1/34. Reactive hypoglycaemia due to late dumping syndrome: successful treatment with acarbose. Reactive hypoglycaemia is a rare disease which occurs postprandially in everyday life involving blood glucose levels below 2.5 to 2.8 mmol/l. We report on a 66-year-old patient who developed symptomatic reactive hypoglycaemia due to late dumping syndrome 10 years after oesophagectomy with cervical anastomosis. A 75 g sucrose load revealed a plasma glucose level of 9.4 mmol/l after one hour, followed by symptomatic hypoglycaemia with a plasma glucose level of 1.8 mmol/l after three hours. Concomitantly, high concentrations of insulin (3216 pmol/l at a glucose level of 9.4 mmol/l and 335 pmol/l at a glucose level of 1.8 mmol/l) and glucagon-like peptide 1 (GLP-1) (375 pmol/l at a glucose level of 9.4 mmol/l and 85 pmol/l at a glucose level of 1.8 mmol/l) were measured. While the patient was under treatment with acarbose, another sucrose load did not provoke symptomatic hypoglycaemia (plasma glucose nadir of 4.6 mmol/l after two hours). Insulin and GLP-1 levels increased much less, to peak levels of 375 pmol/l and 75 pmol/l respectively, after one hour when plasma glucose was 6.8 mmol/l. We conclude that in patients with reactive hypoglycaemia due to gastrointestinal surgery, acarbose decreases rapid glucose absorption associated with hyperglycaemia and GLP-1 secretion, and thus diminishes excessive insulin release. acarbose is therefore a successful treatment modality for reactive hypoglycaemia due to late dumping syndrome. ( info) |
2/34. dumping syndrome: a common problem following Nissen fundoplication in young children. Within a 3-year period we observed six children, aged 3 months to 4 years, with dumping syndrome (DS) following Nissen fundoplication. Five were neurologically normal and one was slightly mentally retarded. Symptoms included postprandial tachycardia, diaphoresis, lethargy, severe retching, meteorism or gas-bloat syndrome, watery diarrhea, refusal to eat with failure to thrive, and developmental delay. Results of an oral glucose tolerance test did not correlate with the severity of symptoms. In one child severe retching led to recurrent paraesophageal gastric herniation, necessitating two reoperations and a gastrostomy. A lack of meal stimulated pancreatic polypeptide release in this patient indicated vagal damage. Initially five of the six children needed continuous intragastric feeding until bolus application of a carbohydrate-modified diet was tolerated. We conclude that the diagnosis of DS is often delayed in spite of characteristic clinical signs. Intensive postoperative follow-up after antireflux surgery should be mandatory in children. ( info) |
3/34. Proximal jejunal reversal procedure without interposition for management of dumping syndrome. For control of disabling dumping syndrome, a short jejunal reversal interposition between the gastric remnant and the duodenum or between the gastric remnant and the jejunum with or without a second jejunal reversal is in current use. A new procedure, proximal jejunal reversal based on a modified antiperistaltic Roux-en-Y without interposition of the jejunal loop is presented and three cases are reported. ( info) |
4/34. A protein dietary supplement for the severe dumping syndrome. A protein dietary supplement has been developed for use in patients with severe dumping symptoms unresponsive to the usual medical regimens. The supplement, consisting entirely of casein and soy, is given three times a day and supplies 1,155 calories. This has not been associated with dumping symptoms or diarrhea. Three patients with severe malnutrition from the dumping syndrome were given the supplement over a six month period. They all evidenced rapid weight gain and maintained the weight gain even after the supplement was discontinued. ( info) |
5/34. Clinical and therapeutic applications of a new pathogenetic theory on the dumping syndrome. Based on experimental and clinical studies we have deduced the existence of a neuro-osmotic dumping syndrome and a truly osmotic dumping syndrome that differ in pathogenesis and clinical symptoms. ( info) |
6/34. acarbose treatment of infant dumping syndrome: extensive study of glucose dynamics and long-term follow-up. dumping syndrome is a sequel of gastric surgery in adults and Nissen fundoplication in children. The syndrome is characterized by various gastrointestinal symptoms as well as irritability, diaphoresis and lethargy. Shortly after a meal, symptoms are associated with hyperglycemia (early dumping), followed by late dumping symptoms associated with reactive hypoglycemia. Several therapeutic and dietary manipulations failed to control these symptoms in previous reports as well as in an infant we have followed after Nissen fundoplication. acarbose, an alpha-glucosidase inhibitor, has been used sporadically in adults after gastric surgery, but only once in children. In most of these studies, the effect of acarbose (on reactive hypoglycemia) was evaluated over several hours postprandially or after oral glucose load. In our study, we recorded glucose dynamics by a continuous glucose monitor system over 2 to 3 days before and during acarbose treatment, while the patient was on a well-controlled diet. These measurements (720 before and 832 on therapy) suggested that both early and late dumping symptoms are causally related to the rate of glucose elevation and decline, rather than to glucose peak and nadir, respectively. acarbose attenuated both postprandial glucose hyperglycemia and reactive hypoglycemia, which subsequently led to a significant reduction in dumping symptoms. In a follow-up of 14 months, acarbose was well tolerated and the frequency of dumping symptoms was remarkably reduced. ( info) |
| BACKGROUND: Late dumping syndrome is a possible side-effect of gastric bypass. Hypoglycemic symptoms may develop 3-4 hours after certain types of foods.There may exist patients, however, who present hypoglycemia in the absence of dumping syndrome. The presence of only mild symptoms of hypoglycemia may make the evaluation of these patients difficult and delay the identification of other possible sources of hyperinsulinemia, including an insulinoma. CASE REPORT: A 65-year-old woman underwent gastric bypass for continued weight gain and morbid obesity. After surgery, the patient had repeated episodes of hypoglycemia, diagnosed at follow-up as late dumping syndrome. The persistence of hypoglycemic episodes after nutritional counseling and modifications in the feeding pattern led to consideration of an autonomous source of hyperinsulinemia, and MRI and CT identified insulinoma. After a laparotomy and pancreatic tumor resection, she remains free of symptoms. CONCLUSION: Hypoglycemic episodes after obesity surgery are not always related to dumping syndrome. The persistence of hypoglycemia in spite of nutritional counseling should raise the possibility that there may exist other causes. insulinoma, the most common cause of endogenous hyperinsulinemia, should be investigated in these patients, since it is a tumor that can be cured. ( info) |
8/34. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. AIMS/HYPOTHESIS: Postprandial hypoglycaemia following gastric bypass for obesity is considered a late manifestation of the dumping syndrome and can usually be managed with dietary modification. We investigated three patients with severe postprandial hypoglycaemia and hyperinsulinaemia unresponsive to diet, octreotide and diazoxide with the aim of elucidating the pathological mechanisms involved. methods: Glucose, insulin, and c-peptide were measured in the fasting and postprandial state, and insulin secretion was assessed following selective intra-arterial calcium injection. pancreas histopathology was assessed in all three patients. RESULTS: All three patients had evidence of severe postprandial hyperinsulinaemia and hypoglycaemia. In one patient, reversal of gastric bypass was ineffective in reversing hypoglycaemia. All three patients ultimately required partial pancreatectomy for control of neuroglycopenia; pancreas pathology of all patients revealed diffuse islet hyperplasia and expansion of beta cell mass. CONCLUSIONS/INTERPRETATION: These findings suggest that gastric bypass-induced weight loss may unmask an underlying beta cell defect or contribute to pathological islet hyperplasia, perhaps via glucagon-like peptide 1-mediated pathways. ( info) |
| BACKGROUND: dumping syndrome is a recognized complication of various gastric surgical procedures, such as vagotomy, pyloroplasty, and gastrojejunostomy. However, it has not to date been reported following laparoscopic Nissen fundoplication in adults. CASE REPORT: We describe the case of a 34-year-old woman who developed late dumping syndrome following an uneventful laparoscopic Nissen fundoplication for gastroesophageal reflux disease. CONCLUSION: This condition should be considered in patients who develop hypoglycemic symptoms following laparoscopic fundoplication. ( info) |
10/34. Simultaneous measurement of intestinal blood flow and plasma levels of vasoactive substances in a case of early dumping syndrome. Case report. Increase in intestinal blood flow was observed in a patient with postprandial hypotension. Simultaneous measurement of hemodynamic parameters and plasma levels of gut hormones revealed that the release of various vasoactive substances and resulting vasodilation of abdominal organs were responsible for the vasomotor changes of early dumping syndrome. ( info) |