Journal of the New Zealand Medical Association, 09-November-2007, Vol 120 No 1265
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.
A 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.
Dumping 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: email@example.com
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