dumping syndrome
Introduction
Introduction to dumping syndrome Dumping syndrome refers to the loss of the pylorus or its normal function after gastrectomy and gastrojejunostomy due to surgery. The food in the stomach suddenly falls to the duodenum or jejunum, which can cause a series of symptoms that can occur in any type of stomach. After the operation, it is more common after the Billroth II type gastric resection. The vagus nerve injury caused by esophageal surgery can also cause dumping symptoms. After gastrectomy, the patient lost the pyloric regulation function, the volume of the residual stomach was reduced, and the vagus nerve resection affected the relaxation of the stomach after the meal, so that a large number of hypertonic chyme suddenly poured into the duodenum or jejunum after eating. The hyperosmolar sugar in the intestine and the extracellular fluid in the intestinal wall are rapidly exchanged to maintain the balance of the osmotic pressure between the intestinal cavity and the intestinal wall, and cause a significant increase in blood glucose and a decrease in blood volume in a short period of time. Up to a quarter of the fluid with an effective circulating blood volume can penetrate into the intestinal lumen, causing the blood to concentrate, causing symptoms such as pulse acceleration and collapse. basic knowledge Sickness ratio: 35% Susceptible people: no specific population Mode of infection: non-infectious Complications: syncope, hypoglycemia
Cause
Cause of dumping syndrome
Blood sugar and blood volume changes (30%):
After gastrectomy, the patient lost the pyloric regulation function, the volume of the residual stomach was reduced, and the vagus nerve resection affected the relaxation of the stomach after the meal, so that a large number of hypertonic chyme suddenly poured into the duodenum or jejunum after eating. The hyperosmolar sugar in the intestine and the extracellular fluid in the intestinal wall are rapidly exchanged to maintain the balance of the osmotic pressure between the intestinal cavity and the intestinal wall, and cause a significant increase in blood glucose and a decrease in blood volume in a short period of time. Up to a quarter of the fluid with an effective circulating blood volume can penetrate into the intestinal lumen, causing the blood to concentrate, causing symptoms such as pulse acceleration and collapse.
The role of digestive tract hormones (30%):
(1) vasorine-bradykinin: patients with gastric resection have a rise in serum tachykinin in patients with dumping syndrome, and no patients with no dumping syndrome. Intravenous bradykinin production in normal subjects and dumping syndrome are closely related to the level of bradykinin in the blood. Angione can increase peripheral blood flow and capillary permeability, and can increase gastrointestinal smooth muscle contraction, which can lead to vasodilation and gastrointestinal symptoms. Therefore, it is believed that the occurrence of intrinsic symptoms is related to the activity of the vasopressin-bradykinin system.
(2) vasoactive intestinal peptide: the blood vasoactive intestinal peptide was significantly increased in patients after gastrectomy, and the increase in concurrent dumping syndrome was particularly significant. The intravenous input of vasoactive intestinal peptide to normal people may have similar dumping syndrome. symptom.
In addition, gastric atrophin, motilin, serotonin, substance P, etc. have also been considered to be related to the occurrence of this disease, but there is no conclusion yet.
Neurological factors (25%):
Clinical observations have shown that the preoperative mental state of the patient is excitatory or stress-type, and the dumping syndrome is more likely to occur after surgery. Psycho-neural factors can cause pyloric regulation of dysfunction and accelerate gastric emptying, and even dumping syndrome can occur in patients who have not undergone gastrectomy.
Pathogenesis
The mechanism by which symptoms are produced is generally considered to be:
1. A large amount of food directly enters the small intestine to expand and expand the intestine. The hypertonic food in the small intestine sucks a large amount of body fluid from the intestinal wall and also expands and expands the intestinal tube.
2. The expansion of the intestine can cause a reflex response of the autonomic nerve, so that the intestinal wall releases serotonin, bradykinin, substance P, and other intestinal vasoactive intestinal peptides, which leads to increased intestinal peristalsis and vasodilation. The latter causes a decrease in blood pressure and a cyclical symptom such as an increase in heart rate.
3. Infiltration of extracellular fluid into the intestine can cause a decrease in effective circulating blood volume, a decrease in serum K, aggravation of the symptoms of the circulatory system, and a faster emptying of the food during the standing position. The above symptoms are more pronounced. In short, the postprandial symptom group It is a comprehensive response of the above three factors.
Prevention
Dumping syndrome prevention
The method of prevention should be that the gastric resection should not be excessive during surgery, the residual stomach should not be too small, the anastomosis should be moderately sized, generally suitable for 4cm width. If there is symptoms after eating, it should be supine, try to eat high-nutrition and digestible solids. Food, eat less and eat more, and avoid too sweet, too salty, too concentrated diet and dairy products, drinking water and liquid food can be taken between meals, not at mealtimes, most patients with post-prandial symptom group after surgery are mild. After a period of gastrointestinal adaptation and dietary adjustment, the symptoms can disappear or be easily controlled. The control of dietary ingredients and eating meals is the most important part of all treatments. Dietary intake should be low-sugar, high-protein foods.
Complication
Dumping syndrome complications Complications, syncope, hypoglycemia
1. Dizziness, palpitations, tachycardia, extreme weakness, a lot of sweating, trembling, pale or flushing, heavy blood pressure, syncope.
2. Late dumping syndrome is more than half a year after surgery, and symptoms of hypoglycemia appear 1 to 3 hours after a meal, such as weakness, hunger, palpitation, sweating, dizziness, anxiety and even confusion, syncope.
Symptom
Dumping syndrome symptoms Common symptoms Postprandial syndrome Postprandial hypoglycemia Diarrhea tachycardia Xennia vertigo Anxiety bowel syndrome Dumping syndrome Blood pressure drop
Symptoms appear within 30 minutes after eating or after meals, lasting for 15 to 60 minutes, and lying down after meals can alleviate symptoms. Early postprandial symptoms mainly include two groups of symptoms:
One group is a gastrointestinal symptom. The most common one is a slight sensation of fullness. Then, the upper abdomen is full of discomfort, nausea and vomiting. The vomit is alkaline with bile, the abdomen has colic, the bowel sounds increase, and diarrhea. Rare.
The other group is symptoms of the circulatory system, palpitations, tachycardia, sweating, dizziness, paleness, fever, weakness, and decreased blood pressure.
Examine
Examination of dumping syndrome
Check systemic symptoms: dizziness, palpitations, tachycardia, extreme weakness, excessive sweating, trembling, pale or flushing, severe blood pressure, syncope; gastrointestinal symptoms: upper abdominal warmth, fullness discomfort, Nausea, vomiting, belching, bowel, diarrhea, and sometimes a sense of urgency. Weight loss in critically ill patients, manifestations of malnutrition. And measure blood sugar.
Diagnosis
Diagnosis and diagnosis of dumping syndrome
diagnosis
The diagnosis of dumping syndrome lacks objective criteria. The diagnosis is based on detailed medical history data. The early dumping syndrome occurs more than 1 to 3 weeks after the start of eating. The symptoms appear within 1 hour after the meal, while in the fasted state. Asymptomatic, fluid and carbohydrate-rich foods are particularly difficult to tolerate, the severity of the symptoms are different, clinical symptoms can be divided into systemic physical symptoms and gastrointestinal symptoms, systemic physical symptoms: dizziness, palpitations, palpitations Speed, extremely weak, a lot of sweating, trembling, pale or flushing, heavy blood pressure drop, syncope; gastrointestinal symptoms: upper abdominal warmth, fullness discomfort, nausea, vomiting, belching, bowel, diarrhea, Sometimes there is a sense of urgency in bowel movements. It usually lasts for about 1 hour and can be relieved by itself. After a meal, supine can avoid seizures. Severe patients can lose weight due to fear of eating, and often have malnutrition.
Late dumping syndrome is more than half a year after surgery, and symptoms of hypoglycemia appear 1 to 3 hours after a meal, such as weakness, hunger, palpitation, sweating, dizziness, anxiety and even confusion, syncope.
The vast majority of patients have early-onset dumping, or both early-onset and late-onset dumpings occur simultaneously, with a few patients showing only late-onset dumping.
Some researchers have used simple oral glucose stimulation to induce dumping syndrome test: heart rate increased by 10 times/min or more within 1 hour after oral administration of 50g glucose for sensitivity (100%) and specificity (92%) for diagnosis of early-onset dumping syndrome. Indicia, the hydrogen breath test reflects rapid migration into the distal ileum or colon after oral glucose, with a sensitivity of 100% and a lower specificity.
Differential diagnosis
Because of the typical symptoms of fullness, sweating, tachycardia, and blood pressure drop after the patient has undergone major gastrectomy, it is easy to differentiate from other causes of hypoglycemia and hypotension.
