Gastric dumping syndrome differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Umar Ahmad, M.D.[2]

Overview

Dumping syndrome may often be confused with other similar diseases that cause upper abdominal pain, nausea, and fatigue.

Differentiating Dumping Syndrome from other Diseases

Diseases with similar symptoms

• Post-gastrectomy complications:
  • Post-vagotomy diarrhea
  • Small capacity syndrome
  • Short bowel syndrome
  • Afferent loop syndrome
  • Efferent loop syndrome
• Peptic ulcer disease
• Fistula
• Adhesion
• Stenosis
• Ischemia
• Gastritis
• Internal Hernia
• Insulinoma
• Glucose-lowering medication abuse
• Symptomatic gallstone disease
• Postprandial Hypotension
• Irritable bowel syndrome (IBS)

Differentials based on nausea, vomiting, diarrhea, fatigue and abdominal pain

Gastric dumping syndrome should be differentiated from other diseases presenting with nausea, vomiting, diarrhea, fatigue and abdominal pain. The differentials include the following: Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments Symptoms Signs Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Chronic pancreatitis Epigastric − − ± ± − + + − − − − N Increased amylase / lipase Increased stool fat content Pancreatic function test CT scan Calcification Pseudocyst Dilation of main pancreatic duct Predisposes to pancreatic cancer Pancreatic carcinoma Epigastric − − + + − + + − − − − N ↑ Alkaline phosphatase ↑ serum bilirubin ↑ gamma-glutamyl transpeptidase ↑ CA 19-9  MDCT with  PET/CT MRI Skin manifestations may include: Bullous pemphigoid Cicatricial pemphigoid Migratory superficial thrombophlebitis (classic Trousseau's syndrome) Pancreatic panniculitis Dumping syndrome Lower and then diffuse − − + − − + + − + − − Hyperactive Glucose challenge test Hydrogen breath test Upper GI series Gastric emptying study Postgastrectomy Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + − − ± − − Positive in perforated appendicitis + + Hypoactive Leukocytosis Ct scan Ultrasound Positive Rovsing sign Positive Obturator sign Positive Iliopsoas sign Acute diverticulitis LLQ + ± + − + ± − + Positive in perforated diverticulitis + + Hypoactive Leukocytosis CT scan Ultrasound History of constipation Infective colitis Diffuse + − ± − − + − + Positive in fulminant colitis ± ± Hyperactive Stool culture and studies Shiga toxin in bloody diarrhea PCR CT scan Bowel wall thickening Edema Viral hepatitis RUQ + − + + − Positive in Hep A and E + − Positive in fulminant hepatitis Positive in acute + N Abnormal LFTs Viral serology US Hep A and E have fecal-oral route of transmission Hep B and C transmits via blood transfusion and sexual contact. Liver abscess RUQ + + + + − ± + − + + ± Normal or hypoactive CBC Blood cultures Abnormal liver function tests US CT Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous − + − − + + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous − Hyperactive to absent Leukocytosis and lactic acidosis Amylase levels D-dimer CT angiography SMA or SMV thrombosis Also known as abdominal angina that worsens with eating Acute ischemic colitis Diffuse + ± + − − + + + + + + Hyperactive then absent Leukocytosis Abdominal x-ray Distension and pneumatosis CT scan Double halo appearance, thumbprinting Thickening of bowel May lead to shock Pneumonia RUQ/LUQ + + + − − ± − − + − − Normal or hypoactive ABGs Leukocytosis Pancytopenia CXR CT chest Bronchoscopy Shortness of breath Cough

Differential diagnosis of dumping syndrome based on post-vagotomy complications:

They are the following:

Differential Diagnosis for Postgastrectomy complications	Clinical features	Diagnosis
Short bowel syndrome	Upper abdominal pain, diarrhea, malnutrition, weight loss	LFTs, liver biopsy, Upper GI series, CT scan
Small-capacity syndrome	Early satiety, malnutrition, weight loss	Clinical diagnosis with a history of surgery
Afferent loop syndrome	Upper abdominal pain, early satiety, relief after vomiting	Ultrasound, Barium enema
Efferent loop syndrome	Upper abdominal pain, distention, vomiting	CT scan, Upper GI series
Postvagotomy diarrhea	Watery Diarrhea	Clinical diagnosis with a history of surgery

Differential diagnosis of dumping syndrome based on early dumping syndrome symptoms:

Early dumping syndrome should be differentiated from other diseases presenting with abdominal pain, vomiting, nausea and early satiety. The differentials include the following::

Differential Diagnosis for Early Dumping Syndrome symptoms	Clinical features	Diagnosis
Adhesions	Upper abdominal pain, vomiting, distention	CT scan, Upper GI series
Internal hernia	Upper abdominal pain, vomiting, early satiety	CT scan, Diagnostic laproscopy
Fistula	Upper abdominal pain, relief after vomiting, early satiety	Fistuloscopy, Endoscopy, Colonoscopy, Dye injection, CT scan
Ischemia	Upper abdominal pain, vomiting, diarrhea, distention	CT Angiography
Ulcer	Upper abdominal pain with food, nausea, acid reflux	Gastroscopy
Stenosis	Upper abdominal pain with food, nausea, acid reflux, dysphagia	Gastroscopy, Gastrografin swallow

Differential Diagnosis of dumping syndrome based on late dumping syndrome symptoms:

The differential diagnosis of dumping syndrome is based on the early dumping syndrome timeline.They are as follows:

Differential Diagnosis for Late Dumping Syndrome symptoms	Clinical features	Diagnosis
Insulinoma	Fasting hypoglycemia	After a 72 hour fast do labs: Serum Glucose, C-peptide, Insulin, Proinsulin
Glucose-lowering medication abuse	Hypoglycemia	Sulfonylurea and C-peptide assay
Postprandial Hypotension	Nausea, lightheadedness,	Blood pressure checked before and after a meal