Dumping syndrome: Causes, management, and patient education Learn how to identify and manage this under-recognized syndrome.

By Lynnette Rodgers, RN, CDE, EMT, and Carolyn A. Phillips, PhD, RN

(DS), a bari atric surgeries. The incidence and DUMPING SYNDROME What is DS? well-established yet under-recog - DS is a cluster of symptoms that severity of postsurgical DS corre - nized side effect of upper GI sur - can occur when sponds to the type of surgery per - gery, occurs when the body reacts undigested formed. (See Surgery and to food moving too rapidly from the food moves too DS .) DS also has been re - stomach into the intestine, resulting quickly into the ported in patients with in unpleasant symptoms such as a intestines. The , cyclic vomiting pounding pulse, sweating, dizziness, symptoms typically syndrome, and Zollinger- and . DS was first described occur after eating Ellison syndrome. DS in 1913 as a complication after a a large amount can occur after a bolus gastroenterostomy; the term “dump - tube feeding, especially if ing” was coined in 1920 when a the formula is high osmo - physician attempted to describe the lality or a feed ing is given rapid gastric emptying he saw dur - in large amounts over a short ing a radiographic observation. time. DS occurs after 20% to 75% of all esophageal and gastric surger - Pathophysiology and ies. Its incidence decreased dur - symptoms ing the 20th century when the DS clinical manifestations are discovery of Helicobacter pylori categorized as either early or made most gastric surgical inter - late, depending on how ventions to treat chronic soon they begin after a and unnec - meal. (See DS symp toms .) essary and treatment shifted to Early dumping, experi - medication. But the recent in - enced by about 75% of crease in bariatric surgery and those who report symp - gastric or esophageal surgery toms, occurs within 10 to to treat cancer has led to an 30 minutes after eating. increase in the incidence Symptoms arise when the of DS. undigested food moves too Many people who have un - quickly into the duode - dergone upper GI surgery aren’t num, causing fluid to shift aware of DS and haven’t been ad - from the surrounding tissues equately educated about it. In ad - into the intestine to aid in the dition, DS symptoms frequently are rapid dilution of the concentrated misdiagnosed. Nurses and other food. This rapid fluid shift leads to healthcare providers should under - GI symptoms, such as bloat ing, ab - stand the etiology, symptoms, and dominal pain, and nausea. The management of DS to educate pa - of food or a high-, high- movement of fluid into the intestine tients and to improve their health fat meal. It’s most frequently associ - is associated with excessive intravas - outcomes and quality of life. ated with gastric, esophageal, and cular fluid loss, resulting in vasomo -

American Nurse Today Volume 13, Number 1 AmericanNurseToday.com 6 Surgery and DS DS symptoms Several surgical procedures may lead Dumping syndrome (DS) symptoms to dumping syndrome (DS). cause physiologic and psychologic fall into two categories—early and late. concerns. Severe dumping can be a Procedure Incidence reported precursor to several complications, Early DS including malnutrition and weight Gastrointestinal symptoms Bariatric surgery loss due to nutrient • abdominal pain Gastric bypass Up to 75% and chronic . DS also can • Gastric sleeve 40% • borborygmi lead to social impairments and per - diarrhea Esophagectomy 50% • sistent lethargy because of inade - • nausea/vomiting quate nutrition. Fundoplication 30% Vasomotor symptoms Up to 78% • diaphoresis How is DS diagnosed? • flushing Partial gastrectomy 20% Many patients with DS have symp - • headache toms similar to irritable bowel syn - hypotension 20% • drome or (delayed • palpitations gastric emptying), which can result • syncope Sources: in misdiagnosis. Unless the patient • tachycardia Chaves and Destefani 2016. Tack et al 2009. reports a history of upper GI sur - gery, the healthcare provider may Late DS Tack and Deloose 2014. Adrenergic symptoms have difficulty distinguishing be - van Beek et al 2017. • palpitations tween many of the GI disorders. • perspiration Diagnosis typically is based on clin - • tremor tor symptoms, including diaphoresis, ical manifestations and the timing Neuroglycopenic symptoms tachycardia, hypotension, and, in of the symptoms, although a few • difficulty concentrating some cases, syncope. diagnostic tools can be helpful. • fatigue Late dumping, which occurs in The Sigstad scoring system was • hunger about 25% of patients, typically pre - developed in 1970 to aid in the di - • syncope sents within 1 to 3 hours after eat - agnosis of DS. (See Sigstad scoring ing. The rapid movement of carbo - system .) The patient circles the symp - hydrates into the intestine releases toms he or she has experienced ment of the dye and measure the an excessive amount of and corresponding points are as - rate of gastric emptying. DS is diag - from the in an attempt to signed. A score above 7 indicates nosed if an accelerated rate of maintain normoglycemia, but ulti - DS; a score less than 4 may suggest emptying is noted. mately resulting in hypoglycemia. a different diagnosis, such inflam - The Dumping Symptom Rating The subsequent symptoms are a di - matory bowel disease, celiac dis - Scale questionnaire is reliable for rect consequence of the hyperinsu - ease, or . detecting the severity and frequen - linemic response: fatigue, difficulty For the modified oral glucose tol - cy of dumping symptoms. It uses concentrating, hunger, confusion, erance test , the patient fasts for 10 a 7-point Likert scale to grade the perspiration, tremors, and low blood hours, then drinks a solution con - severity of 11 DS symptoms along glucose. Most people who experi - taining 50 g of glucose. His or her with three questions about foods ence late dumping also exhibit ear - glucose level, heart rate, blood that may cause symptoms. ly dumping symptoms. pressure, and hematocrit are meas - Another factor that may play a ured every 30 minutes. A diagnosis How is DS managed? role in the pathophysiology of both of early DS is made if within 30 to Diet is the most effective way to early and late dumping is increased 60 minutes the patient experiences manage DS. Patient education is secretion of GI hormones, although a 10 beats/minute heart rate in - particularly beneficial for people their exact mechanism is unclear. crease or the hematocrit rises 3% in with mild to moderate DS symp - Hor mones such as enteroglucagon, the first 30 minutes. Late dumping toms because they respond well to peptide YY, and glucagon-like pep - is suspected if hypoglycemia occurs dietary changes; those with more tide 1 are suspected to cause irregular 2 to 3 hours after glucose ingestion. severe DS symptoms may not re - GI motility, hemodynamic responses, Patients undergoing gastric emp - spond well to dietary changes and increased insulin release. tying scintigraphy eat a bland meal alone. General recommendations containing a small amount of ra - include eating small, frequent, Complications dioactive dye. An abdominal x-ray high-protein meals and snacks; DS isn’t life-threatening, but persist - is then taken every hour for 4 hours avoiding liquids with meals; avoid - ent symptoms can be alarming and after the meal to follow the move - ing simple (cookies,

AmericanNurseToday.com January 2018 American Nurse Today 7 Sigstad scoring candy, sweetened drinks, and ice system the patient’s symptoms. For exam - cream); and lying down for 15 Patients circle the symptoms they ple, a pyloric reconstruction may minutes after eating. People with experience and the assigned scores be used for patients who previously DS should maintain a food journal are totaled to make a diagnosis. A underwent a pyloroplasty (proce - that includes what they eat, when total score > 7 suggests dumping dure to widen the opening in the syndrome; a score < 4 suggests a they eat, and the timing and nature lower part of the stomach [] different diagnosis and the need for of their DS symptoms. The journal additional assessment. to allow for increased emptying in - can help identify foods that may to the ). Roux-en-Y, trigger or exacerbate their symp - Shock +5 a bariatric procedure, is an option toms so that patients can avoid for patients whose DS began after a Fainting, syncope, +4 those foods. (See Patient educa - partial gastrectomy. Patients with unconsciousness tion tips. ) unmanageable symptoms may un - Desire to lie or sit down +4 dergo placement of a continuous enteral jejunostomy feeding tube to Pharmacologic interventions Breathlessness, dyspnea +3 If dietary modifications are ineffec - completely bypass the upper-GI sys - tive, pharmacologic interventions Weakness, exhaustion +3 tem. This invasive procedure may are the next step. (See Pharmaco - Sleepiness, drowsiness, +3 impair the patient’s quality of life. logic interventions .) Acarbose, typi - apathy, falling asleep cally prescribed for type 2 diabetes, Nursing interventions is the recommended initial pharma - Palpitations +3 Nurses play a unique role in the ed - cologic treatment for DS. To slow Restlessness +2 ucation of patients, ensuring that the digestion of carbohydrates and they understand their condition and aid in maintaining normal blood Dizziness +2 its treatments. Primary interventions glucose, patients are prescribed 50 Headaches +1 for patients with DS include teaching to 100 mg three times a day; how - them how to maintain a symptom Feeling of warmth, sweating, +1 ever, some people can’t tolerate the journal, providing dietary instruction, pallor, clammy skin GI side effects, which include flatu - and promoting self-management. lence, abdominal discomfort, and Nausea +1 Stress the importance of learning diarrhea. Abdominal fullness, meteorism +1 what foods trigger or aggravate their has been shown to symptoms because patient self-man - improve both early and late dump - Borborygmus +1 agement has been shown to be the ing. It’s administered by injecting 50 Eructation -1 best approach to controlling early to 100 micrograms subcutaneously and late dumping. three to four times a day, 30 min - Vomiting -4 Some patients may experience DS utes before each meal. It causes a symptoms while receiving care in a delay in gastric emptying, resulting Adapted from Tack and Deloose 2014. hospital or clinic. Your responsibili - in a smaller amount of food entering ties in these settings depend on the the intestine at one time. Octreotide DS symptoms, such as diarrhea, type of dumping. Patients who are also is available as a long-acting for - nausea, or bloating. These medi - experiencing early dumping should mulation that’s injected intramuscu - ca tions also have side effects that be placed in the low Fowler’s posi - larly every 4 weeks. Although the may be troublesome. tion for 20 to 30 minutes after a long-acting 20-mg dose has been meal to help delay gastric emptying shown to decrease DS symptoms, Surgical interventions and minimize symptoms. If the pa - increase compliance, and improve As a last resort, surgical interven - tient is exhibiting symptoms of late patient quality of life compared to tion may be necessary for DS suf - dumping, give him or her a small the three-times daily dose, it’s not as ferers who have been compliant amount of fast-acting carbohydrates, effective at improving hypoglycemia. with dietary or pharmacologic ther - such as fruit juice or regular soda; Side effects include painful injec - apy for at least 1 year but continue symptoms typically subside 10 to 15 tions, weight gain, (ex - to be troubled by their symptoms. minutes after consumption. Warn cess fat in the feces), and Several surgical procedures have patients that they’re at risk of falling formation. In addition, octreotide is been deemed somewhat successful if they feel dizzy, weak, or light - significantly more expensive than in treating DS, but they aren’t al - headed and need to rush to the other DS treatments. ways curative. bathroom. To avoid DS symptoms Over-the-counter products can The choice of surgical interven - after a tube feeding, ensure that the be used to manage the severity of tion depends on what precipitated formula is at room temperature, in -

American Nurse Today Volume 13, Number 1 AmericanNurseToday.com 8 Patient education tips Share these tips with your patients who have dumping syndrome (DS) to help manage their symptoms. other healthcare providers must be mindful of the conditions that may • Avoid foods high in simple carbohydrates (candy, cookies, cakes, fruit juices, sweetened drinks, ice cream, canned fruits in heavy syrup, sugar alcohols). lead to DS and its symptoms to • Eat protein with each meal and snack (eggs, cheese, meats, fish, poultry, properly educate patients. Regard - legumes, low-fat milk). less of the healthcare setting, nurses • Avoid drinking liquids with meals. Instead, drink 30 to 45 minutes before and should be able to assess the needs 1 hour after the meal. of patients with DS, provide gener - • Limit the use of caffeine, tea, and alcohol. These beverages can stimulate gas - al recommendations, and, if neces - tric motility. Discuss the appropriate intake of alcohol with your healthcare sary, make a referral to a dietitian provider. or healthcare provider who can of - • Eat five to six small meals a day to avoid overloading the stomach. fer individual assistance with di - • Lie down for about 15 minutes after eating to help slow gastric emptying. etary or medical treatments. • Avoid very hot or very cold foods and liquids; they can increase the severity of DS. • Choose high-fiber foods to decrease the risk of late dumping. Visit americannursetoday.com/?p=37195 for a list of selected references. still the feeding slowly or via contin - ageal or gastric surgery or other med - Lynnette Rodgers is a PhD nursing student at the Uni - versity of Texas Medical Branch in Galveston and a uous I.V. drip, and keep the patient ical conditions that cause rapid medical liaison at Novo Nordisk Inc., Plainsboro, New in semi Fowler’s position for 1 hour emptying of the stomach may not Jersey. Carolyn A. Phillips is an associate professor and after the feeding. be aware of DS, but they’re experi - Dibrell Family Professor in the nursing PhD program at Many patients who’ve had esoph - encing the symptoms. Nurses and the University of Texas Medical Branch in Galveston. Pharmacologic interventions Symptoms Nursing Name Action Dose Side effects targeted implications Acarbose • Slows digestion of 50 to 100 mg • Flatulence Late dumping • Observe patient for signs carbohydrates three times a • Abdominal and symptoms of • Decreases post- day, given with discomfort hypoglycemia prandial rise of first bite of each • Diarrhea • Monitor serum glucose and glucose and insulin meal glycosylated hemoglobin release periodically during therapy to evaluate effectiveness Octreotide • Delays gastric 50 to 100 mcg • Painful Early and late • Assess frequency and emptying subcutaneous injections dumping consistency of stools and • Slows transit through injection 30 • Diarrhea bowel sounds throughout the small bowel minutes before • Gallstone therapy • Increases intestinal each meal formation • Monitor pulse and blood absorption of water • Steatorrhea pressure before and and sodium • Weight gain periodically during therapy Octreotide LAR 20 mg • Assess patient’s fluid and intramuscular electrolyte balance and injection every skin turgor for dehydration 4 weeks • Assess for • Assess for gallbladder pain periodically during prolonged therapy Anticholinergics • Slows gastric 20 to 40 mg • Paralytic Early and late • Assess for symptoms of emptying three times a • dumping • Antispasmodic day 30 minutes • Heartburn before and during therapy before meals • Dry mouth • Assess for abdominal • Nausea and distention and auscultate for vomiting bowel sounds • Monitor intake and output ratios; may cause urinary retention

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