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| Journal of the New Zealand Medical Association,
09-November-2007, Vol 120 No 1265
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Dumping syndrome presenting three decades after
vagotomy
Catherine Patton, Onyebuchi E Okosieme, L Marc Evans
The development of postprandial symptoms in a patient with a
previous vagotomy should raise a suspicion of dumping syndrome. We describe a
patient who developed symptoms of dumping syndrome 32 years after
vagotomy.
Case reportA 65-year-old man was referred to our clinic in July 2005.
He had presented to his general practitioner with complaints of unexplained
weakness of 6 months duration. An elevated random blood glucose (13.2 mmol/L)
had raised the possibility of diabetes. Upon being questioned, however, the
patient described episodes of debilitating weakness and dizziness which were
usually triggered by meals.
Maximal symptoms occurred between 2 and 3 hours after food
and were aggravated by eating a high carbohydrate breakfast or by indulging in
fizzy (carbonated) drinks and chocolates. On occasion, he spent whole mornings
in bed feeling drained and unable to move.
Figure 1. Prolonged oral glucose tolerance test
with a 75g-gram glucose challenge
 Weight loss followed from fear of eating. He had no symptoms
of polyuria or polydipsia and gave no family history of diabetes. He had
undergone a vagotomy 32 years earlier for a duodenal ulcer but had otherwise
remained in excellent health. He was not receiving any medications and neither
smoked cigarettes nor consumed alcohol. Physical examination was unremarkable;
body mass index was 24 kg/m2 and blood pressure
was 135/74 mmHg. Renal, liver, lipid, thyroid, and haematological profiles were
normal. Haemoglobin A1c was 5.4%.
Based on a suspicion of late dumping syndrome, we performed
a prolonged oral glucose tolerance test (Figure 1). This showed a normal fasting
blood glucose, early postprandial hyperglycaemia, and subsequent hypoglycaemia.
A peak insulin rise was observed at 60 minutes and a blood glucose nadir was
associated with reproduction of symptoms after 2 hours (Figure 1).
We made a diagnosis of late dumping syndrome and advised the
patient to avoid carbohydrate-rich foods and to eat small frequent meals. His
symptoms resolved with these dietary modifications and he remains in good health
as at his last review in September 2006.
DiscussionDumping syndrome is a recognised complication of most forms
of gastric surgery.1 It is classified into an
early and a late form depending on the time interval between food intake and the
onset of symptoms. Early dumping occurs within 2 hours of a meal and consists of
vasomotor symptoms such as sweating, palpitations, and dizziness as well as
gastrointestinal symptoms like nausea, vomiting, and diarrhoea. Late dumping as
in this case occurs 2 to 4 hours after food, presenting mainly with symptoms
related to hypoglycaemia.1
The pathophysiology of the syndrome is poorly understood but
is believed to relate to accelerated gastric emptying with rapid absorption of
fluids and osmotic substances like glucose leading to hyperglycaemia, a reactive
insulin response and subsequent rebound
hypoglycaemia.1 Release of the gut hormone
glucagon-like peptide-1 appears to play a role in mediating hyperinsulinaemia
and hypoglycaemia.2
Symptoms of hypoglycaemia occur 2 to 4 hours after food, are
worsened by eating carbohydrate-rich foods, and can be improved by dietary
modifications, like reducing carbohydrate intake and eating small frequent
meals. Where diet is inadequate to control symptoms, drug therapy with the
α-glucosidase inhibitor, acarbose,3 or the
somatostatin analogue, octreotide,4 have proven
to be beneficial.
The diagnosis of late dumping syndrome is confirmed with a
prolonged oral glucose tolerance test which characteristically shows a profile
of early postprandial hyperglycaemia, an exaggerated insulin response, and
subsequent hypoglycaemia with reproduction of
symptoms.1 The random hyperglycaemia in this
case was thus consistent with dumping rather than diabetes which was effectively
excluded by the glucose tolerance profile.
Although the symptoms of dumping are easily recognisable in
the period following gastric procedures, the diagnosis may not always be
apparent especially when symptoms arise many years after surgery. Clinicians
should therefore be alert to the possibility of dumping even in patients who
present decades after surgery. A careful history and an oral glucose challenge
will clarify the diagnosis in most cases.
Author information: Catherine Patton,
Onyebuchi E Okosieme, L Marc Evans; Endocrinologists; Centre for Endocrine and
Diabetes Sciences, School of Medicine, Cardiff University, Cardiff, Wales,
United Kingdom
Correspondence: Dr OE Okosieme, Centre for
Endocrine and Diabetes Sciences, School of Medicine, Cardiff University,
Cardiff, CF14 4XN, United Kingdom. Email: okosiemeoe@cf.ac.uk
References:
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