (116 for belching and 50 for regurgitation) (p=0.03). Seven patients had a 81.1(57.1- 93.3)% reduction in number of symptom events with baclofen. At baseline, 295 individual flow events were identified (32 reflux, 71 rumination, 151 supragastric belching and 41 aerophagia episodes), and these were reduced to 197 (42 reflux, 25 rumination, 120 supragastric belching and 10 aerophagia) after baclofen (p=0.05). Six patients had a 64.3(33.8- 81.4%) reduction in number of flow events with baclofen. Conclusion Patients with rumination or supragastric belching/aerophagia may benefit from treatment with baclofen. This will need to be addressed in a placebo controlled prospective trial. .