Dumping Syndrome

What is Dumping Syndrome?

Dumping syndrome is a term used to describe the cluster of symptoms seen when predominantly undigested food that is hyperosmolar (having increased osmolarity) moves very quickly from the stomach to the duodenum, the first part of the small bowel. It is also referred to as rapid gastric emptying.

Dumping syndrome is of two major types, based on the timing of symptoms

• Early dumping syndrome - symptoms occur within 10 to 30 minutes following a meal
• Late dumping syndrome - symptoms occur 2 to 3 hours after ingestion of the meal.

Overview of the Alimentary Tract Structure

The gastrointestinal (GI) or alimentary or digestive tract begins in the oral cavity (mouth), and ends in the anal opening, where the stool exits the body. In between, lie a series of hollow, muscular tubes, where the food is broken down into simpler components that can be easily absorbed by the body to provide energy and fuel for its metabolic functions.

The upper portion of the GI tract consists of the mouth, food pipe (esophagus), stomach (gastric cavity), and the small bowel, which further is subdivided into three parts, namely the duodenum (first part), jejunum and ileum.

The lower portion of the GI tract consists of the large intestine or colon, the anal canal and the anus. The large intestine measures nearly 5 feet in length, beginning at the terminal portion of the small intestine, and ending at the anal verge.

The Digestive Process - In Brief

Stated simply, the GI tract digests the food using the mixing action of the muscles present along the entire tract, with the aid of secreted enzymes and digestive hormones.

The food that is swallowed, is propelled via the food pipe (esophagus), into the stomach. In the stomach, partial digestion of the food occurs, and the semisolid food enters the first portion of the small intestine, the duodenum for further digestion and absorption into the circulation.

The liver and pancreas are the two accessory organs of digestion, that produce digestive juices which reach the intestine via tubes called ducts. They take part in the digestion of the food occurring in the small intestine.

From the small intestine, water, and any remaining nutrients pass into the large intestine to be absorbed. The main process taking place in the large intestine, is only absorption of water. The semisolid/liquid food is thus converted into solid waste matter or stools to be excreted from the body through the anus.

Why does Dumping Syndrome Occur?

Early dumping syndrome occurs when a large quantity of hyperosmolar food like food containing high amounts of sugar suddenly enters the small bowel. The increased osmolarity of the food particles causes water to move rapidly into the lumen of the small intestine, causing its distension, followed by the characteristic symptoms described below.

Late dumping syndrome occurs when food containing large amounts of sugar is rapidly absorbed by the small intestine, leading to a sudden spike in blood glucose levels, and release of insulin from the pancreas in response to the elevated blood glucose. The effects of insulin are responsible for the symptoms of late dumping syndrome.

What are the Causes of Dumping Syndrome?

As mentioned earlier, rapid emptying of the contents of the stomach into the small intestine is responsible for a majority of the symptoms of dumping syndrome. Normally, the stomach acts as a reservoir (storage) for the food while it is digested, and the contents are gradually released into the small intestine.

However, when surgery is done to remove either a part of the stomach or the entire stomach due to reasons such as cancer, or more recently weight loss or bariatric (weight loss) surgery, the capacity of the stomach is reduced, leading to rapid emptying of the contents into the small intestine. Surgical removal of the esophagus and vagotomy (cutting of the vagus nerve that innervates the stomach) may also produce a similar effect.

The various stomach surgery procedures that may lead to dumping syndrome include:

• Partial or complete gastrectomy (surgical removal of stomach)
• Gastroenterostomy or gastrojejunostomy (part of the stomach is removed, and the cut end is attached to the small intestine)
• Gastric bypass surgery (Roux-en-Y operation) where a created stomach pouch is directly attached to the jejunum, bypassing the initial portion of the small intestine (duodenum).
• Fundoplication (the fundus of the stomach is wrapped around the lower end of the food pipe, and stitched in place).

Symptoms of dumping syndrome become overt, when a person resumes normal diet following stomach surgery. Refined foods are more likely to trigger dumping syndrome symptoms.

What are the Signs and Symptoms of Dumping Syndrome?

Symptoms of Early Dumping Syndrome

The sudden influx of a large amount of food from the stomach into the small intestine leads to digestive and cardiovascular symptoms. Symptoms of early dumping syndrome include:

• Nausea
• Vomiting
• Diarrhea
• Cramping and abdominal pain
• Stomach rumbling
• Feeling uncomfortable or bloated after a meal
• Sweating
• Dizziness
• Weakness
• Rapid or irregular heartbeat
• Flushing, or blushing of the face or skin

Symptoms of Late Dumping Syndrome

As stated earlier, there is a sudden spike in blood glucose levels following rapid absorption of sugar. This leads to release of insulin, leading to what is known as a 'reactive hypoglycemia' or low blood sugar levels, causing the characteristic symptoms of late dumping syndrome.

• Feelings of hunger
• Sweating
• Weakness and tiredness
• Confusion
• Agitation
• Feeling faint

How is Dumping Syndrome Diagnosed?

Dumping syndrome is diagnosed based on the following methods

1. History and examination

The doctor notes down the symptoms following a detailed history. A scoring system is employed, assigning points to each symptom. A score of above 7 increases the likelihood of dumping syndrome.

The following tests may be employed to confirm the diagnosis, and to distinguish from conditions that present with a similar picture.

2. Modified oral glucose tolerance test

This test is performed in the hospital or clinic under the supervision of doctors, by qualified personnel.

Following overnight fast, the patient is given a solution containing glucose to drink.

The person's blood is drawn before the administration of glucose to check the baseline values, and compared with the measurements after the test. Blood is drawn at 30 minute intervals after drinking glucose till 180 minutes.

The parameters measured include:

• Blood glucose levels
• Hematocrit
• Blood pressure

A diagnosis of dumping syndrome may be confirmed in the presence of the following findings

• Low blood sugar levels between 120 to 180 minute measurements
• Rise in hematocrit to more than 3 percent at 30 minutes
• Increase in pulse rate by more than 10 beats at 30 minutes

3. Gastric emptying Scintigraphy test

This test is performed in a hospital or imaging center by a trained radiology technician, and the results are interpreted by a radiologist. Anesthesia is not needed.

The person is given a bland meal containing a small quantity of radioactive material. Images are taken at 1, 2, 3 and 4 hours to measure the rate of gastric emptying, while a camera scans the abdomen to locate the position of the radioactive material.

4. Other tests

Other tests that may be done to determine any structural abnormalities of the upper GI tract include:

Upper GI endoscopy - The procedure is performed in an outpatient facility by a gastroenterologist, under local or I.V anesthesia.

A flexible tube (endoscope), with a camera attached to its tip is passed down the mouth into the esophagus, stomach and duodenum. The camera captures images and transmits to a video monitor for viewing. Lesions of the upper GI tract such as ulcers or cancer may be seen.

Upper GI series - The test is performed in a hospital outpatient facility or an imaging center.

The patient is administered a chalky white liquid (Barium meal) and images of the upper GI tract are captured at regular intervals. The barium will outline the inner surface more clearly enabling any lesion or pathology to show up clearly on the x-ray.

How is Dumping Syndrome Treated?

Treatment for dumping syndrome involves changes in eating habits and diet, intake of medications; and, occasionally, surgery. Most people suffering from dumping syndrome have mild symptoms that improve over time with conservative management such as dietary and eating habit changes.

Changes in eating habits and diet

• Taking five or six small meals per day instead of three larger meals
• Postponing liquid intake until at least 30 minutes following a meal
• Intake of more protein, fiber, and complex carbohydrates and avoiding simple sugars
• Increasing the thickness of food by adding pectin or guar gum
• Lying down after meals for about 30 minutes

Medications

The drug most often employed to manage symptoms of dumping syndrome is octreotide (Sandostatin). It acts by delaying gastric emptying and preventing the secretion of insulin and other GI hormones. It is administered as an injection either multiple times a day or once a month depending on the formulation.

Acarbose has been shown to reduce symptoms of late dumping by delaying carbohydrate absorption.

Surgery

Surgery may be rarely necessary if the dumping syndrome does not respond to dietary changes and medications.

How is Dumping Syndrome Prevented?

The symptoms of dumping can be minimized, if not totally prevented by following some basic measures that include:

• Take 5 to 6 small meals spaced throughout the day instead of 3 larger meals. This will reduce the feeling of fullness and bloating.
• Eat slowly and chew the food thoroughly so that it becomes easier to digest.
• Avoid drinking water or liquids half an hour before and after meals.
• Eat ground meat instead of, for example, a piece of steak; dumping is more often stimulated by solid food that requires to be broken down in the stomach.
• Avoid foods containing simple sugars, as they rapidly pass from the stomach and are more likely to cause diarrhea and cramping. Examples of such foods include fruit drinks and juices, soda, cakes, cookies, candy, doughnuts and pies.
• Include complex sugar containing foods such as rice, potatoes, pastas, bagels, breads, unsweetened cereals and whole grains.
• Include foods that contain high amounts of soluble fiber, such as apples, pears, beets, spinach, oats and Brussel sprouts. These slow stomach emptying and prevent sugar from being absorbed too quickly.
• Include foods rich in protein in the diet, such as eggs, fish, milk, cheese, yogurt, peanuts and peanut butter, and lean meat.

• A small quantity of fat may be included in the diet, as fat delays emptying of stomach. Examples include butter, margarine, mayonnaise, vegetable oils, salad dressing and cream cheese.
• Avoid milk and milk products if they trigger dumping symptoms; an alternative would be lactose free milk, soy milk, or almond milk.
• Ensure that you get adequate amounts of calcium and vitamin D from diet and supplements.
• Sit upright while eating and avoid lying down after meals for at least an hour.
• It may be well to limit or avoid gastric stimulants such as caffeine, tea and alcohol.

References:

1. Dumping syndrome - (http://www.mayoclinic.org/diseases-conditions/dumping-syndrome/basics/definition/con-20028034)
2. What is dumping syndrome? - (https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/dumping-syndrome/Pages/facts.aspx)
3. Dietary and Nutritional Recommendations For Patients with Dumping Syndrome - (https://en.wikipedia.org/wiki/Gastric_dumping_syndrome)
4. Know About Dumping syndrome - (http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/dumping-syndrome/?region=on)

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