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

The stomach is a hollow, muscular, and the most dilated part of our gastrointestinal system, present between esophagus and duodenum (the first part of small intestine). It is divided into three main parts with their respective roles in the digestion of food. They are cardia, fundus, body, and pylorus. The food from esophagus enters into the cardia, which is the most proximal part of stomach. The fundus and body (of stomach) are commonly known as a storage tank for all our consumed meals. The body churns the food and mixes it with all the digestive enzymes, and finally, the pylorus discharges the food in a systematic manner to duodenum. The pylorus is surrounded by a muscular valve, the pyloric sphincter, that controls the flow of food into the duodenum. Gastric movements are controlled by myogenic, hormonal, and neural activity.

The stomach can store around two (02) liters of food content in adults due to its greater distensibility. Any change in the gastric structure (e.g. gastrectomy), hormonal status, myogenic or neural activity may have deep effects on the gastric storage tank and the pyloric sphincter function. This results in a constellation of symptoms occurring after a meal termed as “dumping syndrome” or “rapid drainage of stomach”, which was first described by Hertz, in 1913.

Dumping syndrome: It is the collection of gastrointestinal and vasomotor symptoms that occur after a meal, commonly in patients with gastrectomy.

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 functions of the stomach are to act as a food reservoir, to start the digestion process by secreting gastric acid and enzymes, and to grind the food into smaller parts (around 1-2 mm) by organized muscular contractions. This partially digested food then passes through the pylorus into the duodenum. The pyloric sphincter makes sure that only small food particles are passed into the duodenum and that too gradually as not to overload the small intestine for proper food digestion and absorption.

The gastric surgeries reduce the storage capacity of stomach, remove the gastric glands, and damage the pylorus are unable to control the rate of passage of food into the duodenum causing the stomach to empty rapidly. This increased gastric emptying is one of the main features of diagnosing dumping syndrome.

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 are the newer drugs, proton pump inhibitors and anti-histamine 2, along with efficacious eradication therapy for Helicobacter pylori, which have reduced the cases of peptic ulcers and hence need for gastric surgeries, reducing this syndrome drastically.

Clinical Features of Dumping Syndrome

Early symptoms of dumping syndrome

The early dumping syndrome occurs due to rapid gastric emptying. The hyperosmolar food rapidly enters the small intestine overwhelming its digestive and absoprtive capabilties. The “hyperosmolar” food contents further cause the water to shift from the cells into the intestinal lumen. These patients often present with the following symptoms 30 – 60 minutes after a meal.

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

Late symptoms of dumping syndrome

The late dumping syndrome occurs due to reactive hypoglycemia that occurs 1 – 3 hours after a meal. As food containing carbohydrates quickly passes into the small intestine and absorbed, rapid hyperglycemia occurs that leads to a rapid secretion of insulin, resulting in a hyperinsulinemic state, which remains for prolonged time than the hyperglycemia and is responsible for the subsequent hypoglycemia and the following symptoms:

  • Perspiration
  • Shivering
  • Hunger
  • Decreased consciousness
  • Tiredness and fatigue

Management of Dumping Syndrome

The dumping syndrome can be managed by multiple steps. The first and foremost is the lifestyle and dietary modifications. The patient is advised to take frequent small meals. The sugar content (carbohydrate) should be reduced. The fluid and water intake should be reduced during the meal.

The medical options that have shown good benefit in the management of dumping syndrome include:

  • Acarbose: It is an alpha-glycoside hydrolase inhibitor that decreases the dumping syndrome by delaying the carbohydrate absorption and reducing the time between the hyperglycemia and insulin.
  • Octreotide: It is a somatostatin analogue that decreases the dumping syndrome by mainly inhibiting the release of insulin and other gastrointestinal hormones that result in a delay in gastric emptying and small intestinal transit time. It further induces a fasting intestinal pattern and causes splanchnic vasoconstriction.
Structural formula of octreotide

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

The surgical intervention options that help in the management of dumping syndrome 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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