in this video i'm going to provide an overview of dumping syndrome including the causes of it and how to manage it with diet modification [Music] dumping syndrome is a disorder of the gastrointestinal tract that results from the rapid delivery of nutrients to the small intestine it's characterized by a set of symptoms that are categorized as early dumping and late dumping early dumping includes gastrointestinal symptoms like abdominal pain bloating cramping nausea and diarrhea as well as vasomotor symptoms like fatigue weakness dizziness flushing sweating and palpitations these occur within the first hour after a meal late dumping includes symptoms related to hypoglycemia like fatigue weakness confusion hunger irritability sweating and palpitations these usually occur one to three hours after a meal a patient with dumping syndrome can have early dumping late dumping or both of them but early dumping occurs more often the symptoms can also change improve or resolve over time dumping syndrome is problematic because it can lead to decreased quality of life and contribute to poor nutritional status especially if the patient develops fear and anxiety around eating dumping syndrome is most common when there are anatomical changes to the gastrointestinal tract this can be from reduced gastric capacity or it can be from a gastroenterostomy which is a surgical procedure that connects a portion of the stomach to the small intestine under normal circumstances the stomach serves as a reservoir for a large volume of liquids and solids it grinds and mixes them and begins to dilute them to the appropriate concentration before gradually releasing them as chyme through the pyloric sphincter into the small intestine when gastrointestinal anatomy changes some or all of these functions are disrupted and the nutrients from food enter the small intestine much faster than they normally do the biggest contributor to dumping syndrome is bariatric surgery this is a set of procedures aimed at inducing weight loss for patients living with obesity the sleeve gastrectomy is a popular type of bariatric surgery that reduces gastric capacity by removing 70 to 80 percent of the stomach the ruin y gastric bypass is another popular type but it's a gastroenterostomy that creates a small pouch in the upper portion of the stomach and bypasses the remainder of it another significant contributor to dumping syndrome is gastrointestinal cancer stomach cancer may require a partial or total gastrectomy which can limit gastric capacity or result in a loss of the pyloric sphincter additional causes of dumping syndrome include esophageal cancer resulting in the need for an esophagectomy gerd resulting in the need for a nissan fundoplication and diabetes in the early stages of nerve damage from chronic hyperglycemia some cases are considered idiopathic meaning they have no known cause however these make up the smallest number of cases at this stage we've seen a definition for dumping syndrome and reviewed the etiologies of it now we're going to dive into early and late dumping syndrome separately to see why they happen then we'll see how to identify them using objective measures early dumping seems to occur through two mechanisms first it seems to occur from the high osmolarity of nutrients in the small intestine the basic biological phenomenon osmosis teaches us that when there's a semi-permeable membrane separating two solutions water will flow from the side of low solute concentration to the site of high solute concentration the lining of the small intestine is a semi-permeable membrane blood plasma is a solution and chyme is a solution so if we have a high concentration of nutrients as solute in the small intestine water will get pulled in from the blood plasma this generally doesn't happen with normal anatomy and digestion because fully digested nutrients arrive in the small intestine in a slower more controlled way and they've been diluted to the appropriate concentration by various gastrointestinal secretions nevertheless i want to point out that it doesn't always happen with altered anatomy and digestion either since the small intestine can adapt to increase its absorptive capacity this is one explanation for why dumping syndrome often resolves on its own over time water shifting from the blood plasma to the gastrointestinal tract can set off both the gastrointestinal symptoms and the vasomotor symptoms symptoms like cramping bloating and diarrhea occur because of the excess water in the digestive tract and the high amount of undigested nutrients that pass into the large intestine to be feasted on by gut bacteria vasomotor symptoms like weakness fatigue and palpitations happen because of a decrease in blood volume when blood volume goes down less blood reaches tissues throughout the body meaning fewer nutrients and less oxygen for all of the body cells including those in the brain and skeletal muscle palpitations are part of the body's response as the heart pumps faster and harder to get the blood where it needs to be the second mechanism of early dumping seems to occur because of gastrointestinal hormones hormones like gastric inhibitory polypeptide glucagon-like peptide 1 neurotension and vasoactive intestinal peptide are released in a greater quantity with dumping syndrome all of these hormones have acute effects on gastrointestinal motility and vasomotor activity that implicate them in the symptoms that are observed late dumping is caused by reactive hypoglycemia which is sometimes called postprandial hypoglycemia the rapid delivery and absorption of carbohydrates in the small intestine produces a hyperinsulinemic response that drives blood glucose below the level that supports homeostasis a major contributor to this appears to be the amplified release of the gastrointestinal hormone glp-1 glp-1 boosts the insulin response to eating and inhibits the release of glucagon so the forces that drive blood sugar down are strengthened while the forces that drive blood sugar up are weakened the resulting symptoms are consistent with what's seen in hypoglycemia from any cause including impaired blood sugar regulation and diabetes since the symptoms of both early and late dumping syndrome are non-specific meaning they can occur from a number of medical conditions it's important that patients undergo the appropriate diagnostic testing to identify it this process should be completed by a medical doctor because some of the symptoms overlap with much more serious complications like an intestinal stricture adhesions or an insulinoma which should all be ruled out first at the time of making this video in 2022 the preferred diagnostic test for dumping syndrome is the modified oral glucose tolerance test or ogtt in this test the patient ingests 75 grams of glucose in a solution after an overnight fast blood glucose hematocrit level pulse rate and blood pressure are all measured before the glucose is consumed and at 30 minute intervals for up to three hours early dumping is diagnosed if after 30 minutes there's a hematocrit increase of greater than 3 percent or if there's a pulse rate increase of greater than 10 beats per minute both of these measurements reflect changes in blood volume from water being drawn from the plasma into the small intestine hematocrit is the percentage of red blood cells in blood so an acute increase in percentage points suggest that the amount of plasma has gone down the pulse rate increases because with a decreased blood volume the heart must beat faster to get the same amount of blood to tissues late dumping is diagnosed if after one to three hours the blood glucose drops below 50 milligrams per deciliter what you'll see is an acute increase in glucose shortly after ingestion followed by a drop below fasting levels which suggests a hyperinsulinemic response now that we've seen why dumping syndrome happens and how it's diagnosed we're going to take a look at the management of it but first i want to make sure you hit the like button on this video and are subscribed to the channel once dumping syndrome has been diagnosed the initial approach to managing it is diet modification i've identified six ways to manage dumping syndrome aim for small frequent meals separate fluid intake from meals by at least 30 minutes avoid rapidly absorbable carbohydrates balance meals with protein and a healthy source of fat eat slowly and chew thoroughly together these recommendations are meant to slow gastric emptying and slow carbohydrate absorption stretching the stomach with a large meal size and the simultaneous ingestion of solids and liquids increase the rate of gastric emptying which is clearly an undesirable effect it's also unfavorable after bariatric surgery where the goal is to keep the stomach small and tight to avoid overeating rapidly absorbable carbohydrates should be avoided primarily to avoid a sharp rise in blood glucose after a meal which sets the stage for the hyperinsulinemic response seen in late dumping examples include refined grains like white bread and pasta sugar-sweetened beverages like soda and juice sweet snacks like candy and dessert foods like cake cookies and ice cream more appropriate carbohydrate sources are those that are high in fiber since it slows gastric emptying and slows the release of sugars from the food this includes whole grains legumes sweet potatoes non-starchy vegetables and low glycemic fruits like berries cherries apples and oranges on top of choosing from these sources patients should aim to complete their meals by adding a source of protein like poultry seafood eggs or greek yogurt and then adding a small amount of a healthy source of fat like olive oil avocado nuts or seeds finding this balance of fiber-rich carbohydrates protein and a healthy source of fat puts the patient in the best position to slow digestion and absorption last but not least eating slowly may reduce the speed the nutrients reach the small intestine and chewing thoroughly can help to break down the nutrients to make them best available for absorption in the small intestine perhaps equally important both of these actions can help to optimize the hormonal response to eating by promoting feelings of fullness and reducing the risk of overeating overall the focus should be on minimizing symptoms while still incorporating foods from all food groups and meeting the nutritional needs for things like protein fluid and micronutrients other areas of the diet that may require scrutiny include the intake of fried and greasy foods sugar alcohols caffeine and alcohol not every patient finds these items contribute to their symptoms so i feel it's best left up to investigation on a case-by-case basis the final two aspects of management that we're going to explore are dietary supplements and enteral nutrition researchers have explored the effectiveness of using supplements like guar gum pectin and glucomannan to manage dumping syndrome these supplements are sources of soluble fiber as such they're added to meals to try to slow gastric emptying reduce the release of gastrointestinal hormones and improve the glycemic response although a few studies have produced some promising results these supplements are generally not recommended at this time not only do they reduce the palatability and tolerability of the food they're added to but they can also thicken food to the point it may increase the risk of choking and bowel obstruction this is particularly true when patients are being told to avoid fluids with their meals as for enteral nutrition it's been proposed as a tool for managing late dumping that doesn't respond to dietary modification or medications the theory here is that a slow continuous infusion of carbohydrates can reduce the risk of reactive hypoglycemia outside of a few case reports where this was effective the evidence to support enteral nutrition to manage dumping syndrome is scarce it's not recommended but might be considered if no other intervention works treatment with medication is beyond the scope of this video however they're generally accepted as a second line treatment if diet modification is unsuccessful or only marginally successful drugs that are often used include a carbos which helps with late dumping by slowing the absorption of carbohydrates and somatostatin analogues which help with early and late dumping by slowing motility and inhibiting the release of gastrointestinal hormones and insulin surgical interventions or re-interventions to treat dumping syndrome are not currently recommended make sure you check out my other videos on gastrointestinal diseases like gerd and gastroparesis thank you for watching and i hope to see you again soon