Bombay Hospital Journal Vol 51 No 1 2009135Iatrogenic Dumping Syn - PDF document

Bombay Hospital Journal, Vol. 51, No. 1, 2009135Iatrogenic Dumping SyndromeK Hemalatha*, R Narayani**, M Paul Korath***, K Jagadeesan****AbstractDumping syndrome is a common post surgical complication after gastric surgery and is causedby large amount of food passing quickly into the small intestine. It is accompanied by a numberof gastrointestinal and vasomotor symptoms due to changes in the anatomy and physiology ofthe stomach caused by gastric surgery. In this paper we report an interesting case who had notundergone any surgery of the stomach and yet displayed symptoms of ‘late dumping syndrome’after food, whenever he was on proton pump inhibitors. The symptoms of late dumping werenot observed when the PPI was discontinued.Introductionumping syndrome is a relatively raredisorder in which the stomach contentsare delivered too quickly to the smallintestine. It occurs as a physiological reactionto the consumption of too much simple orrefined sugar in some persons, when simplesugar exits the stomach too rapidly it attractsfluid into the upper intestine, and the bloodvolume decreases as it attempts to absorb thesugar. Dumping syndrome is one of theunwanted post operative sequelae to partialgastrectomy. This symptom complex isbelieved to be due to rapid emptying of thegastric contents into the upper smallintestine and also an increased transit ratethrough the small bowel itself right throughthe colon. As a consequence of this dumpinga large volume of hyperosmotic fluid entersthe small intestine. In an attempt to bringthe osmotic tension to the physiological rangelarge amount of fluid cross the intestinalmucosa. As a result the plasma volume isreduced which in turn exerts a vasomotor*Medical Officer; **Professor and Head BiochemistryDept.; ***Director (Chief Physician); ***Chairmanand ****Founder and Director, KJ Hospital Researchand Postgraduate Centre, Chennai 600 084.effect. The vasomotor symptoms comprisegeneral weakness, pallor, sweating,palpitation and light headedness. Another setof symptoms of gastrointestinal disturbancesuch as epigastric discomfort, nausea,vomiting and possibly an episode of diarrhoeais observed. The biochemical changes thatoccur in dumping syndrome arehyperinsulinaemia followed by hypoglycaemiadue to rapid transport and absorption of foodfrom small intestine after a meal. Since theconversion of glucose to glycogen and itsstorage consumes potassium, its level inblood decreases in dumping syndrome andhence hypokalaemia may be seen too. Thesesymptoms classically occur some 5-30 minutesafter eating and are more marked if the mealis large particularly if it contains a substantialamount of carbohydrate and liquid. Thechoices for managing dumping syndromeinclude dietary changes, medications andsurgery. Although dumping syndromeclassically develops after gall bladder surgery,it may also occur after other abdominaloperations, such as duodenal ulcer surgeryor surgery for severe reflux.7-8 Sometimes itmay be seen in people born with unusuallysmall stomach and very rarely in those withstomach abnormalities. Here we report a 136Bombay Hospital Journal, Vol. 51, No. 1,

2009unique and interesting case who had notundergone any surgery of the GI tract andyet manifested the symptoms of dumpingwhenever he was treated with proton pumpinhibitors (PPI) and was relieved of the samewhen the treatment was discontinued.Case ReportA 60-year-old male presented with complaints ofuneasiness of chest and flushing 2 hours after takingproton pump inhibitors (PPI). The patient passed largebulky stools following which he developed lethargy,myalgia and extreme prostration. He was unable toeven stand, however no fainting episodes occurred.The patient was on Pantoprazole a PPI formanagement of his acid peptic disease. The patientdiscontinued PPI for about five months during whichhe was normal without the above symptoms. Butwhen he was restarted with the PPI he developed theabove symptoms again. He was investigated for thesame and since the symptoms were more in alignmentwith dumping syndrome, he was subjected to test fordumping.Test for DumpingInitially blood test was done to determine thebaseline values of all parameters included in the study.Next the patient was given a carbohydrate feed andwas kept under observation. This consisted of 75 g ofdextrose and a breakfast of 2 dosas with tea. Twohours after this intake, the patient had a feeling ofbowel mass evacuation reaction and passed a verylarge bulky stool. Thereafter the patient felt extremeweakness, tiredness and felt like lying down to takerest. After being in a supine position for 10 minuteshe felt relieved. Simultaneously his vitals wererecorded and blood samples were withdrawn forestimating sugar, insulin and electrolytes at regularintervals after taking the meal. Corresponding urinesamples were also collected for investigations and hisECG was also recorded.DiscussionWhen the signs and symptoms of dumpingoccur during a meal or within 15 to 30minutes following a meal it is called earlydumping and if it occurs after 2 hours, it iscalled late dumping. Some people experienceboth early and late dumping signs andsymptoms. The subject in this studyexperienced late signs like extremeweakness, fatigue after 2 hours and lay downto take rest for about 10 minutes after whichhe felt better.In this case of dumping syndrome, nomatter when problems develop, the symptomswere worse in the aftermath of a highcarbohydrate meal, especially one that is richin sugars such as sucrose (table sugar) orfructose (fruit sugar). In concordance in thispatient also these symptoms were observedtwo hours after he consumed a meal of dosasand 75 gms dextrose in water. Some peoplealso experience hypoglycaemia related toexcessive levels of insulin delivered to theblood stream. In this patient too the bloodsugar levels increased to 146 mg/dl after 1hour and subsequently decreased to 74 mg/dlafter 2 hours. Insulin levels increased to249.10 µIU/ml at the end of 30 minutes andit was 163.10 µIU/ml after 1 hour. This canbe explained as follows. Thehyperinsulinaemia is due to rapid passage offood to the small intestine. The highconcentration of carbohydrates in this regionresults in rapid absorption of glucose andhence hyperinsulinaemia. This inturn wasresponsi

ble for the decrease in glucose levelsseen in this subject after 2 hours. In thissubject hypokalaemia was observed becausepotassium level was 2.9 mmol/l at 30 minutesafter the meal, and the corresponding insulinand glucose levels were 249.1 IU/ml and 130mg/dl respectively. Table 1 gives the valuesof the various parameters tested. Since theirintroduction in the late 1980’s proton pumpinhibitors have demonstrated gastric acidsuppression superior to that of histamine H2-receptor blockers and have enabled improvedtreatment of various acid peptic disorders.PPIs are absorbed in the proximal small boweland cross the parietal cell membrane andenter the acidic parietal cell canaliculus. Inthe acidic environment PPI becomes Bombay Hospital Journal, Vol. 51, No. 1, 2009137protonated which is the active form that bindsto the H+/K+ AT Pase enzyme and causesirreversible inhibition of acid secretion by theproton pump. The most striking feature ofthis case was however the fact that thedumping syndrome manifested when thepatient was put on proton pump inhibitors.The symptoms of dumping syndromedisappeared when he was off the same.ConclusionGastric mucosal function is altered bysurgery and acid and enzymatic secretionsare decreased. Also hormonal secretions thatregulate the gastric phase of digestion areadversely affected after gastric surgery andas a consequence dumping syndromemanifests in the patient. Whether prolongeduse of PPI lead to alterations in acid secretionand inturn resulted in a condition similar todumping syndrome as evidenced in the caseof the patient described in this paper isdebatable.Vecht J, Masclee AA, Lamers CB. The dumpingsyndrome. Current insights into pathophysiology,diagnosis and treatment. Scand J GastroenterolSuppl 1997; 223 : 21-27.2.Iain E Gillespie, Nasim Ansari, et al. The stomach.In: Guide to Surgical Principles and Practice.Churchill Livingstone 1992; 257-88.3.Hertz AF. Cause and treatment of certainunfavourable after effect of gastroenterostomy.Ann Surg 1913; 58 : 466-72.4.Gray JL, Debas HT, Mulvihill SJ. Control ofdumping symptoms by somatostatin analogue inpatients after gastric surgery. Arch Surg 1991;126 : 1231-35.5.Penning C, Vecht J, Masclee AA. Efficacy of depotlong acting release octreotide therapy in severedumping syndrome. Aliment Pharmacol There2005; 22 : 963-69.6.Lyons TJ, McLoughlin JC, Shaw C, et al. Effect ofacarbose on biochemical responses and clinicalsymptoms in dumping syndrome. Digestion 1985;31 : 89-96.7.Wyllys E, Andrews E, Mix CK. Dumping stomachand other results of gastrojejunostomy: Operativecure by disconnecting old stoma. Surg ClinChicago 1920; 4 : 879-92.8.Mallory GN, Macgregor AM, Rand CS. TheInfluence of dumping on weight loss after gastricrestrictive surgery for morbid obesity. Obes Surg1996; 6 : 474-78.Table 1 : Shows the various parameters recorded including vitals and blood investigationsVitalsBlood SamplesSample No.Temp.Resp. RateB.P.mm Hgmmol/lmmol/lI. Resting98.422/mt375(To give 75 gms of Glucose orally)II. At the end of 15 mts98.224/mtIII. At the end of 30 mts98.420/mtIV. At the end of 1 hr98.224/mtV. At the end of 2 hrs98.422/mt