Early dumping K91.1

In 1913, Hertz first described the relationship between postprandial symptoms and rapid gastric emptying after gastric surgery. The term "dumping" was coined by Wyllys et al. in 1920 for patients with typical symptoms after gastrectomy (Mala 2015).

The Sigstad scoring system to aid in the diagnosis of early dumping was first used in 1970 (Scarpellini 2020).

The Arts questionnaire was developed by Arts et al. in 2009 for severity of dumping syndrome (Scarpellini 2020).

In early dumping, intestinal disturbances occur approximately 20 min after eating (Herold 2022) in patients with gastric or esophageal surgery (Scarpellini 2020).

At the 2020 Delphi consensus process with international multidisciplinary experts, an international consensus on the diagnosis and treatment of dumping syndrome was established for the first time (Scarpellini 2020).

Dumping syndrome (DS [Rindel 2018]) is divided into early and late dumping. Both can occur together or individually (Scarpellini 2020).

Dumping syndrome represents a common but rarely diagnosed complication after gastric or esophageal surgery, including bariatric surgery (also referred to as metabolic surgery). For the past 15 years or so, it has occurred most frequently after bariatric surgery, previously primarily in cases of Z. n. gastric resection (Scarpellini 2020).

It occurs in approximately 10% of patients after vagotomy with pyloroplasty or resection of the distal stomach, in up to 50% after esophagectomy with gastric elevation, and in up to 75% after fundoplication and bariatric procedures such as Roux- en- Y- gastric bypass (Fuchs 2020).

Early dumping occurs 3 x as frequently as late dumping. Five years after gastric resection, Mala (2015) found early dumping in 68% of patients.

Early dumping may be caused by:

- Falling emptying of the gastric stump in Z. n. partial gastric resection (Herold 2022)

- Passenger hypovolemia

This may occur due to hyperosmotic easily soluble carbohydrates (Herold 2022).

In rare cases, also due to:

- Involvement of the enteric nervous system such as in functional dyspepsia.

- in the context of diabetes mellitus with accelerated gastric emptying (Fuchs 2020)

There is a pull on the mesentery during a fall emptying of the gastric stump due to overstretching of the draining loop. This triggers vagus stimulation with release of intestinal hormones and vasoactive substances such as bradykinin and serotonin (Herold 2022).

Rapid emptying of a hyperosmolar gastric content into the ileum results in a shift of fluid from the intravascular space (Scarpellini 2020) into the intestinal lumen with contraction of plasma volume and acute distension of the intestine. Vasoactive GI hormones such as vasoactive intestinal polypeptide, neurotensin, motilin are also thought to play a role (Kasper 2015).

A study by Yang (2020) showed that the early p. p. changes in hemodynamics and GI hormone secretion were greater in patients who had undergone gastrectomy than in patients with partial gastric resection. Thus, early p. p. changes play a critical role in the pathophysiology of early dumping syndrome.

If the pylorus is preserved during surgery, as is the case with the tubular stomach, dumping syndrome rarely occurs because ingested food then continues to be released into the small intestine in small quantities (Felsenreich 2021).

The majority of affected patients usually only suffer from mild symptoms that improve over time. However, in 10 - 20 % there are pronounced symptoms and in 1 - 5 % even severe symptoms (Mala 2015).

The symptoms of a dumping syndrome typically appear a short time after surgery. If symptoms appear p. o. only after a longer period of time, another cause should be considered (Mala 2015).

Postprandial, early dumping is found after approximately 20 min:

- abdominal pain

- borborygmus (audible bowel sounds)

- possibly diarrhea or nausea (Herold 2022)

- Belching (Kasper 2015)

- Flatulence (Rindel 2018).

Cardiovascular symptoms may also be present in the form of:

- Palpitations

- dizziness

- sweating

- general weakness (Herold 2022)

- tachycardias

- hypotension (Rindel 2018)

- flushing (Scarpellini 2020)

- rare occurrence of syncope (Kasper 2015)

- Weight loss

Because of p. p. symptoms, patients often avoid food intake, resulting in weight loss (Scarpellini 2020).

Nowadays, the modified oral glucose tolerance test is the preferred diagnostic test. Typically there is

- a hematocrit increase of > 3 % (due to fluid shift)

or

- An increase in heart rate to > 10 bpm 30 min after glucose ingestion (Scarpellini 2020). The sensitivity of heart rate elevation is 100% and the specificity is 92% (Mala 2015).

Other methods diagnostic auxiliary methods are:

- Sigstad scoring system.

Here, symptoms named by the patient are assigned points and these are then added together. A total score > 7 indicates a dumping syndrome. Meanwhile, the questionnaire is not considered reliable enough (Scarpellini 2020).

- Arts questionnaire / Arts dumping questionnaire.

This questionnaire primarily provides information about the severity of the dumping syndrome. Meanwhile, the questionnaire is also considered not reliable enough regarding the diagnosis (Scarpellini 2020).

- Gastric emptying tests.

The sensitivity and specificity of these tests have been shown to be too low in dumping syndrome (Scarpellini 2020).

- Feeding loop syndrome (Koop 2009).

- Sitophobia (fear of edibles)

- Weight loss (Mala 2015)

The patient is recommended:

- frequent small meals (Herold 2022)

- food should be eaten slowly and chewed well (Scarpellini 2020)

- the diet should be rich in proteins and low in carbohydrates

- liquids during meals should be avoided (Herold 2022). They should be consumed at the earliest 30 min after a meal (Scarpellini 2020).

- After eating, the patient should lie down for ½ hour (Herold 2022).

If these dietary changes do not result in sufficient improvement in symptoms, pharmacological intervention should be considered (Scarpellini 2020).

This includes taking a bulking agent such as guar with meals, as well as administration of a spasmolytic such as N- butyl- scopolamine (Herold 2022).

In addition, the following medications are recommended:

- Somatostatin- analogues such as octreotide to reduce intestinal secretion. Dosage recommendation: Short-acting octreotide s. c. 50 - 100 µg up to 3 x / d, long-acting octreotide 1 x monthly i. m. 20 mg / 90 mg (Scarpellini 2020).

- Acarbose:

- inhibits glucose absorption

- reduces gastrointestinal hormone release

- reduces the occurrence of hypoglycemia

- is mainly used successfully in late dumping, but success is also reported in early dumping

Dosage recommendation: 50 - 100 mg 3 x / d with meals (Scarpellini 2020).

The last option would be a new surgical intervention, although this has uncertain results and the optimal procedure has not yet been established. Therefore, a purely conservative approach is currently recommended (Scarpellini 2020).

Patients who require bariatric surgery and whose occupation does not allow for dumping syndrome in any case, especially hypoglycemia such as in professional drivers, should receive a surgical procedure in which the pylorus is preserved because only with the pylorus preserved can ingested food continue to be delivered in small amounts to the small intestine (Felsenreich 2021).

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