Dumping syndrome or “too rapid drainage of the stomach” is a condition most often found in patients post-gastrectomy. Symptoms for this condition can be separated in vasomotor symptoms (such as palpitations, flushing, or diaphoresis) or abdominal symptoms (such as diarrhea, nausea, or cramps). The symptoms often resolve within over several months. Medication is often helpful and surgical intervention is rarely necessary.

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Background and Definitions

Our stomach is divided into three main functionary parts with their respective roles in the digestion of food. They are cardia, fundus and pylorus. The cardia, which is commonly known as a storage tank for all our consumed meals, fundus churns the food and mixes it with all the digestive enzymes which help us digest the food, and finally, the pylorus discharges the food in a systematic manner to duodenum.

The stomach’s ability to store in adults is around 2 litres, which serves as a great purpose for distensibility. Gastric movements are controlled by myogenic and neural activity. Any change in the structure of it may have deep effects on the gastric storage tank and pyloric sphincter, which is also known as postgastrectomy conditions.

Postgastrectomy conditions are induced syndromes, which rise with the half gastrectomies or operations that are done for any disease whether it’s ulcer, cancer or weight loss. In 1913, Hertz described this syndrome and the reason behind this condition as “rapid drainage of stomach”, which he witnessed radiographically in patients.

Pathophysiology of Dumping Syndrome

Stomach labeled

Image: “The anatomy of the stomach” by OpenStax College – Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. License: CC BY 3.0

The important function of our stomach is to act as a reservoir of our food and to start the digestion process with the help of some ingesting acid before sending it to the antrum, where the vibration of higher density grinds and crushes the food, which shrinks the size of food to 2 mm. When solids get shrunk to the preferred size then they pass through the pylorus, which averts the bigger solid particles from going through the duodenum.

Those who are subtle to choking on their food can choose to drink small amounts of liquid with their meals. However, some people love to drink water after every chew of their food to permit it through the stomach to fundus easily. Some people drink a large quantity of water after every meal and they are advised to not drink water before and after a meal. The condition gets worse with the sugar content of the food which increases the chances of dumping syndrome.

Surgeries in which the pylorus gets damaged surge the rate of emptying the stomach rapidly. Increased gastric emptying is one of the main features and a significant stage of diagnosing dumping syndrome.

After the operation, the gastric mucosal gets changed and all the excretion of vital enzymes and acids gets reduced and badly affected. The accommodation response and the phasic contractility of the stomach in response to distention are abolished after vagotomy or partial gastric resection. This probably accounts for the immediate transfer of ingested contents into the duodenum.

Epidemiology of Dumping Syndrome

In the United States, around 10-40% of patients who have undertaken gastric surgery are diagnosed with dumping syndrome. 5% of these people are diagnosed with severe dumping symptoms. The frequency of dumping syndrome has been reported to be 10-14% in those patients who have undertaken vagotomy surgery and 14-20% after partial gastrectomy.

Reductions in the need for elective gastric surgery have led to a decline in the frequency of postgastrectomy syndromes. In the last 20 years, there has been 10-15 times reduction in gastric surgery.

The main reason behind the decline is the new drug histamine-2, which reduces the cases of any gastric problems and all in all reduces the syndrome drastically. Those patients who had ulcer disease, now try to pass the surgery because now there is Helicobator pylori treatment which helps the patient to get rid of ulcer problems, which also decreases the cases of the syndrome.

Clinical Features of Dumping Syndrome

Early symptoms of dumping syndrome

  • Fatigue
  • Faintness
  • Syncope
  • Flushing
  • Headache
  • Palpitations
  • Diarrhea
  • Nausea
  • Epigastric fullness
  • Abdominal cramps
  • Borborygmi

Late symptoms of dumping syndrome

  • Getting sweaty frequently
  • Body shivering
  • Tiredness and fatigue
  • Decreased consciousness
  • Hunger

Management of Dumping Syndrome

Dumping syndrome can be diagnosed by the simple glucose test 50g oral glucose and can be cured by various options; some of the common options include:

  • Acarbose: it has been found by research that acarbose is able to decrease dumping syndrome because it delays carbohydrate absorption and reduces the suspension between the hyperglycemia and insulin.
  • Octreotide: it reduces the gastric emptying by rearranging the motor complex and fasting level. It has been found by research that octerotide helped the masses in different ways and helped them in solving the problems without the need for surgery.

Octreotide works by the following mechanism:

Structural formula of octreotide

Image: “Structural diagram of octreotide.” by Fvasconcellos – Own work. License: Public Domain

  • Delay in the accelerated initial gastric emptying
  • Delay in small intestinal transit time
  • Inhibition of enteral hormone release
  • Induction of a fasting intestinal pattern
  • Inhibition of insulin release
  • Splanchnic vasoconstriction
  • Inhibition of postprandial vasodilation

Surgical intervention options include:

  • Stomal revision
  • Conversion of Billroth II to Billroth I anastomoses
  • Pyloric reconstruction
  • Jejunal interposition
  • Roux-en-Y conversion
  • Laparoscopic conversion

Popular Exam Questions on Dumping Syndrome

The correct answers can be found below the references.

1. A 63-year-old gentleman presents to your office one month after partial gastrectomy, which was done due to a gastric tumor. In his visit, he complains to you of nausea, vomiting, diarrhea, and postprandial abdominal pain. He also complains of shortness of breath and flushing. He does not drink alcohol or smoke. His drug history includes only two drugs: atorvastatin and omeprazole. Abdominal distention and increased bowel sounds were revealed by physical examination. What is the most appropriate treatment for this gentleman?
A. Add simple accessible carbohydrates to his diet
B. Prescribe loperamide
C. Increase fibers in his diet
D. Decrease the intake of carbohydrates
E. Increase the omeprazole dose

2. All of the following sentences regarding dumping syndrome are correct except:
A. Tachycardia is a common symptom of Dumping syndrome
B. Flushing is a common clinical feature of the syndrome
C. A somatostatin analog can control the symptoms
D. Early post-vagotomy dumping syndrome usually resolves spontaneously
E. Some of the symptoms may be alleviated by separating solids and liquids in oral intake of the patient

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