Dumping syndrome early and late. In patients operated eating can cause varying degrees of reaction expressed. Depending on the time of onset of symptoms after eating distinguish between early and late forms post alimentary syndromes (Table 1). Dumping syndrome (syn. early dumping syndrome) after resection is observed in the majority of operated during recovery, and later, 30% mild and 10% severe. After vagotomy with draining operations stomach dumping syndrome occurs in 12%, rarely severe. After selective proximal vagotomy he is rarely observed mainly mild. Table 1 Post alimentary syndromes

Clinical manifestations: typical. Eating causes a reaction in patients. During or after a meal in 10 - 15 minutes, especially after taking the sweet, dairy foods, there are weakness, dizziness, headache, confusion, and sometimes fainting, pain in the heart, palpitations, hot flushes "in the whole body sweat. Along with these symptoms there is a feeling of heaviness and bursting open in the epigastric region, nausea, vomiting, scanty, rumbling and colic cutting abdominal pain, and diarrhea. Because of the severe muscle weakness of the patients are forced to take a horizontal position. 

Pathogenesis: the main cause of symptoms of dumping reaction is the flow of the operated stomach a significant amount of undigested food in the upper section of the small intestine. This causes inadequate stimulation of the receptors intestine, increasing the osmolarity of the contents and then moving into the lumen of intestine extracellular fluid in order to achieve osmotic balance, stretching the walls of the intestines and release from the mucosa of biologically active substances - histamine, serotonin, kinin, vasoactive intestinal polypeptide, etc. result is vasodilation, decreased circulating plasma volume, increases motor activity of the intestine. Reducing the volume of circulating plasma at 15 - 20% is decisive in the occurrence of vasomotor symptoms: weakness, dizziness, fainting, collapse, palpitations, blood pressure lability, initially with a tendency to hypotension, then replaced an increase in blood pressure mainly due to systolic. Increased motility of the small intestine is the cause of intestinal colic and diarrhea.  After meal a early reaction develops against the backdrop of the rapid rise in blood sugar

The main criteria for early dumping syndrome (syn- dumping)

Late dumping (syn-hypoglycemic syndrome)

Associated with eating immediately after a meal after meal for 2-hour or

or immediately after a meal for 2 hours

Aggravating factors are are abundant, especially liquid food easily digestible carbohydrates, milk

Carbohydrates

Key symptoms syndromes Sense of filling in epigastric the General area, episodic-skie intestinal cramps, diarrhea, weakness, dizziness, tachycardia, feeling "hot flushes, perspiration

The feeling of emptiness in the epi-gastric region, nausea, hunger, weak Bost, tremors (shaking), chills, sweat

Factors facilitating easing of the condition

Horizontal position Repeated ingestion

Factors causing deterioration of the condition

Further meal Physical stress

levels. Because asynchronism between the entry of food into the small intestine and pancreatic juice with bile, reducing the amount of enzymes in pancreatic juice, the accelerated passage of chyme in the small intestine is disturbed the digestion of proteins, fats, carbohydrates and reduces the absorption of the products of their hydrolysis. As a result, about weight loss, develop beriberi, anemia. 

Diagnosis: based on the characteristic symptoms of dumping reaction occurring at the meal. For the objective characteristics of the severity of the dumping reaction can be used hemodynamic changes compared with baseline data (pulse rate, blood pressure, the volume of circulating plasma). For dumping provocation-reaction give the patient to drink 150 ml of 50% glucose solution. Changing the pulse rate is a constant feature of dumping reactions, increased pulse rate so LARGE, the heavier the damping response. The normalization of the pulse rate to the outcome of the indicator is in a longer time in patients with severe dumping-reaction. Prolonged tachycardia (more than 1 h) is an objective criterion of severe dumping reaction. These radiologic studies are an important complement to clinical evaluation of severity of dumping syndrome. Using water mist sulphate (sulfate), barium reveals the nature of the previously postponed surgery patients, anatomical and functional changes of the same-ludka and small intestine. The most frequently observed rapid emptying of the operated stomach, increased peristalsis of small intestine, alternating with inactivity. Diagnostic significance is the fact of rapid evacuation of the type "failure" of the first portion of gastric contents, when 1 / 3 or more of its acts in the small intestine. This usually occurs in patients with significant Dumping syndrome which developed after gastrectomy with gastrojejunal anastomosis. Investigation with X-ray food is a mixture of patients with dumping-reaction, the severity of which can match the severity of the reaction is usually observed early in the meal. Passage X-ray food mixture, the small intestine occurs faster in the 5-fold compared with the passage of aqueous suspensions of barium sulfate, and the observed accumulation of fluid in the lumen of the intestine and its extension. Often, there is increased motor activity of the colon, clinically manifested diarrhea occurring in 15 minutes after eating a mixture of X-ray. There are three severity of dumping syndrome by estimating the find expression and duration of the dumping reaction to food intake, the values of deficit of body weight, disability, the effectiveness of an integrated conservative treatment. 

Dumping syndrome late or hypoglycemic develops within 2 - 3 h after the meal, replacing the earlier dumping reaction. Pathogenesis: associated with excessive secretion of insulin during the early Democratic-ping reaction, accompanied by increases in blood sugar. As a result, hyperinsulinemia is reduced blood sugar levels to subnormal performance. Symptoms: weakness, sudden hunger, aching pain in the epigastric region, tremor, dizziness, palpitations, lowered blood pressure, sometimes bradycardia, pale skin, sweat. These symptoms rapidly disappear after receiving a small amount of food, especially carbohydrates.To avoid pronounced manifestations of hypoglycemic syndrome, patients often try to eat, carry with them the sugar, biscuits or bread, and take them in the event of the first signs of hypoglycemia. Diagnosis: based on typical patient complaints, the observation data for patients at the time of attack, low blood sugar (0,75 - 0, 50 g / l, or 75 - 50 mg%) at this time. Symptoms hypoglycemic syndrome again: from the occasionally emerging weakness, fast walking, to severe manifestations, observed daily. Permanent combination hypoglycemic syndrome with dumping-syndrome due to their pathogenetic commonality, while leading pain is dumping syndrome, which should be directed therapeutic activities. 

Table 2 Classification of dumping syndrome severity 

Severity Characteristics of the patient Hemodynamic changes Duration of

Bodymass

True-to-ACT-sob-ness

Results of treatment of diet, medication)

Light Damping the reaction to the reception only sweet and dairy dishes easy: there is little weak

Increased heart rate at 15 per minute

15 - 30 minutes

Rate or deficit not exceeding 5 kg

retained Effective exclusion of diet foods that provoke damping reaction

Average Damping the reaction to the reception of any pi expression, at an altitude of dumping reaction patients have to go

Increased heart rate for 20 - 24 per minute, labile blood pressure with a tendency to increase systolic

45 - 60 minutes

Deficit up to 10kg

Reduced Inpatient and sanatorium treatment provides short-term improvement

Weightlifting Damping the reaction to receiving any food difficult: because of the pronounced weakness of the pain forced to eat lying down and placed in a horizontal position 1.5 -3 h

Increased heart rate by more than 30 per minute. Labile blood pressure, increased systolic and diastolic decrease with increasing pulse pressure of 10 mm Hg. Art. and more, sometimes bradycardia, hypotension, collapse

1/2- 3 hours

Deficit of more than 10 kg

Lost Inpatient and sanatorium treatment is ineffective

Patients with dumping-syndrome observed neuro psychotic disorder, the main ones are astheno-neurotic syndrome, hysteroformic syndrome, depressive syndrome, hypochondriasis. 

Treatment: conservative and surgical dumping syndrome. Principles of conservative treatment following. 1. Medical nutrition to prevent or reduce the manifestations deping reaction. Diet physiologically normal, and not mechanically sparing. The chemical composition of the diet: high protein with (130 - 140 g), the normal fat content (100 - 115 g), the restriction of complex carbohydrates (310g), a significant limitation or exclusion of simple carbohydrates, the normal salt content (15 g). Excluding food and dishes, cause the development of the dumping syndrome. Calories about 2800 - 3200 kkalory. All dishes cooked in boiled or steamed. The food is served warm. Avoid hot and cold dishes. Separate eating solid and liquid, in small portions, 5 - 6 times a day, in a prone position. 2. To reduce the response to the rapid flow of food into the small intestine appointed before eating Novocain, anesthesia, antihistamines (pipolfen, diphenhydramine, suprastin), reserpine, insulin subcutaneously. 3. Substitution therapy: gastric juice, hydrochloric acid with pepsin, pancreatin, panzinorm, abomin, B-vitamins, ascorbic acid, folic acid, fat-soluble vitamin, iron supplements, calcium, magnesium, potassium, protein drugs - a plasma protein, protein hydrolysates. 4. Treatment of psychopathological syndromes in consultation with a psychiatrist. 

Principles of surgical treatment

Of the following. Surgical treatment of dumping syndrome of severe and moderate degree of inefficiency is shown at therapeutic feeding and complex medication. The purpose of the operation - the removal of anatomical conditions contributing to the development of the dumping syndrome. When dumping syndrome that developed after gastrectomy with gastrojejunal anastomosis, to address the rapid evacuation of food from the stump to lean intestine and used to improve digestion gastro jejunoduodenoplasty providing passage of food through the duodenum. When dumping syndrome,

developed after gastrectomy with gastroduodenal anastomosis can also be performed gastrojejunoduodenoplasty. Patients who have previously been performed on the resection of gastric peptic duodenal ulcer, reconstruction gastrojejunoduodenoplasty can help reconstruct acid-forming functions of the mucous membrane of the stump. In this regard, for the prevention of peptic ulcers in the intestinal graft reconstructive gastrojejunoduodenoplasty must be supplemented by vagotomy.Small Intestinal transplant provides a proportional evacuation of stomach contents into the duodenum. As a resultof gastrojejunoduodeno plasty flowing from the stomach into the duodenum, the food is mixed with pancreatic juice and bile, there is an alignment osmolarity of duodenal contents with the osmolarity of plasma, the hydrolysis is carried out all the ingredients of food in the underlying layers of the jejunum. With this in jejunum improved processes of digestion and absorption of products of hydrolysis of food, vitamins, electrolytes. Patients who underwent reconstructive gastrojejunoduodenoplasty, dumping response to food intake becomes less pronounced or not occur, body weight increases.