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c 2018 The Korean Society of Neurogastroenterology and Motility J Neurogastroenterol Motil, Vol. 24 No. 3 July, 2018 www.jnmjournal.org TO THE EDITOR: We present the case of a 63-year-old patient, with a long history of recurrent regurgitation of undigested food that occurred about 15 minutes after eating and could last for hours. Vomiting was absent. She complained of occasional heartburn but repeated trials of proton pump inhibitors and prokinetics failed to relieve symptoms. Previously, an extensive investigation including an upper endoscopy and blood test were rigorously normal. To exclude gastroesophageal reflux disease, her physician ordered a 24-hour impedance pH monitoring that we completed in our motility unit. Remarkably, this showed a multitude of episodes that the software identifies as non-acid reflux after meals without any episodes during the nocturnal period. It was observed that immediately after a normal swallow these episodes appeared with a retrograde decrease in the impedance trace that reached the proximal sensor followed by anterograde recovery, with the esophageal pH above 4 during these events. Accordingly, high-resolution impedance manometry (HRIM) was performed in the supine position, performed as follows: (1) standard protocol study with 10 liquid swallows of 10 mL of saline that was normal and (2) solid meal consisting of chicken sandwich which revealed a sudden increase in intragastric pressure (> 30 mmHg) that reached and opened the upper esophageal sphincter. The impedance showed that the increase of the gastric pressure caused a retrograde movement of the intragastric content to the hypopharyngeal area followed by a swallow that clarifies the bolus (Fig. 1), occurring a number of times after the ingestion (Fig. 2). Consequently, we concluded the diagnosis of rumination syndrome, proposing biofeedback treatment. We present an example of a pathology whose diagnostic ap-

Rumination Syndrome: Unknown Pathology Easy to Diagnose With High-resolution Impedance Manometry