Gastric dumping syndrome medical therapy

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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

The main therapy for the management of dumping syndrome includes diet and pharmacological intervention.

Approach to Management

The following algorithm demonstrates the course of action in the approach of the management of dumping syndrome:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastric or Esophageal Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early dumping syndrome
 
 
 
Late dumping syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosis
 
 
 
 
 
 
 
 
Measure Glucose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm diagnosis with OGTT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dietary modifications
 
 
 
Dietary supplements
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acarbose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment
 
 
 
 
 
 
 
 
 
Somatostatin analogues
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment refractory dumping syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical re-intervention or Continuous enteral feeding
 
 
 
 
 
 
 
 
 
 
 
 


Medical Therapy

Medical therapy for dumping syndrome includes diet and drug therapy.[1]

Level of evidence Type of evidence
I Evidence from meta-analysis of multiple, well-designed, controlled studies (randomized trials with low false-positive and low false-negative errors)
II Evidence from at least 1 well-designed, quasi-experimental study (randomized trials with high false-positive and high false-negative errors)
III Evidence from well-designed, quasi-experimental studies (nonrandomized, controlled, single-group, pre–post, cohort and time or matched case–control series)
IV Evidence from well-designed, non-experimental studies (comparative and correlational descriptive and case studies)
V Evidence from case reports
Grade of recommendation Level of evidence
A Level I evidence or consistent findings from multiple studies (level II, III or IV)
B Level II, III or IV evidence with generally consistent findings
C Level II, III or IV evidence with inconsistent findings
D Little or no systematic empirical evidence

Diet

Dietary Modifications (Level III; Grade B)

  • Decrease carbohydrate intake
    • Avoid simple sugars like soda, candy sweets, and cookies
  • Fluid restriction
    • Wait at least 30 minutes after a meal before drinking
  • Increase protein intake
  • Increase fat intake
  • Increase fiber intake
  • Dairy and dairy product restriction
  • Shorter meals
  • Eat slowly
  • Chew properly
  • Lying supine for 30 minutes after a meal
  • Glycemic index education of foods is important

Dietary Supplements (Level III; Grade C)

The following work similarly to each other. These supplements increase viscosity which in turn decreases gastric emptying and causes a delay in glucose absorption.

Dietary Foods

The following is a table that illustrates the types of food to take and avoid in the case of dumping syndrome.

Breads, Cereals, Rice and Pasta Foods To Choose  Foods to Avoid
  • 6-11 servings each day
  • One serving equals: 1 slice bread, 1 cup ready-to-eat cereal
    • 1/2 cup cooked cereal, rice, or pasta
  • Breads, bagels, rolls, unsweetened cereals, pasta, potatoes, rice, crackers, and soup (only if taken one hour after solid foods at medium temperature).
  • Sweet rolls and doughnuts
  • Sweetened cereals
  • Pancakes and waffles with syrup
  • Soup (taken with solid foods)
Fruits Foods to Choose Foods To Avoid
  •  2-4 servings each day
  • One serving equals: 1 medium size fresh, 1/2 cup canned, 3/4 cup juice 
  •  All fresh fruit
  • Drained, unsweetened canned fruit
  • Unsweetened frozen fruit
  • 100 percent pure juice (taken one hour after meals)
  • Canned fruits in heavy syrup
  • Sweetened frozen fruit
  • Sweetened juice (that is, punch or sports drinks)
  • Candied fruit
Milk and Dairy Products Foods To Choose Foods to Avoid
  • Limit to 2 servings each day
  • One serving equals: 1 cup milk or yogurt
  • Plain or unsweetened yogurt
  • Skim, 2 percent, or whole milk (taken one hour after meals)
  • Milkshakes and chocolate milk
  • Sweetened yogurt 
Meats, Poultry, Fish, Dry Beans, Peas, Eggs and Cheese Foods to Choose Foods to Avoid
  •  2-3 servings or a total of six ounces daily
    • One serving equals: 2-3 ounces cooked meat, chicken, or fish (about the size of a deck of cards)
    • or 1/2 to 3/4 cup cottage cheese or tuna fish
    • or one egg, 1/2 cup cooked beans, two tablespoons peanut butter, or one ounce of cheese.
  • Choose leaner cuts of beef and meat and limit the amount of high-fat items like eggs and cheese.
  • All meat, fish, poultry, peanut butter, cheese, eggs, and dried beans or legumes
  • Any not tolerated
Vegetables Foods to Choose Foods to Avoid
  •  3-5 servings each day
  • One serving equals: 1 cup raw, 1/2 cup cooked or chopped. 
  • All vegetables
  • Any not tolerated
Fats, Condiments and Beverages Foods to Choose Foods to Avoid
 
  • All butter, margarine, cream, oil, and salad dressings
  • Salt, herbs, spices, and condiments
  • Any sugar-free beverage (coffee, tea, diet soda, etc., taken one hour after solids)
  • Sweet pickles or relish
  • Sweetened drinks (regular lemonade, soda)
  • Any others not tolerated
Snacks, Sweets, and Desserts Foods to Choose Foods to Avoid
 
  • Sugar-free gelatin
  • Sugar-free pudding
  • Sugar-free candy
  • Sugar substitutes
  • Sugar
  • Candy and chocolate
  • Cakes and cookies
  • Ice cream and sherbet
  • Honey, syrup, and jelly
  • Sugar alcohols such as sorbitol, xylitol, and mannitol

Drug Therapy

Although there are no FDA approved medications specific for dumping syndrome the following pharmacological interventions are used off-label:

Acarbose (Level III; Grade B) Octreotide (Level II; Grade A)
Use Late dumping syndrome Early and Late dumping syndrome
Mechanism of Action Inhibits carbohydrate absorption Strong inhibitor of the gut hormones (especially insulin)
Dose
  • Initiate effect: 25-50 μg S.C two-three times daily (BID or TID)
  • Maximum effect: 100-200 μg S.C two-three times daily (BID or TID)
  • Long-acting (New) I.M once monthly
Effect
  • Decrease symptoms
  • Improves Sigstad's score
  • Inhibits vasodilation
  • Decrease insulin levels
Additional information


Somatostatin analogues

Drug summary

Drug Dose Effect
Tolbutamide[2] 0.25-0.75 g, TID Subjective improvement
Propranolol[3] 10 mg, QID Reduced early dumping
Cyproheptadine[4] 4-8 mg, TID Preventing vasomotor symptoms
Methysergide maleate[5] 4-8 mg, TID Reduced vasomotor symptoms
Verapamil[6] 120-240 mg, QD Reduced vasomotor symptoms
Acarbose[7] 50-100 mg, TID Reduced late dumping
Octreotide[8] 25-100 mcg, TID Reduced vasomotor symptoms
Pantoprazole (PPI)[9] Subjective improvement
Cholestyramine[10] Subjective improvement
Diazoxide[11] 75-260 mg, QD Subjective improvement
Nifedipine[12] 30 mg, QD Reduced hypoglycemic symptoms
Exendin 9-39[13] 7500 pmol/kg prime  Reduced hypoglycemic symptoms


Effects of surgery on medications


References

  1. Ukleja A (2005). "Dumping syndrome: pathophysiology and treatment". Nutr Clin Pract. 20 (5): 517–25. doi:10.1177/0115426505020005517. PMID 16207692.
  2. Sigstad H (1969). "Effect of tolbutamide on the dumping syndrome". Scand. J. Gastroenterol. 4 (3): 227–31. PMID 5346670.
  3. Niv Y (1988). "The early dumping syndrome and propranolol". Ann. Intern. Med. 108 (6): 910–1. PMID 3369789.
  4. Leichter SB, Permutt MA (1975). "Effect of adrenergic agents on postgastrectomy hypoglycemia". Diabetes. 24 (11): 1005–10. PMID 1183731.
  5. Bernard PF, Baschet C, Le Henand F, Bouderlique JR, Lortat-Jacob JL (1970). "[Treatment of 65 cases of dumping syndrome with methysergide in recently gastrectomized patients]". Presse Med (in French). 78 (12): 549–50. PMID 5439191.
  6. Tabibian N (1990). "Successful treatment of refractory post-vagotomy syndrome with verapamil (Calan SR)". Am. J. Gastroenterol. 85 (3): 328–9. PMID 2309689.
  7. Hasegawa T, Yoneda M, Nakamura K, Ohnishi K, Harada H, Kyouda T, Yoshida Y, Makino I (1998). "Long-term effect of alpha-glucosidase inhibitor on late dumping syndrome". J. Gastroenterol. Hepatol. 13 (12): 1201–6. PMID 9918426.
  8. Vecht J, Masclee AA, Lamers CB (1997). "The dumping syndrome. Current insights into pathophysiology, diagnosis and treatment". Scand. J. Gastroenterol. Suppl. 223: 21–7. PMID 9200302.
  9. Sanaka M, Yamamoto T, Kuyama Y (2010). "Effects of proton pump inhibitors on gastric emptying: a systematic review". Dig. Dis. Sci. 55 (9): 2431–40. doi:10.1007/s10620-009-1076-x. PMID 20012198.
  10. Barkun AN, Love J, Gould M, Pluta H, Steinhart H (2013). "Bile acid malabsorption in chronic diarrhea: pathophysiology and treatment". Can. J. Gastroenterol. 27 (11): 653–9. PMC 3816948. PMID 24199211.
  11. Vilarrasa N, Goday A, Rubio MA, Caixàs A, Pellitero S, Ciudin A, Calañas A, Botella JI, Bretón I, Morales MJ, Díaz-Fernández MJ, García-Luna PP, Lecube A (2016). "Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry". Obes Facts. 9 (1): 41–51. doi:10.1159/000442764. PMC 5644871. PMID 26901345.
  12. Guseva N, Phillips D, Mordes JP (2010). "Successful treatment of persistent hyperinsulinemic hypoglycemia with nifedipine in an adult patient". Endocr Pract. 16 (1): 107–11. doi:10.4158/EP09110.CRR. PMC 3979460. PMID 19625246.
  13. Salehi M, Gastaldelli A, D'Alessio DA (2014). "Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass". Gastroenterology. 146 (3): 669–680.e2. doi:10.1053/j.gastro.2013.11.044. PMC 3943944. PMID 24315990.
  14. Padwal R, Klarenbach S, Wiebe N, Hazel M, Birch D, Karmali S, Sharma AM, Manns B, Tonelli M (2011). "Bariatric surgery: a systematic review of the clinical and economic evidence". J Gen Intern Med. 26 (10): 1183–94. doi:10.1007/s11606-011-1721-x. PMC 3181300. PMID 21538168.
  15. Smith A, Henriksen B, Cohen A (2011). "Pharmacokinetic considerations in Roux-en-Y gastric bypass patients". Am J Health Syst Pharm. 68 (23): 2241–7. doi:10.2146/ajhp100630. PMID 22095812.
  16. Padwal R, Brocks D, Sharma AM (2010). "A systematic review of drug absorption following bariatric surgery and its theoretical implications". Obes Rev. 11 (1): 41–50. doi:10.1111/j.1467-789X.2009.00614.x. PMID 19493300.
  17. Brocks DR, Ben-Eltriki M, Gabr RQ, Padwal RS (2012). "The effects of gastric bypass surgery on drug absorption and pharmacokinetics". Expert Opin Drug Metab Toxicol. 8 (12): 1505–19. doi:10.1517/17425255.2012.722757. PMID 22998066.
  18. Titus R, Kastenmeier A, Otterson MF (2013). "Consequences of gastrointestinal surgery on drug absorption". Nutr Clin Pract. 28 (4): 429–36. doi:10.1177/0884533613490740. PMID 23835364.

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