Dumping syndrome

NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #35
Carol Rees Parrish, R.D., M.S., Series Editor

Dumping Syndrome

Andrew Ukleja

Dumping syndrome is a constellation of gastrointestinal and vasomotor symptoms resulting from changes in the anatomy and physiology of the stomach created by gastric surgery. Dumping syndrome is frequently attributed to the rapid emptying of gastric content intothe small bowel. However, the etiology of dumping syndrome is multifactorial. Severe dumping can be complicated by malnutrition and it can be associated with poor quality of life. Most patients with dumping syndrome can be treated conservatively with dietary modifications. Octreotide is the most effective drug therapy for patients with incapacitating symptoms. Those patients who failed medicaltherapy may be considered as surgical candidates. The aim of this article is to review the clinical features and pathophysiology of dumping syndrome in addition to providing guidelines for its management.

INTRODUCTION

O

perations on the stomach can lead to a variety of undesirable and chronic sequelea. The dumping syndrome refers to gastrointestinal (GI) and vasomotor symptoms that occurfollowing ingestion of a meal in individuals after gastric surgery. The association between postprandial symptoms and rapid drainage of the stomach after gastroenterostomy was first described by Hertz in 1913 (1). The term “dumping” was introduced by Andrews and Mix in 1920, who reported a radiographic observation of rapid gastric emptying of contrast in patients with typical dumping symptoms aftergastrectomy (2).

Andrew Ukleja, M.D., Assistant Professor of Medicine, Department of Gastroenterology, Cleveland Clinic, Weston, Florida. 32
PRACTICAL GASTROENTEROLOGY • FEBRUARY 2006

The incidence and severity of the symptoms associated with dumping correlate with the type of gastric surgery. Dumping occurs in approximately 15%–20% of patients after partial gastrectomy (3). Significantdumping has been reported in 6%–14% of patients who have undergone truncal vagotomy with drainage. A lower incidence of dumping has been observed after proximal gastric vagotomy without drainage procedure. After Roux-en-Y gastric bypass, 50% to 70% of patients experience dumping syndrome in the early post-operative period (4). However, symptoms of dumping subside after 15–18 months from gastricbypass. In children, dumping syndrome has been reported almost exclusively after fundoplication (5). Only a minority (1%–5%) of patients with dumping syndrome suffer from severe, disabling symptoms.
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Dumping Syndrome

NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #35
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CLINICAL FEATURES OF DUMPING SYNDROME
The clinical manifestations of dumpinginclude GI and vasomotor symptoms. Dumping syndrome can be divided into early and late dumping depending on the relation of symptoms to the time elapsed after a meal (Table 1). The severity of symptoms varies between individuals. Symptoms of early dumping occur within 10–30 minutes after meals. They result from accelerated gastric emptying of hyperosmolar content into the duodenum or small bowel,followed by fluid shifts from the intravascular compartment into the intestinal lumen. This leads to small bowel distention and increased intestine contractility, both, believed to be responsible for GI symptoms such as nausea, bloating, abdominal cramps, and explosive diarrhea (6). The majority of patients have early dumping and they suffer from both GI and vasomotor symptoms. Late dumping occurs1–3 hours after a meal, and it is characterized predominantly by systemic vascular symptoms including flushing, dizziness, palpitations, and an intense desire to lie down. Physical exam of these patients may reveal profound orthostatic changes including drop in blood pressure and increased heart rate. Late dumping occurs in approximately 25% of patients with dumping syndrome. Those patients with...