eMedicine Specialties > Gastroenterology > Stomach
Dumping Syndrome: Treatment & Medication
Updated: Jun 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Multimedia
Treatment
Medical Care
- Acarbose
- The use of acarbose, an alpha-glycoside hydrolase inhibitor, interferes with carbohydrate absorption and has been shown to help in patients with late dumping.
- Acarbose use may be limited by the occurrence of diarrhea secondary to fermentation of unabsorbed carbohydrates as manifested by increased breath hydrogen excretion and symptoms such as flatulence.
- Acarbose delays production of monosaccharides by inhibiting alpha-glucosidases associated with the brush border of the intestine. These enzymes are responsible for digestion of complex polysaccharides and sucrose.
- In healthy individuals, acarbose in doses of 100-200 mg significantly blunts the postprandial rise in glucose, insulin, and triglycerides. Acarbose has been shown to significantly lower postprandial blood glucose levels.
- Octreotide
- Somatostatin and its synthetic analogue octreotide (Sandostatin, SMS 201-995) have been used with short-term success in patients with dumping syndrome, but the long-term efficacy of octreotide is much less favorable. They exert a strong inhibitory effect on the release of insulin and several gut-derived hormones.
- In patients with dumping syndrome, octreotide likely decreases gastric emptying by resetting the migrating motor complex to the fasting level.
- The effectiveness of octreotide in controlling the symptoms of both early and late dumping has been demonstrated in several randomized control trials (see Table below).
- The mechanisms of action of octreotide in dumping syndrome are as follows:
- 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
- The usual initial dose of octreotide is 50 mcg administered subcutaneously bid/tid 30 minutes prior to each meal. The dose may be increased if smaller doses are not effective; however, higher doses are seldom effective if the smaller doses do not work.
- Octreotide improves the symptoms in about 90% of patients with severe dumping refractory to other forms of medical interventions.
- In all studies, octreotide in the short term decreased the symptom score, pulse rate, and plasma insulin levels when compared to placebo (see Table below). However, whether long-term octreotide use is as beneficial as short-term use is unclear. Reports on long-term use of octreotide are scarce, and the number of patients in these reports is small. In one study, Geer et al reported 8 of 10 patients with continued diminution of symptoms after 15 months of follow-up.7 They reported 11% weight gain. No major adverse effects were noted, and liver enzyme levels remained normal.
- During octreotide treatment, fecal fat excretion increases significantly. Despite this increase in steatorrhea, an increase in mean body weight is reported. This probably occurs because of increased energy intake as patients are able to tolerate more food.
- Octreotide appears to be a safe in the long-term management of refractory dumping syndrome; however, the occurrence of diarrhea in patients who already have malabsorption and maldigestion may be a major limiting factor.
- Depot long-acting release octreotide (Sandostatin-LAR), as compared with octreotide, resulted in a significantly greater GI specific quality of life index and body weight gain.
- Table. Randomized, Double-Blinded, Placebo-Controlled Crossover Trials of Octreotide Treatment for Severe Dumping
Open table in new window
Table
| Author, Year | n | Treatment | Symptom Score | Pulse Rate | Hematocrit, % |
| Hopman et al, 1988 | 1 | Control | 11.7 ±2.1 | 85 ±7 | 41 ±2 |
| 2 | Octreotide | 4.6 ±1.6 | 67 ±7 | 41 ±2 | |
| Tulassay et al, 1989 | 8 | Control | | 102 ±3 | 43 ±3.5 |
| | Octreotide | | 70 ±2 | 38 ±1 | |
| Geer et al, 1990 | 1 | Control | 8.5 ±0.5 | 87 ±5 | |
| 0 | Octreotide | 1.7 ±0.5 | 66 ±4 | | |
| Gray et al, 1991 | 9 | Control | 15.7 ±1.6 | 105 ±6 | 41 ±2 |
| | Octreotide | 4.6 ±1.7 | 80 ±3 | 39 ±1 |
| Author, Year | n | Treatment | Symptom Score | Pulse Rate | Hematocrit, % |
| Hopman et al, 1988 | 1 | Control | 11.7 ±2.1 | 85 ±7 | 41 ±2 |
| 2 | Octreotide | 4.6 ±1.6 | 67 ±7 | 41 ±2 | |
| Tulassay et al, 1989 | 8 | Control | | 102 ±3 | 43 ±3.5 |
| | Octreotide | | 70 ±2 | 38 ±1 | |
| Geer et al, 1990 | 1 | Control | 8.5 ±0.5 | 87 ±5 | |
| 0 | Octreotide | 1.7 ±0.5 | 66 ±4 | | |
| Gray et al, 1991 | 9 | Control | 15.7 ±1.6 | 105 ±6 | 41 ±2 |
| | Octreotide | 4.6 ±1.7 | 80 ±3 | 39 ±1 |
Surgical Care
Preventing dumping syndrome is preferable to treating its symptoms. Consider anatomic factors that relate to the syndrome, and, if possible, determine the exact type of surgical procedure needed. Proximal gastric vagotomy is now the procedure of choice for the surgical management of intractable ulcer disease. Although the long-term ulcer recurrence rate is higher after this procedure compared to antrectomy and truncal vagotomy, it has the lowest incidence of postoperative dumping and diarrhea. If more extensive surgery is necessary, resection is preferable to a Roux-en-Y gastrojejunostomy because it decreases the rate of dumping syndrome compared to pyloroplasty or loop gastrojejunostomy.
Consider remedial surgery in patients refractory to medical treatment or in patients unwilling to continue medical therapy. Patients should be approached conservatively because most patients improve with time and remedial surgery is not always effective.
Several surgical procedures have been designed to rectify the symptoms of dumping. These include surgical narrowing of the gastrojejunal stoma, conversion of Billroth II anastomosis to Billroth I gastroduodenostomy, jejunal interposition, conversion to Roux-en-Y gastrojejunostomy, and pyloric reconstruction. No long-term studies have assessed the effectiveness of these procedures. Furthermore, no controlled trials have examined the efficacy of one procedure compared to the other.
- Stomal revision
- One strategy for surgical correction of the pathophysiology of dumping is to slow down gastric emptying.
- Porter and Claman reported good results by narrowing the gastrojejunal stoma.8
- Determining the exact size of the stomal reconstruction is difficult.
- Stomal strictures with gastric outlet obstruction are common adverse effects of the operation.
- This technique has been abandoned in favor of other procedures.
- Conversion of Billroth II to Billroth I anastomoses
- Woodward et al and Perman have shown that conversion of a Billroth II to a Billroth I gastroduodenostomy improves dumping syndrome in 75% of patients.9
- This procedure restores the physiologic delivery of the meal to the duodenum, without risk of gastric outlet obstruction.
- Overall, the procedure is useful because of its simplicity and low rate of complications.
- Pyloric reconstruction
- In this procedure, the pyloroplasty scar is identified and is cut along its length. The sphincter muscle is identified and approximated. The incision is then closed longitudinally.
- In a series of 14 patients reported by Koruth et al, 9 showed excellent results, while another 3 had good resolution of their dumping symptoms.10
- Cheadle and coworkers reported a series of 9 patients, 8 of whom had excellent results.11
- This procedure is low-risk and seems to be fairly effective in patients who have severe dumping after pyloroplasty.
- Jejunal interposition
- Schoemaker is credited with the first attempt at interposing an isoperistaltic jejunal loop after gastric surgery.
- Henley has reported extensive use of an interposed jejunal segment between the gastric pouch and the duodenum for correction of postgastrectomy dumping in more than 300 patients.12 In his series, all patients improved, including those with early postprandial dumping. However, other smaller series have failed to show such excellent results with the use of isoperistaltic interposition.
- Sawyers and Herrington had only a 20% satisfactory result in 10 patients.13 In an 11-year experience using antiperistaltic jejunal loops in 28 patients, they reported excellent results in 20 patients and good results in another 6 patients. In their experience, a 10-cm reversed jejunal segment effectively prolongs the gastric emptying time without obstruction.
- Unsuccessful results with interposition of 6 cm of reversed jejunal segments have been reported, whereas a good response has been reported with 10-cm segments.
- Using longer lengths of jejunum has resulted in ulcerations and stenosis in the interposed segment. Care should be taken to rotate the interposed segment no greater than 180° to avoid undue torsion on the mesentery. Mesenteric defects should be carefully repaired to avoid internal herniation.
- Reversed segments have been shown to be effective for as long as 10 years after interposition.
- Double iso-antiperistaltic jejunal limb pouches have also been used, but their efficacy is inferior to the antiperistaltic loop interposition.
- Roux-en-Y conversion
- Recently, conversion to a Roux-en-Y gastrojejunostomy as a remedial operation has gained favor.
- With this operation, favorable outcomes have been reported in 85-90% of patients. Of patients with dumping symptoms after Billroth I and II gastrectomy, 85-90% have favorable outcomes with Roux-en-Y conversion.
- Vogel et al reported 19 of 22 patients with favorable outcomes with this operation.14 Of the 3 failures, 1 was due to persistent dumping syndrome, while the other 2 patients had Roux stasis syndrome.
- The mechanism by which this conversion works in providing relief from dumping is unknown, but it may be due to interruption of the migration motor complex, diminished jejunal contractions, and retrograde jejunal contractions.
- This procedure is easier to perform and has fewer long-term adverse effects.
- Experimental procedures
- Because no operation for intractable dumping is uniformly successful, new approaches have been considered.
- In dogs prepared with truncal vagotomy, distal gastrectomy, and Roux-en-Y reconstruction, retrograde electrical pacing of the Roux-en-Y reconstruction significantly delayed gastric emptying and absorption of a glucose meal and decreased postcibal hemoconcentration.
- Summary of remedial operations
- For patients with prior pyloroplasty, pyloric reconstruction should be the initial remedial operation.
- For patients with Billroth I and Billroth II gastrectomies, Roux-en-Y reconstruction is the simplest and most effective therapy.
- For patients who already have a Roux-en-Y reconstruction, a 10-cm antiperistaltic jejunal loop should be interposed.
- Conclusion
- Dumping syndrome is a common postsurgical complication after gastric surgery. The symptoms of dumping produce considerable morbidity. Fortunately, the indications for gastric surgery are declining, although the need for gastric surgery in emergency cases has not changed.
- Initially, patients with this condition should be treated medically with dietary modifications and octreotide. Close attention should be given to the patient's nutritional status. If medical management fails to provide adequate symptom relief, remedial surgery should be offered with the understanding that even surgical intervention may not be successful.
Diet
Dietary prohibitions and instructions are very important in the management of dumping syndrome.
- Daily energy intake is divided into 6 meals.
- Fluid intake during and with meals is restricted. Avoiding liquids for at least half an hour after a meal is helpful.
- Simple sugars are best avoided.
- Milk and milk products are generally not tolerated and should be avoided.
- Because carbohydrate intake is restricted, protein and fat intake should be increased to fulfill energy needs.
- Most patients have relatively mild symptoms and respond well to dietary manipulations. In some patients with postprandial hypotension, lying supine for 30 minutes after meals may delay gastric emptying and also increase venous return, thereby minimizing the chances of syncope.
- Supplementation of dietary fibers has proven effective in the treatment of hypoglycemic episodes. Many medical therapies have been tested, including pectin, guar gum, and glucomannan. These dietary fibers form gels with carbohydrates, resulting in delayed glucose absorption and prolongation of bowel transit time.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Hypoglycemic agents
Shown to be helpful for late dumping.
Acarbose (Precose, Prandase)
Lowers blood sugar by delaying GI absorption of carbohydrates. Decreases postprandial hyperglycemia.
Adult
100-200 mg PO tid
Pediatric
Not established
Serum digoxin concentrations may be reduced with coadministration; digestive enzymes or charcoal may reduce effect
Documented hypersensitivity, active liver disease, ketoacidosis, GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects include flatulence, diarrhea, and abdominal discomfort, which generally diminish in frequency and intensity
Antisecretory agents
These agents may improve morbidity.
Octreotide (Somatostatin)
Acts primarily on somatostatin receptor subtypes II and V. Inhibits GH secretion and has a multitude of other endocrine and nonendocrine effects, including inhibition of glucagon, VIP, and GI peptides.
Adult
Initially: 50 mcg SC bid/tid 30 min ac
Pediatric
Not established
May reduce effects of cyclosporine; patients on insulin, PO hypoglycemics, beta-blockers, and calcium channel blockers may need dosage adjustments
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects are primarily related to altered GI motility and include nausea, abdominal pain, diarrhea, and increased incidence of gallstones and biliary sludge; hypoglycemia or hyperglycemia may occur because of alteration in counter-regulatory hormones (eg, insulin, glucagon, GH); bradycardia, cardiac conduction abnormalities, and arrhythmias have been reported; hypothyroidism may occur because of inhibition of TSH secretion; use caution in patients with renal impairment
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Further Reading
Keywords
postgastrectomy syndromes, small stomach capacity, dumping, bile gastritis, afferent loop syndrome, efferent loop syndrome, anemia, metabolic bone disease, postprandial syndrome, peptic ulcer disease, vagotomy, partial gastric resection, stomach surgery, Nissen fundoplication, rapid gastric emptying, gastrojejunostomy, bloating, explosive diarrhea, early satiety, epigastric fullness, crampy abdominal pain, syncope, borborygmi, Sigstad's diagnostic index, Visick classification
