Dumping syndrome: symptoms and treatment
Dumping syndrome - violations of the digestive system, which are associated with rapid gastric emptying.People who transferred removal( resection) of a fragment of this body are mainly ill.Although there are often clinical cases of disease with a fully preserved stomach.Even if the food that enters the body is qualitative, balanced and "supplied" in sufficient quantity - it does not stay in the cavity of the stomach, passes "in transit" without having had time to give the body useful nutritional components.From the point of view of dietetics, this is a condition that can be characterized figuratively by the words "to translate food in vain".As a result, the quality of life decreases, and in severe cases there is a decrease and even a complete loss of working capacity and vital activity.Table of contents:
Two main causes of the dumping syndrome were identified:
- stomach resection, which can be performed for a variety of indications( ulcer, swelling, massive scars, etc.);
- Vagotomy - surgical dissection of the trunk of the vagus nerve or its branches.
But sometimes the disease occurs in patients who have not previously undergone surgical treatment.
Pathogenesis of the dumping syndrome
The main functions of the stomach are as follows:
- secretory - the release of substances taking part in digestion;
- motor-evacuation - pushing the food lump on the gastrointestinal tract;
- tank - holding the food lump in the stomach cavity for some time.
They are adjusted by nature in such a way that they are not carried out unintentionally, but are connected with each other.Rapid emptying of the stomach cavity from food occurs due to the failure of these three interrelated functions.
The stomach does not have time to properly digest the food lump, it moves to the intestine, where it undergoes accelerated treatment - hydrolysis, which from a chemical point of view means splitting under the influence of water. After processing, this content acquires the properties of a hypertonic solution with a higher concentration of solutes, due to which it is able to draw water from the cells.
This hypertonic substance passes without special consequences the first fragment of the small intestine - the 12-colon, but being already in the jejunum, provokes to release into its lumen an extracellular fluid "stretched" from the tissues of the intestinal walls( including plasma).Excess fluid leads to overgrowth of the jejunum( clinically it pours out into diarrhea).
Stretching of the jejunum provokes irritation of the nerve roots.It responds to regulatory mechanisms that trigger the release of serotonin into the blood - one of the main neurotransmitters, which affects the motor function.In parallel, due to sweating of the liquid in the intestines, the volume of circulating plasma decreases. These two factors trigger the vasomotor symptoms observed during dumping syndrome - shortness of breath, a feeling of heat and so on.
Accelerated evacuation of contents from the stomach leads to an increase in the jejunum quantity of carbohydrates, ready for absorption - and this, in turn, leads to a rapid increase in blood glucose levels. The body can not promptly process a sharply increased amount of sugar into glycogen, as a result of short-term hyperglycemia.The organism reacts to it by activation of the parasympathetic part of the autonomic nervous system, and it, in turn, stimulates the excitation of the insular apparatus of the pancreas. There is a release of an increased amount of insulin into the bloodstream, which leads to a decrease in blood sugar and the development of hypoglycemia.
The pathogenetic mechanism of development of the dumping syndrome has not yet been studied thoroughly.Physiologists note that it is also based on the violation of numerous feedbacks between physiological links( the entry into the jejunum of hypertonic contents, its stretching, hypertreatment of serotonin, and so on). This disease is associated with disorders in the gastrointestinal tract - but with it are associated and neuropsychiatric disorders, which occur with dumping syndrome as co-occurring.
Emergence of dumping syndrome after transfer of operation
Disease develops in patients who have had:
- stomach resection;
- is a vagotomy.
Gastric resection is performed in a number of its diseases or conditions:
- neoplasm( in particular, malignant);
- peptic ulcer, manifesting with a prolonged course with periodic exacerbations, the intensity of which increases;
- non-healing or large ulcers;
- penetrating ulcers( penetrating through all layers of the gastric wall until spreading to neighboring organs);
- perforated( breakthrough) ulcers;
- callous( with cartilaginous walls and bottom) ulcers, which also belong to the category of non-healing;
- low level of acidity of gastric juice;
- stenosis of the pylorus( narrowing of the place of passage of the stomach into the 12-colon) due to pathological structure or cicatricial changes;
- bleeding in a gastric ulcer, which can not be stopped either by conservative methods, or by exposure to the focus of bleeding during surgery( in particular, if it is a large foci, across the entire inner surface of the stomach).
All patients with such pathologies in the future are contenders for the development of dumping syndrome.
The main causes of dumping after stomach removal:
- violation of reservoir function;
- violation of the motor-evacuation function.
After this operation:
- the volume of the stomach decreases;
- a remote pylorus( pyloric sphincter), which normally regulates the ingestion of the food lump into the 12-colon, "drops out" of work.
The severity of the dumping syndrome may depend on the manner in which the stomach resection was performed:
- if the pyloric section( an antral fragment of the stomach with the gatekeeper) was removed and the stomach stump was connected to the stump of the 12-colon as physiologically as possible - the end inEnd( operation by Billroth I), then the disease is observed less often, since digestion is carried out in the duodenum;
- if, after removal of the stomach, a gastroeurostomy was formed( stitched stomach stump with jejunum as "end-to-side"; is a Birotro II resection);The risk of dumping syndrome in this case is the highest , because digestion moves to the jejunum, and it is not adapted to some of its leaving.
After patients underwent resection of the pyloric fragment of the stomach with the doorkeeper, in 20-80% of patients the dumping syndrome develops during the first year after the operation.
The temperament type of patients plays an important role in the onset of dumping syndrome after gastrectomy. Disease:
- often develops in choleric and melancholic individuals;
- is less common in sanguine and phlegmatic patients.
Most often, postoperative dumping syndrome manifests itself in the first 6 months after surgical treatment.A year after the operation, dumping symptomatology is on the wane.
Of all the complications and disorders on the part of organs and systems that occur after a resection of the stomach, it is the dumping syndrome that most often and most often causes the sufferings of the patients.
Appearance of dumping syndrome after vagotomy
The wandering nerve is responsible for many functions - including for gastric secretion.It is strengthened with recurrent( repeated) gastric and duodenum ulcers .To reduce the secretion of vagotomy.It can be performed together with a draining operation, which creates an artificial communication between the stomach and the 12th gut or lean.After such an operative intervention, the dumping syndrome is observed in 3.5-10% of the operated.
If the so-called selective proximal vagotomy is performed( in this case, the branches of the vagus nerve are dissected into the upper parts of the stomach), then such a surgical intervention does not require a drainage operation, therefore it is very difficult to dumping the syndrome very rarely.
As after resection of the stomach, the dumping syndrome after vagotomy manifests itself in the first six months, and a year later its symptoms subsided.
Vagotomy is considered to be a more gentle, alternative surgical intervention for peptic ulcer disease, but does not guarantee a lower risk of dumping syndrome than after resection.
The emergence of dumping syndrome in non-operated patients
This is the so-called functional dumping syndrome.
In patients with preserved gastric malfunction of the secretory, motor-evacuation and reservoir functions of the stomach, pulling a dumping syndrome, can occur due to a variety of diseases of the gastrointestinal tract. First of all it is:
- chronic, periodically exacerbated gastritis;
- peptic ulcer of the stomach and duodenum;
- chronic nonspecific inflammatory diseases of the small intestine( enteritis).
In these cases, the dumping syndrome:
- is less developed;
- is not as pronounced as in the operated patients.
Dumping syndrome: symptoms
With dumping syndrome from the gastrointestinal tract, the following symptoms are observed:
- sensation of pressure in the upper abdomen;
- nausea, which can sometimes be accompanied by vomiting;
- burp, sometimes sonorous and rolling.
Symptoms of the cardiovascular system:
- shortness of breath;
- change in heart rate - can be observed as tachycardia( frequent), and bradycardia( a rare pulse);
- blood pressure jumps - hypertension or hypotension.
Dumping syndrome belongs to the category of diseases with a rich picture of pronounced common features - , first of all it is:
- causeless fatigue;
- is a sudden malaise;
- increased sweating( especially paradoxically it looks in low ambient temperatures);
- weakness and tremor( tremor) in the muscles of the body and limbs;
- sensation of heat throughout the body;
- weight loss.
In this disease, neurological symptoms are also observed:
- intermittent headache;
- drowsiness or excited state.
Weakness, headaches, dizziness and drowsiness due to dumping syndrome are triggered by low sugar content in the blood.
Attacks appear in the form of so-called dumping attacks. Their types:
The type of dumping attack depends on which hormones and neurotransmitters are discharged into the bloodstream( epinephrine, norepinephrine, acetylcholine and others).
Sympathetic-adrenal type of dumping attack
With this type of dumping attack from the digestive system, the following are observed:
- Drying in the mouth;
- atony( weakness of the tonus) of the intestine and, as a consequence, constipation.
Symptoms of the cardiovascular system:
- cool to the touch.
Changes from the nervous system:
- causeless excitement;
- anxiety right up to a sense of anxiety;
- feeling of numbness of the limbs;
Vagotonic type of dumping attack
With it, the symptoms from the digestive tract are as follows:
- salivation in increased quantities;
- pain in the upper abdominal areas;
Changes in the cardiovascular system:
- sensation of suffocation.
Clinical signs from the skin:
- increased sweating.
Disturbances from the nervous system:
- dizziness, sometimes with "flies" in front of the eyes;
- marked with drowsiness.
Manifestations from the respiratory system:
- sense of nasal congestion.
Types of dumping syndrome depending on the development time
Patients with gastric resection of a dumping attack may experience:
- during meals;
- immediately after meals;
- a few hours after eating.
The dumping syndrome, which manifests itself during or immediately after eating, is also called the early . The symptomatology depends on the type of dumping attack.The main feature - regardless of the type of early attack is accompanied by extremely pronounced weakness.The general condition of such a patient is very contrasting before and during( after) eating: the patient, as usual, walked, talked, engaged in household chores, and when he sat down - he was overcome by a sudden weakness, forcing to give up any action and immediately lie downto bed.
In most cases, the attack is provoked by:
- large portions of food( even if the patient has eaten them without difficulty before the disease);
- liquid food - borscht, soups, tea, juices, fruit drinks;
- milk and products of its processing, which are in liquid form( kefir, yogurts, whey);
- carbohydrate food.
Most of all, dumping-induced food with a high content of simple carbohydrates is:
- fizzy drinks;
- bread, loaves and pastry( biscuits, cakes, pastries, puffs, donuts, cookies);
- sweet fruit( pear, plum, certain sorts of apples);
- sweet berries( strawberries);
- sweet vegetables( tomatoes).
A dumping attack that develops 2-3 hours after a meal is called a late dumping syndrome. This is actually a hypoglycemic attack.Its manifestations :
- marked general weakness;
- dizziness accompanied by darkening in the eyes;
- pallor of the skin;
- pain in the projection of the heart;
- severe sweating;
- tremor( trembling) of the trunk, upper and lower extremities;
- anxiety right up to the fear of death;
- at the peak of hypoglycemia development is an unconscious state with loss of memory( the patient may not remember what happened to him immediately before fainting).
- The condition is facilitated after repeated meals.
Symptomatic, depending on severity
There are three degrees of severity of the dumping syndrome:
- attack - mild, developing in response to the intake of dairy foods or products containing carbohydrates;
- duration of the attack - a maximum of 30 minutes;
- frequency of seizures - 2-3-4 times a month;
- body mass deficit - not more than 5 kg;
- work capacity is preserved in full;
- is well treated with a diet with restriction of products that provoke an attack and compliance with the correct diet.
- seizure can cause any food;
- attack expressed, to ease the patient should take a horizontal position( in this case, slowing the release of chyme from the stomach into the jejunum);
- duration of an attack - from 30 to 60 minutes;
- frequency of seizures - 2-3 times a week;
- body weight deficit - up to 10 kg;
- work capacity is partially preserved;
- conservative therapy( in particular, diet and diet) has a transient effect.
- strong attack after taking any type of food;
- the patient is forced to take food in a horizontal position, and after that it is in it for 2-3 hours;
- duration of the attack - 2-3 hours;
- frequency of seizures - every day from one to several;
- body mass deficit - more than 10 kg;
- disability has been lost;
- conservative treatment does not give any effect.
It's easy to diagnose dumping syndrome if you take into account the patient's characteristic complaints related to food intake, and in most cases the fact that the patient was previously operated on for stomach disease.
In doubtful cases, the diagnostic value is:
- laboratory tests;
- radiography of the gastrointestinal tract with the use of a contrast agent.
In the case of pronounced disorders from the nervous system( especially the mental sphere) for the purpose of differential diagnosis, a consultation of a neuropathologist and a psychologist is shown.
In order to correctly determine the severity of the dumping syndrome, a provocative glucose test is performed.Before the study, the patient is measured blood pressure, heart rate, determine blood sugar, calculate the amount of circulating in the body of the plasma. Then, in order to provoke dumping symptoms, 150 ml of 50% glucose solution is injected intravenously. In this case :
- if the symptomatic of the dumping attack has developed, again measure blood pressure, heart rate, blood sugar, the volume of circulating plasma;
- if a drug provocation to the occurrence of an attack did not result, then after 10-15 minutes the sample is repeated with a control purpose.
After a few hours, a pool of the following control samples is performed to diagnose hypoglycemia.
X-ray examination with a contrast solution introduced into the gastrointestinal tract through the mouth will help to draw conclusions about what anatomical and functional changes in the stomach and small intestine occurred in the early and late period after resection of the stomach.
When dumping the syndrome, the following is determined radiologically:
- Acceleration of emptying of the stomach stump - at the same time about the third part of the contents of the stomach enters the jejunum in the very first minutes, accelerated emptying of the stomach stump( at least one third of the content immediately enters the jejunum);
- increased peristaltic movements from the small intestine, which alternates with weakened motility;
- increased motor( motor) activity from the large intestine( this is manifested by diarrhea).
If the stomach is not resected, radiography with contrast will help determine the motility of the gastrointestinal tract in dynamics.
Laboratory diagnosis in the diagnosis of dumping syndrome is not informative.Her methods are used to determine the extent of deviations that have occurred as a result of this disease.The following deviations can be detected:
- decrease in the amount of hemoglobin and erythrocytes in the blood;
- polyhypovitaminosis( decrease in the level of vitamins of all groups);
- disorders of electrolyte-salt metabolism( imbalance of salts and minerals in the blood);
- hypoproteinemia( decrease in the level of protein fractions in the blood);
- steatorrhea( the presence of fatty fractions in the feces due to their reduced absorption of fats in the intestine and their excessive excretion with feces).
It is important to diagnose neuropsychiatric disorders, which often accompany a dumping syndrome. Often, these patients develop the following psychopathic syndromes:
- asthenic( the patient can not cope with the least psychological stress, not to mention stress levels);
- neurasthenic( there are increased fatigue, irritability, attacks of headaches down to the intensity of migraines);
- hysteriform( the reaction is expressed by fits of irritability, expressed by a change of mood - from unrestrained laughter to unrestrained crying);
- depressive( any external stimuli do not cause the patient any reaction, he is sluggish and inhibited, indifferent to things that previously caused positive emotions);
- is hypochondriacal( the patient perceives everything that happens around him through the prism of suspiciousness).
Dumping syndrome: treatment
With dumping syndrome, the treatment can be:
Conservative therapy is based on the following items:
- power optimization;
- substitution therapy;
- fortifying agents;
With dumping syndrome, the assignments for the correction of neuropsychiatric disorders are as important as the correction of disorders from the gastrointestinal tract. Such patients are very sensitive - those emotional stresses that a healthy person can easily cope with, for them are "unbearable."
One of the most important items of conservative therapy is the correct approach to nutrition :
- adjusted diet, withdrawal of provocative products of dumping syndrome;
- correctly composed power mode.
Principles of dietary nutrition for dumping syndrome are as follows:
- All food that makes up the daily diet should be divided into 5-7-8 receptions;
- cooking products - boiling in water, steaming, stewing with a low amount of fat, baking( make sure that the crust is not formed). Fried dishes are strictly contraindicated;
- the food should be warm or permissible hot( the temperature can be checked by the back surface of the brush - if it does not burn, then such food can be eaten);
- in the first few months after resection of the stomach, food should be turned into homogeneous puree whenever possible, then it can be finely ground;
- at one time take no more than 1 average glass of liquid( 200 ml);
- liquid and solid foods should be taken separately( for example, from the soup, first drink a decoction, and then eat the remainder).
You also need to exclude from the diet products that are capable of provoking a dumping attack is:
- simple carbohydrates: honey, sugar, jam and others( for a more complete list, see "Types of dumping syndrome depending on the time of manifestation");
- the so-called refined carbohydrates( those that do not exist in nature, but created artificially): bread, instant pasta, snacks( chips, crunches);
- milk, sour cream and mayonnaise;
- smoked meat: fish, sausages, hams.
Approximate daily dietary requirements for patient consumption are as follows( with averaged patient weight of 75-80 kg):
- proteins - 140-160 g( elevated number compared to the norm);
- carbohydrates - 300-350 g( reduced amount);
- fats - 100-110 g( unchanged amount);
- salt - 15 g( normal amount);
- calorie content is 2800-3200 kcal.
With an easy degree of disease, proper nutrition even allows to avoid drug prescriptions and not only to reduce the force of attacks, but also to prevent them for a long time.
Substitution therapy is used to compensate for reduced secretion of the stomach and pancreas. Assign the following:
- hydrochloric acid;
- preparations, which are analogues of normally secreted food enzymes;
Common restorative agents are prescribed to stabilize the general condition for disorders that develop as a result of dumping syndrome - these are:
- violation of the water-salt balance;
In this case, designate:
- complexes of vitamins( enterally and parenterally);
- intravenous drip introduction of saline solutions;
- in severe cases - blood transfusion, as well as its components( plasma, erythrocyte mass).
Adjunctive therapy is used to normalize the gastric motility and evacuation of the food lump from it.For this purpose, local anesthetics are prescribed:
- preparations of insulin;
- desensitizing( antihistamine) agents;
- hormonal preparations;
- antispasmodics( relieving spasms, they reduce the feeling of pain, which means that the role of anesthetics also play a role).
Anabolic medications are prescribed for patients with severe dumping syndrome, which caused severe depletion.These are:
- corticosteroid hormones;
- ganglion blockers;
- complexes of proteins, fats and carbohydrates, which are used as parenteral nutrition( introduction into the body outside the gastrointestinal tract).
Physiotherapeutic methods use:
- electrostimulation to slow the emptying of the stomach;
- electrosleep for general strengthening of an exhausted organism.
When neuropsychic reactions occur, they begin with psychotherapy.If its effect is not observed or less than expected - use sedative drugs . The action of such drugs is aimed at eliminating not only the neuropsychiatric, but also neurocirculatory( vegetovascular) disorders. Applied as a light calming drug( including plant origin), and medications with more pronounced effect. The latter include:
Because of the disrupted secretory and motor-evacuation functions of the stomach, a dumping attack can provoke any product that enters the stomach.This also applies to vegetable tinctures, teas, and collections, which are used in domestic conditions as folk remedies.Therefore, use of herbs in the treatment of dumping syndrome should not be carried out without the agreement of the physician - in addition to the reason that herbal therapy can lead to :
- of the body's allergic reaction;
- of individual intolerance;
- pharmacological conflict of herbal medicines with synthesized pharmaceuticals.
Surgical methods for dumping syndrome are used in the absence of the effect of conservative therapy. These are operations to improve the passage of the food coma through the gastrointestinal tract.
Prevention of dumping syndrome in operated patients is a measure aimed at adapting the body( in particular, the stomach) to new anatomical and physiological conditions:
- compliance with the diet;
- fulfilling the appointments of the doctor( not only in the early postoperative, but also in the further period);
- avoidance of stressful situations;
- revealing and arresting of neuropsychic disorders;
- performing exercises of physical therapy - let them be simple, but they should be done daily.
If the dumping syndrome is already diagnosed, the following requirements must be observed to prevent or at least mitigate its attacks:
- putting on an elastic tire bandage before each meal;
- after each meal - rest in a horizontal position.
Such preventive measures are important not only to eliminate unpleasant subjective sensations - they help to avoid the development of organic changes.
Among preventive measures, the prevention of diseases that lead to gastrectomy is the last one:
- stomach ulcers - particularly complicated;
- stenosis of the pylorus( narrowing of the place of passage of the stomach into the 12-colon);
- functional disorders( decreased acidity of gastric juice);
- neoplasms( they are unpredictable, but a healthy lifestyle reduces the risk of their occurrence).
Forecast for life is difficult in the case of the launched dumping syndrome , when the body critically suffers from a violation of vitamin, water-salt, protein, fat and carbohydrate metabolism.In other cases, dumping syndrome can be successfully suppressed.
In patients who underwent surgical treatment of stomach diseases, the dumping syndrome worries in the first year after the operation, further its manifestations are on a decline, the outlook is improving.
Kovtonyuk Oksana Vladimirovna, medical reviewer, surgeon, consulting doctor