Dumping Syndrome

Dumping syndrome results from rapid delivery of hyperosmolar gastric contents into the small bowel after gastric or oesophageal surgery.

It occurs after gastrectomy, gastrojejunostomy, oesophagectomy and bariatric procedures.

Two overlapping patterns occur.

Early dumping develops within approximately 10 to 60 minutes after eating. Rapid nutrient entry causes an osmotic fluid shift into the intestinal lumen and release of vasoactive gastrointestinal peptides.

Late dumping usually develops 1 to 3 hours after eating. Rapid glucose absorption produces exaggerated insulin release, followed by postprandial hypoglycaemia.

Diagnosis is primarily clinical.

A modified oral glucose tolerance test can confirm uncertain cases.

Evidence of early dumping includes:

Rise in pulse rate greater than 10 beats/min at 30 minutes

Haematocrit increase greater than 3% at 30 minutes

Late dumping is supported by glucose falling below approximately 50 mg/dL, 2.8 mmol/L after the glucose load.

Continuous glucose monitoring is particularly useful when late postprandial hypoglycaemia is the dominant problem, although results should be correlated with symptoms.

Gastric emptying studies are not routinely required to diagnose dumping syndrome.

Dietary treatment

This is first line and controls symptoms in many patients.

Use:

Five or six small meals rather than large meals
High protein intake
Higher fibre and complex carbohydrate content
Avoidance of rapidly absorbed sugars
Avoidance of sweet drinks and liquid carbohydrate loads
Delay fluids until at least 30 minutes after meals
Eat slowly and chew thoroughly

Lying down after meals may help severe early vasomotor symptoms in selected patients, although it is not essential for all patients.

Late dumping

If dietary treatment is insufficient:

Acarbose 50 mg orally with the first mouthful of each carbohydrate containing meal, three times daily.

Increase to:

100 mg three times daily if required and tolerated.

Acarbose delays carbohydrate digestion and is particularly effective for late hypoglycaemia. Flatulence, diarrhoea and bloating are common dose limiting effects.

Refractory early or late dumping

Use a somatostatin analogue when severe symptoms persist despite dietary therapy and acarbose where appropriate.

A practical starting regimen is:

Octreotide 25 to 50 micrograms subcutaneously, approximately 15 to 30 minutes before meals, two to three times daily.

Titrate according to response, commonly up to:

100 micrograms subcutaneously three times daily.

Long acting octreotide can be considered after response to short acting treatment has been demonstrated.

Monitor for gallstones, diarrhoea, steatorrhoea, glucose disturbance and injection site effects.

Surgical revision is a last resort for severe disabling symptoms after comprehensive nutritional and pharmacological therapy. Before reoperation, confirm the anatomy and ensure that symptoms are genuinely due to dumping rather than another postgastrectomy disorder.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Small Bowel Tumour

Small bowel tumours are uncommon and include adenocarcinoma, neuroendocrine tumour, gastrointestinal stromal tumour, lymphoma and less common mesenchymal or metastatic lesions. Histology determines both the operation and systemic treatment. Adenocarcinoma is particularly common in the duodenum, neuroendocrine tumours favour the distal ileum and gastrointestinal stromal tumours commonly arise in the jejunum or ileum.

Clinical behaviour ranges from an incidental small lesion to obstruction, bleeding, intussusception, perforation or metastatic disease.

Presentation is often delayed because the small bowel is difficult to investigate and early symptoms are nonspecific.

High value presentations include:

Intermittent central abdominal pain
Iron deficiency anaemia or occult gastrointestinal bleeding
Recurrent partial bowel obstruction
Unexplained weight loss
Intussusception in an adult
Palpable abdominal mass
Perforation or overt bleeding in advanced disease

Neuroendocrine tumours may produce mesenteric fibrosis with bowel angulation and ischaemia. Carcinoid syndrome generally implies significant metastatic burden, most commonly hepatic metastases.

CT enterography: preferred for suspected mural small bowel tumour; define the lesion, obstruction, regional nodes and metastatic disease.

Capsule endoscopy: useful for occult bleeding or mucosal lesions but avoid when significant obstruction or stricture is suspected.

Device assisted enteroscopy: permits direct biopsy of lesions beyond conventional endoscopic reach.

Once histology is established, stage according to the specific tumour rather than applying one generic small bowel cancer pathway.

Resect symptomatic or potentially malignant localised tumours when an R0 resection is achievable.

For adenocarcinoma, perform segmental bowel resection with regional mesenteric lymphadenectomy.

For small bowel gastrointestinal stromal tumour, perform complete segmental resection with an intact pseudocapsule. Routine lymphadenectomy is unnecessary because nodal metastases are uncommon.

For ileal neuroendocrine tumour, resect the primary lesion and its associated mesenteric nodal disease while preserving mesenteric vascular supply where possible. Carefully inspect the entire distal small bowel because multifocal lesions are common.

Small bowel lymphoma is primarily treated according to histological subtype with systemic therapy. Surgery is reserved for perforation, uncontrolled bleeding, obstruction or a lesion requiring resection for diagnosis or source control.

An obstructing unresectable malignancy may require bypass, stenting where anatomically feasible or another palliative decompressive strategy.

Dumping Syndrome

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management