Dumping syndrome

Dumping syndrome is a medical condition that can occur after certain types of surgery, such as gastrectomy (removal of part of the stomach) or gastric resection, and when gastroesophageal reflux disease (GERD) is treated with surgical correction methods such as Nissen fundoplication.

Dumping syndrome usually occurs due to the rapid movement of food from the stomach to the intestines or due to changes in the anatomy of the stomach after surgery. It can cause a number of unpleasant symptoms that may include:

1. Feelings of fullness, nausea and vomiting.
2. Abdominal pain and intestinal cramps.
3. Diarrhea.
4. Hypoglycemia (low blood sugar), which can lead to weakness, dizziness, and loss of consciousness.

Symptoms of dumping syndrome can occur immediately after eating or several hours after eating, depending on the type of dumping syndrome (rapid or delayed).

Treatment for dumping syndrome includes dietary changes to reduce symptoms and, in some cases, the use of medications that can help manage symptoms. If you suspect dumping syndrome, it is important to see your doctor for diagnosis and to develop the best treatment plan.

Epidemiology

It is estimated that 20-50% of patients undergoing gastric surgery experience symptoms of dumping syndrome. Patients develop severe symptoms at an approximate frequency of 1 to 5%. Early dumping syndrome appears to be more common than late dumping syndrome. [1]

Causes of the dumping syndrome

Dumping syndrome results from changes in the digestive system, usually following gastric or gastrointestinal surgery. The severity of dumping syndrome correlates with the extent of gastric surgery. Surgical etiologies include gastrojejunostomy, antrectomy, pylorectomy, pyloroplasty, esophagectomy, vagotomy, Roux bypass, and Nissen fundoplication. [2], [3] Its main causes include:

1. Gastrectomy: Removal of the stomach (gastrectomy) or part of it can severely alter the anatomy of the digestive system and lead to dumping syndrome.
2. Gastric resection: Gastric resection, where part of the stomach is removed due to various medical problems such as ulcers, cancer or other diseases, can also cause dumping syndrome.
3. Bariatric Surgery: Surgical procedures for weight control, such as biliopancreatic resection, ruis-en-UWT (Roux-en-UWT (Roux-en-UWT), or vertical gastrectomy, can cause dumping syndrome.
4. Rapid emptying of the stomach: After surgical removal of part of the stomach, the remaining stomach can empty quickly into the intestines, causing food to enter the small intestine quickly. This can cause early dumping syndrome.
5. Changes in insulin secretion: Dumping syndrome may be associated with increased insulin secretion in response to the intestinal intake of sugars, resulting in hypoglycemia (low blood sugar) and related symptoms.
6. Change in the speed of food movement: Surgical interventions can change the speed at which food moves through the stomach and intestines, which can cause irritation and symptoms of dumping syndrome.

Pathogenesis

The pathogenesis (mechanism of development) of dumping syndrome is related to the changes that occur in the digestive system after a surgical procedure such as gastrectomy (removal of the stomach) or gastric resection. The change in gastrointestinal physiology leads to undesirable consequences for the patient, resulting from the rapid movement of hyperosmolar chyme from the stomach to the small intestine. [4], [5], [6] Dumping syndrome usually develops due to two main mechanisms: early and late.

1. Early dumping syndrome:

   • Early dumping syndrome is associated with rapid emptying of gastric contents into the small intestine after a meal. This process occurs due to the loss of the reservoir function of the stomach or part of it after surgical intervention.
   • The rapid passage of undigested food into the small intestine can cause increased insulin release from the pancreas in an attempt to balance blood glucose levels.
   • This can lead to a sudden drop in blood sugar levels (hypoglycemia), causing symptoms such as loss of consciousness, dizziness, and a severe feeling of weakness.

2. Late dumping syndrome:

   • Late dumping syndrome is usually associated with an abnormally high concentration of blood sugars after a meal.
   • This type of dumping syndrome can develop because of the rapid absorption of sugars from the intestines into the bloodstream, which occurs due to the lack of normal stomach function to regulate the rate at which food passes through.
   • Elevated sugars can cause the release of large amounts of insulin, which can lead to hypoglycemia and related symptoms.

Both types of dumping syndrome can cause uncomfortable symptoms such as feeling full in the stomach, vomiting, diarrhea, dizziness and others. [7]

In addition, fluid redistribution promotes distension of the duodenum, resulting in intestinal contraction, diarrhea, and abdominal bloating. [8] On the other hand, late dumping occurs due to a hyperinsulinemic state or reactive hypoglycemia. [9] The rapid transit of undigested nutrients into the intestine causes the release of large amounts of insulin into the circulation in response to high glucose concentrations of undigested carbohydrates.

Symptoms of the dumping syndrome

Dumping syndrome can cause a variety of symptoms that can occur after a meal. Symptoms may vary depending on the type of dumping syndrome, namely rapid or delayed dumping, and the individual characteristics of the patient. [10] Here are the common symptoms of dumping syndrome:

Dumping syndrome of the rapid type:

1. A feeling of fullness and pressure in the abdomen after eating.
2. Vomiting and nausea.
3. Gas and abdominal bloating.
4. Diarrhea.
5. Dizziness and weakness.
6. Increased heart rate (tachycardia).
7. Loss of consciousness (less common).

Dumping syndrome of the delayed type:

1. Feeling hungry and hypoglycemia (low blood sugar) several hours after a meal.
2. Feeling faint, shivering, dizziness and loss of consciousness.
3. Increased heart rate.
4. Sweating and nervousness.

Variants of clinical course of dumping syndrome

There are four main types of dumping syndrome: vagotonic type and functional type.

Vagotonic type of dumping syndrome

• This type of dumping syndrome is associated with the rapid and excessive release of insulin into the bloodstream after a meal.
• Clinical manifestations of vagotonic dumping syndrome may include the following symptoms:
  • Tachycardia (rapid pulse).
  • Dizziness and fainting spells.
  • Sweating, especially cold sweats.
  • Irregular heartbeats.
  • Feeling weak and general malaise.
  • Diarrhea and abdominal pain.
  • Other neurological symptoms may occur.

Functional type of dumping syndrome

• Functional dumping syndrome can develop in patients with gastric and intestinal surgery, but without a direct link to vagus nerve hyperactivity or excessive insulin release.
• Clinical manifestations may include symptoms such as nausea, vomiting, abdominal pain, diarrhea, and general malaise, but they may be less severe and less specific than in the vagotonic type.

Early dumping syndrome

Early dumping syndrome is one of the two main types of dumping syndrome that usually occurs within 30 minutes of eating in patients who have undergone gastric or gastrointestinal surgery, such as gastrectomy (removal of the stomach) or gastric resection. Early dumping syndrome is associated with the rapid emptying of stomach contents into the small intestine, resulting in a number of unpleasant symptoms. This syndrome may present in varying degrees of severity in different patients.

The main symptoms of early dumping syndrome include:

1. Feeling overfilled: Patients may feel that their stomach fills up too quickly after eating.
2. Vomiting: This may include nausea and vomiting after eating.
3. Diarrhea: Patients may experience liquid stools after meals.
4. Abdominal pain: Some patients may experience pain or discomfort in the abdominal area.
5. Increased sweating: Patients may begin to sweat and feel hotter after eating.
6. Heart palpitations: Some patients may experience palpitations or palpitations.
7. Dizziness: You may feel dizzy or faint.

Vasomotor symptoms include fatigue, desire to lie down after eating, facial flushing, palpitations, sweating tachycardia, hypotension, and fainting. Late dumping symptoms include hypoglycemia, sweating, palpitations, hunger, fatigue, confusion, aggression, tremors, and fainting. [11]

Classified as well:

• Mild early dumping: Patients may experience a feeling of fullness, gas, dyspepsia (digestive disturbance) and abdominal discomfort after eating. These symptoms may be mild and short-term.
• Severe early dumping: In more serious cases, patients may experience vomiting, diarrhea, loss of consciousness (syncope), and heart palpitations. These symptoms can be quite intense and may require medical attention.

Early dumping syndrome is associated with the rapid absorption of sugars and other substances from food into the bloodstream, which can lead to changes in blood sugar levels and other physiologic reactions. [12]

Late dumping syndrome.

Late dumping syndrome is a form of dumping syndrome that occurs after eating, usually 1-3 hours after a meal. This syndrome is usually associated with gastric surgery, such as gastrectomy (removal of part of the stomach) or gastric resection, and procedures to treat gastroesophageal reflux disease (GERD), such as Nissen fundoplication. [13]

Symptoms of tardive dumping syndrome may include:

1. Hypoglycemia (low blood sugar): This is one of the main symptoms. Hypoglycemia can cause feelings of weakness, dizziness, sweating and shivering.
2. Gastric pain: Patients may experience pain and discomfort in the stomach.
3. Diarrhea: Diarrhea may develop after a meal.
4. Feelings of malaise: Patients may feel tired, restless and even faint in more severe cases.

Classified as well:

• Mild late dumping: Patients may experience a mild feeling of weakness, sweating and irregular heartbeat after eating. These symptoms may be uncomfortable but not too serious.
• Severe late dumping: In more serious cases, patients may lose consciousness (feeling very weak beforehand), experience severe dizziness and heart palpitations, requiring medical attention.

Degrees of dumping syndrome

Degrees of dumping syndrome can range from mild to severe, and they can be graded based on the intensity and frequency of symptoms. Assessing the severity of dumping syndrome can help doctors develop the best treatment plan.

1. Mild degree (minor dumping syndrome): In this form, symptoms are usually mild and short-lived. The patient may experience mild abdominal pressure, rarely nausea and diarrhea. Symptoms of rapid dumping syndrome may be mild in the beginning, while symptoms of delayed dumping syndrome are less intense and prolonged.
2. Middle degree: Symptoms become more noticeable and may interfere with the patient's daily life. In the case of rapid dumping syndrome, this may include a strong feeling of fullness, nausea and diarrhea after meals. Delayed dumping syndrome can cause hypoglycemia and longer-lasting malaise.
3. Severe: In this form of dumping syndrome, symptoms become very intense and can significantly interfere with quality of life. The patient may experience severe abdominal pain, vomiting, diarrhea, and increased sweating. Hypoglycemia in case of delayed dumping syndrome can be severe and lead to loss of consciousness.

Diagnostics of the dumping syndrome

To diagnose dumping syndrome, your doctor may perform the following tests:

1. Clinical Exam: The doctor will identify symptoms such as nausea, vomiting, dizziness, sweating, and measure blood pressure and pulse rate.
2. Gastrointestinal symptoms: The patient may complain of severe abdominal pain, diarrhea, gas and tremors.
3. Glucose test: Dumping syndrome can cause blood glucose levels to spike, so your doctor may order a blood glucose test.
4. Gastrointestinal exams: In some cases, gastrointestinal exams such as gastrofibroscopy, x-rays, or gastroenteroscopy may be needed to evaluate the stomach and intestines in more detail.
5. Lab tests: Your doctor may also perform general blood and urine tests to assess your overall health and identify other possible problems.

To accurately diagnose and manage dumping syndrome, it is important to consult with an experienced physician and perform the recommended tests.

Differential diagnosis

The following factors and other possible causes of symptoms should be considered for the differential diagnosis of dumping syndrome:

1. Postprandial hypoglycemia: Dumping syndrome can cause hypoglycemia (low blood sugar) after a meal. However, other conditions such as diabetes mellitus or hypoglycemia in hyperinsulinism can also cause similar symptoms.
2. Surgical interventions: If the patient has had surgery on the stomach or intestines, it is important to consider what surgical procedures were performed and what complications may arise from them.
3. Other causes of symptoms: Symptoms of dumping syndrome may include nausea, vomiting, dizziness, sweating, weakness, rapid pulse, and others. These symptoms can also occur with other conditions such as gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), food allergies, and others.

To diagnose dumping syndrome and rule out other possible causes of symptoms, the patient may be given various tests including blood glucose monitoring, gastrointestinal tests (e.g. Esophagogastroduodenoscopy), and a history and symptom survey. Only after all necessary tests have been performed can a diagnosis be made and appropriate treatment prescribed.

Treatment of the dumping syndrome

Treatment for dumping syndrome depends on its type (early or late) and the severity of symptoms. Treatment usually involves a combination of dietary changes, managing food intake and, in some cases, the use of medication. Here are the treatments and steps for managing dumping syndrome:

1. Stage 1: Lifestyle and diet:

   • The first step in the treatment of dumping syndrome involves educating the patient on lifestyle and dietary changes.
   • Patients are advised to:
     • Consume food slowly and chew it well.
     • Divide meals into several smaller meals throughout the day.
     • Avoid drinking liquids during meals and for 30-60 minutes after meals.
     • Reduce intake of sugar and fast carbohydrates, which helps reduce symptoms.
     • Increase protein intake to improve satiety.

2. Stage 2: Medication:

   • In some cases, your doctor may prescribe medication to manage the symptoms of dumping syndrome.
   • Examples of such medications include acetylsalicylic acid (aspirin) or octreotide (a medication that can decrease insulin secretion and control symptoms).

3. Step 3: Consultation with specialists:

   • Patients with dumping syndrome may require consultation with a variety of specialists, including nutritionists, endocrinologists, gastroenterologists, and surgeons.
   • Counseling can help develop an individualized treatment and symptom management plan.

4. Step 4: Regular checkups:

   • Patients with dumping syndrome are advised to see their doctor regularly and maintain control of their health.
   • Doctors can monitor changes in symptoms and recommend treatment adjustments if necessary.

Treatment for dumping syndrome is individualized and can be tailored to each patient's specific needs and symptoms. It is important to follow the recommendations of the physician and dietitian to manage this condition and improve quality of life after digestive surgery.

Medications for dumping syndrome

Various medications can be used to treat and manage the symptoms of dumping syndrome, especially when diet and lifestyle changes do not provide enough relief. Here are some of the medications that can be used for dumping syndrome:

1. Octreotide is a somatostatin analog that inhibits some gastrointestinal hormones. The therapeutic effects are manifested by delayed gastric emptying, decreased gastrointestinal hormone release, prolonged transit time through the small intestine, decreased insulin release, and visceral vasoconstriction. Numerous studies have shown that octreotide alleviates the symptoms of dumping syndrome with both short- and long-term therapy. [14]
2. Acarbose is a competitive inhibitor of intestinal brush border α-glucosidase, which has a higher affinity for the enzyme compared to the normal substrate. However, since this is a reversible interaction, the breakdown of oligosaccharides to monosaccharides is delayed. This delayed conversion helps prevent the adverse effects of late dumping. Studies have demonstrated a reduction in symptoms of postprandial hypoglycemia. [15]
3. Prokinetics: Some patients may be prescribed prokinetics such as metoclopramide or domperidone to improve gastric and intestinal motility.
4. Antiseptics: Sometimes antiseptics such as metronidazole may be prescribed to reduce the growth of bacteria in the intestines and reduce symptoms.
5. Other medications: In some cases, other medications, such as blood sugar medications, may be used if dumping syndrome causes hypoglycemia.

Treatment with medications should be supervised by a physician who will determine the best approach to managing the symptoms of dumping syndrome for each individual case. The recommendations and dosages given by the doctor should be followed and any side effects or changes in health status should be reported.

Surgical treatment of dumping syndrome

Surgical treatment of dumping syndrome may be considered when conservative methods do not provide sufficient relief of symptoms or when dumping syndrome is due to surgical abnormalities or complications such as stenosis (narrowing) of the anastomoses (connecting parts of the bowel) or other anatomical problems. However, surgical treatment for dumping syndrome is considered the last option and is very rarely performed. Here are some of the possible surgical treatments for dumping syndrome:

1. Anastomosis revision: If stenosis (narrowing) or other abnormalities are found in anastomoses (connections between different parts of the intestine), surgical revision of their structure and function may be required.
2. Anatomy correction: In some cases, surgical restoration of the digestive system anatomy may be necessary to eliminate factors contributing to dumping syndrome.
3. Bowel resection: In rare cases, surgery may be performed to resect (remove) part of the intestine to change the digestive anatomy and reduce the symptoms of dumping syndrome.
4. Implantation of gastric or intestinal bypasses: These are procedures in which special bypasses or additional pathways for food movement are created to reduce the risk of dumping syndrome.
5. Use of medical devices: In some cases, medical devices such as bandages may be used to control the speed at which food moves through the gastrointestinal tract.

Surgical treatment of dumping syndrome requires a comprehensive approach and an assessment of the risks and benefits for each patient. The decision for surgical intervention should be made individually by the physician and patient after careful consultation and evaluation of the medical history.

Diet for dumping syndrome

Diet plays an important role in managing symptoms and providing relief to patients, especially after gastric or gastrointestinal surgery. Diet aims to reduce the rate of gastric emptying, preventing the rapid absorption of sugars and other food components that can cause symptoms of dumping syndrome. Here are some diet recommendations for dumping syndrome:

1. Many small meals: Divide your meals into 6-8 small meals throughout the day to reduce the amount of food entering your stomach at one time.
2. Chewing Food: Chew your food well and slowly to help the initial stage of digestion in your mouth.
3. Avoid liquids with meals: Avoid drinking liquids with meals and for 30-60 minutes after eating to prevent rapid stomach emptying and reduce the risk of dumping syndrome.
4. Reduce sugars and fast carbohydrates: Limit your intake of sugars, sweets, sugary drinks and foods rich in fast carbohydrates as they can cause a rapid rise in blood sugar levels.
5. Increase protein intake: Include protein foods such as meat, fish, eggs, tofu and dairy products in your diet to increase the feeling of satiety.
6. High-protein and high-fat foods: In some cases, increasing protein and fat intake can help slow the passage of food through the gastrointestinal tract.
7. Avoid specific foods: Some foods may increase the symptoms of dumping syndrome in different people. Consult your doctor or dietitian to identify individual foods to avoid.
8. Nutritional supplements: Your doctor may recommend taking some nutritional supplements, such as iron or vitamins, to compensate for nutrient deficiencies caused by changes in digestion.

It is important to note that the diet for dumping syndrome may vary from patient to patient depending on their individual needs and tolerance. It is always advisable to consult with a physician or dietitian before making significant changes to the diet in order to develop a suitable diet therapy plan.

Clinical Guidelines

Clinical recommendations for dumping syndrome management can vary depending on the patient's specific situation and the type of dumping syndrome (rapid or delayed). However, here are some general recommendations for the management of dumping syndrome:

1. Dietary modification:

   • Consume small portions of food: Eat small meals to reduce the amount of food that goes into your stomach quickly.
   • Avoid fast carbohydrates and sugars: Limit your intake of sugars and easily digestible carbohydrates such as candy, sweets and white bread derivatives.
   • Consume protein and fiber: Include protein and fiber-rich foods such as vegetables and whole grain products in your diet.
   • Drink water between meals: Avoid drinking liquids with meals to avoid speeding up the digestive process.

2. Medication:

   • Your doctor may prescribe medications, such as octreotide, to manage the symptoms of dumping syndrome, especially if symptoms remain severe and are not improved by diet.

3. Regular meals:

   • Keep a regular eating schedule and do not skip meals. This can help reduce symptoms.

4. Food Hygiene:

   • Chew your food slowly and eat in a relaxed environment to improve digestion.

5. Consultation with a physician:

   • It is important to get a consultation with a physician or gastrointestinal specialist to develop a personalized treatment plan that is appropriate for your specific situation.

These recommendations are general and can be customized to meet the specific needs of each patient. It is important to monitor symptoms closely and work with your doctor to find the best strategies for managing dumping syndrome.

Prevention

Prevention of dumping syndrome includes a number of interventions and lifestyle changes that can help reduce the risk of developing it or mitigate its effects after gastric and intestinal surgery. Here are some recommendations:

1. Proper nutrition:

   • Eating should be done slowly and the food should be chewed well.
   • Divide your meals into several smaller meals throughout the day, instead of several large meals.
   • Avoid eating large amounts of carbohydrates all at once, especially fast carbohydrates such as sugar and sweets.

2. Exercise:

   • After eating, you can take a short walk or engage in light physical activity to help improve digestion.

3. Avoiding beverages at mealtimes:

   • Drinks can liquefy stomach contents and help food pass quickly through the stomach. It is better to consume liquids half an hour before and after meals.

4. Smoking cessation:

   • Smoking can worsen the symptoms of dumping syndrome, so it is best to avoid it.

5. Glucose control:

   • Eating foods with a lower glycemic index can help reduce the risk of spikes in blood glucose levels.

6. Adherence to doctor's recommendations:

   • It is important to follow your doctor's instructions and recommendations after stomach and intestinal surgery. He or she can offer individualized recommendations and dietary regimens.

7. Discussion with your doctor:

   • If you have an increased risk of developing dumping syndrome or are already experiencing symptoms, be sure to discuss this with your doctor. Your doctor will be able to offer more specific recommendations and treatment.

Prevention of dumping syndrome can vary depending on the individual situation and patient characteristics. It is important to consult with a medical professional on an individual basis to develop the best strategies for prevention and management of this condition.

List of reputable studies related to the study of dumping syndrome

1. Abell, T. L. & Minocha, A. "Gastrointestinal complications of bariatric surgery: diagnosis and therapy." (2006) - This article discusses the gastrointestinal complications associated with bariatric surgery, including Dumping Syndrome.
2. Sigstad, H. "A clinical diagnostic index in the diagnosis of the dumping syndrome." (1970) - A foundational study providing a diagnostic index for Dumping Syndrome.
3. van der Kleij, F. G., Vecht, J., Lamers, C. B., & Masclee, A. A. "Diagnostic value of dumping provocation in patients after gastric surgery." (1996) - Research on the diagnostic approaches for Dumping Syndrome post-gastric surgery.
4. Arts, J., et al. "Efficacy of the long-acting repeatable formulation of the somatostatin analog octreotide in postoperative dumping." (2009) - A study on the treatment of Dumping Syndrome with octreotide.
5. Lawaetz, O., et al. "Gut hormone profile and gastric emptying in the dumping syndrome." (1983) - Research exploring the pathogenesis of Dumping Syndrome through gut hormone profiles and gastric emptying rates.
6. Johnson, L. P., Sloop, R. D., & Jesseph, R. E. "Etiologic significance of the early symptomatic phase in the dumping syndrome." (1962) - An early study on the causes of Dumping Syndrome.

Literature

• Saveliev, V. S. Clinical Surgery. In 3 vol. Vol. 1 : national manual / Ed. By V. S. Saveliev. С. Savelyev, A. I. Kirienko. - Moscow : GEOTAR-Media, 2008.
• Chissov, V. I. Oncology / Ed. By V. I. Chissov, M. I. Davydov - Moscow : GEOTAR-Media, 2008. I. Chissov, M. I. Davydov - Moscow : GEOTAR-Media, 2008.
• "Dumping syndrome (diagnosis, treatment, prevention)": a monograph - V. P. Akimov and co-authors. Published in 2010. This monograph covers aspects of diagnosis, treatment and prevention of dumping syndrome.
• Dumping syndrome: a modern view of pathogenesis, diagnosis, and treatment. This study discusses the pathogenesis of dumping syndrome, classification, and early and late manifestations of the syndrome. It is based on the works of V.P. Akimov et al. Who investigated the mechanisms of syndrome formation and proposed methods of diagnosis and treatment, including the use of antiserotonin medications and somatostatin derivatives.
• Dumping syndrome (diagnosis, treatment, prevention): monograph. Authors: V. P. Akimov and others. Published under the auspices of the Ministry of Education and Science of the Russian Federation, St. Petersburg Medical Academy of Postgraduate Education and Yaroslav the Wise Novgorod State University in 2010. The monograph contains 151 pages and provides a thorough analysis of dumping syndrome, including its diagnosis, treatment and methods of prevention.