Dumping syndrome is a pathological condition that develops after gastric resection due to a violation of the neurohumoral regulation of the digestive system. The course of dumping syndrome is characterized by vegetative crises with attacks of dizziness, sweating, palpitations, weakness, the development of dyspeptic phenomena, fainting states. Diagnosis is based on the data of anamnesis, objective examination, X-ray examination of the stomach and small intestine. Treatment of mild pathology consists in drug correction of manifestations; with severe symptoms, gastrojunoduodenoplasty is indicated.
Meaning
Dumping syndrome in modern gastroenterology refers to the so-called diseases of the operated stomach or post-resection syndromes. It is characterized by accelerated evacuation, “dumping” of food from the stump of the stomach into the intestines, which is accompanied by a violation of carbohydrate metabolism and the functioning of the digestive system. It develops in 10-30% of patients who have undergone gastric surgery in the immediate or long-term postoperative period. In most cases, it is expressed in a mild or moderate degree; severe severity of the syndrome, requiring surgical intervention, occurs in 1-9% of cases, more often in women.
Causes of dumping syndrome
Dumping syndrome develops at various times after undergoing surgery on the stomach. As a rule, the cause of resection is an ulcer of the duodenum or stomach, less often – stomach cancer. The frequency of occurrence of postresection syndrome depends on the type of operation performed: the maximum number of cases of dumping syndrome is observed after gastric resection according to Billrot II, less – after resection according to Billrot–I, the minimum – after selective proximal vagotomy or stem vagotomy with pyloroplasty.
Pathogenesis
The mechanism of pathology development is caused by too rapid intake of unprocessed food with high osmolarity from the stomach to the upper parts of the small intestine. With rapid emptying of the operated stomach and passage of the contents, the intestinal walls stretch, extracellular fluid and biologically active substances (histamine, serotonin, kinins) are released, which is accompanied by a decrease in BCC, vasodilation and increased intestinal peristalsis.
The balance of hormones of the gastrointestinal tract is disturbed: gastroinhibiting peptide, gastrin, neurotensin, enteroglucagon, etc.; the endocrine regulation of digestion changes, which is manifested by vasomotor and gastrointestinal reactions. Vegetative crises with dumping syndrome in 2/3 of cases occur according to the vagoinsular type, in 1/3 of patients – according to the sympathoadrenal type.
Classification
According to the time of development of a vegetative crisis, early and late dumping syndrome are distinguished: in the first case, symptoms appear 10-15 minutes after eating, in the second – 2-3 hours after eating. According to the severity of manifestations, pathology can occur in mild (I), moderate (II) or severe (III) degrees. A mild degree of reaction develops only in connection with the intake of sweet or dairy dishes; in this case, there is a slight weakness, dizziness, sweating, increased pulse rate by 10-15 beats per minute, palpitations. The attack lasts up to 30 minutes.; the patient’s body weight deficit does not exceed 5 kg, the ability to work does not suffer.
Dumping syndrome of moderate severity develops in response to any food intake; weakness forces the patient to lie down, the pulse increases by 20-30 beats. in min., systolic pressure increases. Patients note nausea, abdominal pain, violent intestinal peristalsis, profuse diarrhea, tinnitus, shivering of the extremities, which is replaced by a feeling of heat. The duration of the attack is up to 1 hour; the weight deficit is up to 10 kg; the ability to work is impaired. Severe dumping syndrome is characterized by symptoms of a pronounced vegetative crisis. Tachycardia (sometimes bradycardia), blood pressure lability, fainting, fear of death are typical. The crisis lasts from 1 to 2 hours and ends with copious urination. The patient is exhausted, unable to work.
Dumping syndrome symptoms
The clinical course of pathology is characterized by general, vasomotor and gastrointestinal manifestations. The clinic of early dumping syndrome develops 10-15 minutes after eating, is characterized by weakness, dizziness, up to fainting, headache, palpitations, cardialgia, profuse sweating, a feeling of heat. At the same time, epigastric pain, vomiting, flatulence, intestinal colic, diarrhea appear. A severe attack forces the patient to take a horizontal position for 2-3 hours after eating.
A late (hypoglycemic) variant of the syndrome develops 2-3 hours after eating. Its mechanism is associated with an increase in blood glucose levels during the early dumping reaction and the subsequent excessive secretion of insulin, which reduces the concentration of sugar in the blood to subnormal values. At the time of the attack, there is a sharp weakness, hunger, trembling, profuse sweating, dizziness, hypotension, bradycardia, acute pain in the epigastrium. These symptoms disappear quickly after taking a carbohydrate meal. The dumping attack lasts from 30 minutes to 1 hour.
Diagnostics
Dumping syndrome is diagnosed on the basis of anamnesis (gastric resection), subjective and objective manifestations. During stomach x-ray, rapid emptying of the operated stomach from contrast suspension is determined. During the radiography of the passage of barium through the small intestine, accelerated progress of barium, dyskinesia of the small intestine is noted. Provocative tests are used in the diagnosis: the dumping reaction can be caused by taking a concentrated glucose solution or sweet syrup. Laboratory tests are used to determine the level of blood glucose, insulin, albumins.
Differential diagnosis of dumping syndrome is carried out with insulinoma, neuroendocrine tumors, Crohn’s disease, partial intestinal obstruction, chronic enteritis, secretory insufficiency of the pancreas. Patients suffering from this disorder need to consult a neurologist to identify and correct autonomic vascular and neuropsychiatric disorders.
Dumping syndrome treatment
With a mild degree of pathology, a diet based on high-calorie fractional nutrition, restriction of fluids and carbohydrates, and a full vitamin composition of food is recommended. Dumping syndrome of moderate severity requires taking medications that reduce the peristalsis of the small intestine (ganglioblockers, atropine preparations, local anesthetics), general strengthening therapy (administration of glucose with insulin, parenteral vitamin therapy), prescribing replacement therapy (intake of gastric juice, hydrochloric acid, pancreatin enzymes). Novocaine blockades of the lumbar region, multi-channel electrical stimulation are used. In case of neuropsychiatric disorders, the use of neuroleptics is indicated.
In case of severe dumping syndrome, ineffectiveness of diet therapy and complex drug therapy, surgical treatment is performed – reconstructive gastrojunoduodenoplasty. The essence of the surgical intervention is the interposition of a segment of the small intestine (a graft from the jejunum diverting loop) between the duodenum and the stomach stump. Due to the imposition of gastrojunoduodenoanastomosis, the passage of food through the duodenum is restored, the normalization of food reflexes, the functions of enzyme and bile excretion, slowing down the passage of food masses in the jejunum.
Prognosis and prevention
Most often, dumping syndrome develops in the first six months after surgery: in 50% of patients, it becomes weaker over time, in 25% it does not progress, and in 25% it increases over the years. Progressive or severe pathology leads to permanent disability.
Prevention consists in the widespread use of organ-preserving interventions in combination with vagotomy in gastric ulcer surgery. If necessary, gastric resection is advisable to apply gastroduodenoanastomosis. In the postoperative period, the patient needs systematic observation of a gastroenterologist, nutritionist, endocrinologist, neurologist; psychosomatic rehabilitation, spa therapy.
