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 .