[Dumping syndrome following gastric surgery]. / Dumpingsyndrom etter kirurgi på magesekken.

BACKGROUND: Dumping syndrome is the term used to describe a common set of symptoms following gastric surgery, and is characterised by postprandial discomfort which can entail nutritional problems. The condition was well known when surgery was the usual treatment for peptic ulcer disease. The increasing number of operations for morbid obesity means that the condition is once again of relevance, and health personnel will encounter these patients in different contexts. This article discusses the prevalence, symptomatology and treatment of dumping syndrome. MATERIAL AND METHOD: This review article is based on a selection of articles identified in PubMed and assessed as having particular relevance for elucidating this issue, as well as on the authors' own clinical experience. RESULTS: Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine. Nausea, abdominal pain, diarrhoea, a sensation of heat, dizziness, reduced blood pressure and palpitations are typical symptoms. Lethargy and sleepiness after meals are common. Late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness. Dumping-related symptoms occur in between 20 and 50% of patients following gastric surgery. Early dumping syndrome is more frequent than late dumping syndrome. It is estimated that 10-20% of patients have pronounced symptoms and 1-5% have severe symptoms. The diagnosis is usually made on the basis of typical symptoms. Most patients experience alleviation of the symptoms over time and with changes in diet and eating habits. Further patient evaluation and drug or surgical intervention may be relevant for some individuals. INTERPRETATION: Dumping-related symptoms are common after gastric surgery. The extent of obesity surgery in particular means that health personnel should be familiar with this condition.

Safety and efficacy of high-dose acarbose treatment for dumping syndrome.

Dumping syndrome (DS) is a complication of Nissen fundoplication. Dietary strategies can ameliorate symptoms, but this approach is not always foolproof. Limited evidence reports the efficacy of acarbose for children who are unresponsive to feeding manipulations. We report 8 patients with DS aged between 7 and 24 months. In 4 of 8 nutritional strategies failed, and acarbose treatment was started. The initial dose was 25 mg for meals, and increased until postprandial glucose was stable. In 3 of 4 children the final dose was higher than previously reported, without adverse effects. Acarbose is useful to treat DS in cases of failure of dietary strategies.

Nutrition management of gastric bypass in patients with chronic kidney disease.

Frequent monitoring by a dietitian can ensure desirable progression of the post-surgery diet, adequate nutritional composition, management of food intolerances, and ongoing education/reinforcement of the post-surgical nutritional needs. Additionally, it is critical for dietitians to assess the type of GBP because increased nutritional risks result with longer limb lengths and will require closer monitoring. With close follow up and adherence to recommendations, patients with CKD who undergo GBP can reduce the risk of post-surgical, nutrition complications.

Postgastrectomy Syndromes and Nutritional Considerations Following Gastric Surgery.

Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.

Early dumping syndrome is not a complication but a desirable feature of Roux-en-Y gastric bypass surgery.

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

Diet therapy in gastrointestinal disease: a commentary.

Dietary regimens in gastrointestinal disease can be divided into two categories: First, those of proven value include: (a) Disaccharide elimination for disaccharidase deficiency and exclusion of monosaccharides for sugar malabsorption; (b) gluten-free diet for celiac/sprue; (c) elimination of certain allergens because of food allergies; (d) protein restriction for portal systemic encephalopathy; (e) low-carbohydrate diet for dumping syndrome; (f) low-fiber diet for diarrheal syndromes; and (g) low-fat diet for steatorrhea. Second, controversial diets include a bland diet for acid-peptic disorders, a high-fiber diet for colonic disorders, and a low-fat diet for gallbladder disease. It is important to separate facts from fancy in the dietary management of patients with gastrointestinal disease and base the recommendations for a particular diet on available objective evidence, not on traditional or fashionable trends.

Medical and nutritional aspects of intractable diarrhea.

Diarrhea can be due to at least five pathogenetic mechanisms. Major examples of each are presented to better illustrate each type of diarrhea and to provide a springboard for discussion of the nutritional management of each class of diarrhea. Certainly, specific diseases require specific therapies, such as avoidance of gluten in adult coeliac disease, but the major dietary/nutritional alterations and subsequent treatment are similar for each class of disease. Nowhere in medicine and nutrition is an admonition to the health care team more important and more proper than in the treatment of chronic diarrheas: The feeding of healthy man, as well as the diet of the sick cannot be left to chance, guided by the appetite, or ruled by tradition, but can be safely directed only according to the laws of digestion and metabolism.

Acarbose treatment of infant dumping syndrome: extensive study of glucose dynamics and long-term follow-up.

Dumping syndrome is a sequel of gastric surgery in adults and Nissen fundoplication in children. The syndrome is characterized by various gastrointestinal symptoms as well as irritability, diaphoresis and lethargy. Shortly after a meal, symptoms are associated with hyperglycemia (early dumping), followed by late dumping symptoms associated with reactive hypoglycemia. Several therapeutic and dietary manipulations failed to control these symptoms in previous reports as well as in an infant we have followed after Nissen fundoplication. Acarbose, an alpha-glucosidase inhibitor, has been used sporadically in adults after gastric surgery, but only once in children. In most of these studies, the effect of acarbose (on reactive hypoglycemia) was evaluated over several hours postprandially or after oral glucose load. In our study, we recorded glucose dynamics by a continuous glucose monitor system over 2 to 3 days before and during acarbose treatment, while the patient was on a well-controlled diet. These measurements (720 before and 832 on therapy) suggested that both early and late dumping symptoms are causally related to the rate of glucose elevation and decline, rather than to glucose peak and nadir, respectively. Acarbose attenuated both postprandial glucose hyperglycemia and reactive hypoglycemia, which subsequently led to a significant reduction in dumping symptoms. In a follow-up of 14 months, acarbose was well tolerated and the frequency of dumping symptoms was remarkably reduced.

Nutritional management of dumping syndrome associated with antireflux surgery.

Eight children were identified as having dumping syndrome by a glucose tolerance test and evidence of rapid gastric emptying. All had undergone a fundoplication with concomitant feeding gastrostomy placement at 18.4 +/- 17.4 months of age (range, 3 to 54 months). Symptoms suggestive of dumping syndrome occurred 1 to 4 months after surgery. There was considerable delay in diagnosis (3 to 8 months). These children were successfully managed with nutritional manipulation alone, using a combination of a complex carbohydrate and a fat emulsion. Complete resolution of symptoms and normoglycemia was achieved in all the children, without any complications.

Diarrhea after gastrectomy and vagotomy.

Development of diarrhea in a patient following gastric surgery can be a confusing problem. The clinician is forced to consider and exclude causes that may be independent of the surgery as well as those that are unique to the postgastrectomy state. An orderly approach is mandatory for appropriate workup and management.

Dumping syndrome in a young Jamaican child.

The dumping syndrome in childhood is an uncommon complication of gastro-oesophageal surgery, principally Nissen fundoplication. A Jamaican child developed the syndrome after fundoplication and pyloroplasty to relieve gastro-oesophageal reflux complicating the repair of a congenital tracheo-oesophageal fistula. He developed marasmus and failed to gain weight on the standard remedial milk-based high-energy diet. An oral glucose tolerance test confirmed the diagnosis of dumping syndrome. A low sugar low milk diet based on adult type meals with continuous nibbling of fried dumplings relieved his diarrhoea and hypoglycaemia and he gained weight. This is a cheaper and more practical dietary therapy than the regimens described previously.

Dietary therapy of gastrointestinal disorders.

Diet therapy is mandatory in only a very small number of GIT disorders. While the available evidence does not support its use in other conditions, many physicians will wish to make an individual decision regarding diet therapy according to the patient's symptoms, to the patient's attitudes and expectations and very importantly, to the financial and social implications of the diet in question.

[Pathogenetic basis of diet therapy in dumping syndrome patients after a stomach resection]. / K patogeneticheskomu obosnovaniia dietoterapii bol'nykh s demping-sindromom posle rezektsii zheludka.

A total of 462 patients with the dumping syndrome after gastric resection for peptic ulcer were under-observation. The critical response to qualitatively different nutritional loads and the content of a number of the vegetative nervous system mediators and insulin were examined. Moreover, function of the digestive organs and metabolic rates reflecting the course of a number of metabolic processes were studied. The evidence obtained furnished a background for validating and elaborating the system of staged differentiated nutritional therapy of the dumping syndrome with due regard for the syndrome gravity, various post-operative periods and the character of concomitant affections.

[The morphofunctional state of the gastric stump in patients with the dumping syndrome and its significance for the formulation of diet therapy]. / K kharakteristike morfofunktsional'nogo sostoianiia kul'ti zheludka u bol'nykh s demping-sindromom i ego znacheniia pri postroenii dietoterapii

In 42 patients with the dumping syndrome. the mucosa of the resected gastric stump was examined histologically. Bioptic materials were obtained by applying fibrobiopsy and aspiration biopsy under roentgenological control. The great majority of the examined demonstrated some or other degree of the glandular atrophy attended by a fall of the secretary function. In spite of a considerable time lapsed since gastric resection the gastric glands remained intact and the secretary function of the stump continued to be normal. According to the authors the severity of the dumping syndrome does not depend on the nature of morphological changes in the gastric stump mucosa. A sizable proportion of the examined patients demonstrated various changes in the motor function of the stump, more often an accelerated evacuation. The listed changes in the morphological-functional condition of the gastric stump were given due consideration in compiling a dietary pattern for patients with the dumping syndrome.

[Characteristics of the motor function of the gallbladder in the dumping syndrome and their importance in establishing a therapeutic diet]. / Osobennosti dvigatel'noi funktsii zhelchnogo puzyria u bol'nykh s demping-sindromom i ikh znachenie v obosnovanii lechebnogo ratsiona.

In 76 patients suffering from the dumping syndrome following gastric resection in connection with peptic ulcer the motor function of the gallbladder and gastric stump was studied. Investigations ascertained the existence of a direct relationship between the type of the gallbladder dyskinesia and evacuation periods from the gastric stump. The authors consider the hypermotor dyskinesia of the gallbladder combined with an accelerated evacuation from the stump to be an optimal combination after excision of the stomach. On the other hand, the hypomotor dyskinesia of the gallbladder with an accelerated emptying of the gastric stump was regarded as am explicit pathology demanding persistent curative measures. Principles of pathogenetic dietotherapy have been evolved.

[Effects of wheat bran on the rate of gastric stump and small intestine evacuation in patients with dumping syndrome after stomach resection]. / Vliianie pshenichnykh otrubei na skorost' oporozhneniia kul'ti zheludka i tonkoi kishki u bol'nykh s demping-sindromom posle rezektsii zheludka.

A total of 65 patients with dumping syndrome after gastric resection were under study. It has been found that addition of 10 and 20 g of wheat bran to semolina porridge significantly (p less than 0.05) inhibits the rate of gastric stump and small intestine evacuation, and in 1/3 of the patients it promotes lowered manifestation and duration of dumping syndrome. It has been suggested that the inhibitory action of wheat bran is caused by bran viscosity and, probably, mediated by intestinal hormones released from endocrine cells of the small intestine mucosa. The results of the investigations conducted can be used in the validation of the diet therapy of patients with dumping syndrome.

[Effect of different types of food loads on the rate of emptying of the gastric stump in patients with the dumping syndrome after gastric resection]. / Vliianie razlichnykh tipov pishchevykh nagruzok na skorost' oporozheniia kul'ti zheludka u bol'nykh s demping-sindromom posle rezektsii zheludka.

The influence of carbohydrate, carbohydrate-fatty and protein test breakfasts on the rate of gastric stump evacuation was studied in 62 patients with dumping syndrome of mild and moderate severity, using the x-ray method developed by the authors. It has been established that in patients with dumping syndrome carbohydrate and carbohydrate-fatty food is most quickly evacuated from the gastric stump. Doubled amount of fat in the carbohydrate-fatty breakfast (up to 40 g) induced no significant deceleration in the gastric stump evacuation, moreover, in some cases its evacuatory function was accelerated. Intake of mineral water before breakfast did not noticeably influence the rate of gastric stump evacuation after carbohydrate and carbohydrate-fatty breakfasts, and significantly decelerates the gastric stump evacuation after protein breakfast.

[Liver exocrine function in patients after gastrectomy for peptic ulcer]. / Vneshnesekretornaia funktsiia pecheni u bol'nykh posle rezektsii zheludka po povodu iazvennoi bolezni.

Exosecretory liver function was studied in patients after gastric resection for peptic ulcer. Disorders of the biochemical composition of the bile were discovered; they were manifested by disproportional formation and secretion of the basic components of the bile: cholic acid, cholesterol and phospholipids, which led to the shift in the bile components ratio and could promote their precipitation. Moreover, the lowering of the content of the basic components of the bile is likely to bring about a substantial derangement of the processes of fat digestion. Dietetic management of these patients exerted a beneficial effect on cholic acid secretion. However, in some patients with grave postoperative syndromes and disturbances in the hepatobiliary system, no noticeable positive results were obtained. The latter circumstance allows the conclusion about the necessity of placing such patients on prolonged treatment including bile expelling agents.

[Patient after stomach resection. What and how he should eat]. / Patient nach Magenresektion. Was und wie er essen sollte.

Complete or partial removal of the stomach results in considerable anatomical and physiological changes, which, in turn lead to more or less pronounced dietary problems. For this reason, patients should receive comprehensive postoperative counseling. In the majority of cases, the major problems can be avoided or symptoms ameliorated. The selection of suitable foods must be discussed, as also the particular importance of drinking. Preprandial exercise to stimulate the appetite is just as important as postprandial resting to avoid diarrhea and the dumping syndrome. A central aspect is the distribution of the food ingested over six to ten small portions. Some nutrients may need to be substituted--for example, vitamin B12, the fat-soluble vitamins, calcium and iron. With increasing time after the operation, alimentation problems usually abate, but in the individual case may persist for years.