Gastric dumping syndrome diagnostic study of choice: Difference between revisions

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{{CMG}} {{AE}}
{{CMG}}; {{AE}} {{UA}}
 
{{Gastric dumping syndrome}}
{{Gastric dumping syndrome}}
== Overview ==
== Overview ==
* The page name should be '''"Diagnostic study of choice for [disease name]"''', with only the first letter of the title capitalized. Note that the page is called "Diagnostic study of choice."
The two most [[Sensitivity (tests)|sensitive]] and [[Specificity (tests)|specific]] tests used in confirming the clinical suspicion and in diagnosing dumping syndrome are the [[Glucose tolerance test|oral glucose tolerance test]] and the [[Hydrogen Breath Test|hydrogen breath test]].
* '''Goal:'''
**To describe the most efficient/sensitive/specific test that is utilized for diagnosis of [disease name].
**To describe the gold standard test for the diagnosis of [disease name].
**To describe the diagnostic criteria, which may be based on clinical findings, physical exam signs, pathological findings, lab findings, findings on imaging, or even findings that exclude other diseases.
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== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==


Population at risk
=== Study of choice: ===
 
* [[Glucose tolerance test|Oral glucose tolerance test]] is the ideal study of choice for the [[diagnosis]] of early [[Gastric dumping syndrome|dumping syndrome]] and late [[Gastric dumping syndrome|dumping syndrome]].<ref name="pmid8976007">{{cite journal |vauthors=van der Kleij FG, Vecht J, Lamers CB, Masclee AA |title=Diagnostic value of dumping provocation in patients after gastric surgery |journal=Scand. J. Gastroenterol. |volume=31 |issue=12 |pages=1162–6 |year=1996 |pmid=8976007 |doi= |url=}}</ref><ref name="pmid89760072">{{cite journal |vauthors=van der Kleij FG, Vecht J, Lamers CB, Masclee AA |title=Diagnostic value of dumping provocation in patients after gastric surgery |journal=Scand. J. Gastroenterol. |volume=31 |issue=12 |pages=1162–6 |year=1996 |pmid=8976007 |doi= |url=}}</ref><ref name="pmid26315925">{{cite journal |vauthors=Emous M, Ubels FL, van Beek AP |title=Diagnostic tools for post-gastric bypass hypoglycaemia |journal=Obes Rev |volume=16 |issue=10 |pages=843–56 |year=2015 |pmid=26315925 |doi=10.1111/obr.12307 |url=}}</ref>
Dumping syndrome should be suspected based on the concurrent presentation of multiple suggestive symptoms in patients who have undergone gastric or esophageal surgery [1]. A carefully obtained medical history and thorough symptom evaluation are very important for the accurate diagnosis of dumping syndrome. Profound fatigue after meal ingestion, with the need to lie down, is an important clinical clue. Various approaches can be used to confirm the presence of dumping syndrome, including symptom-based questionnaires, glycemia monitoring, oral glucose challenge testing and gastric emptying studies. An additional diagnostic evaluation may also be necessary to exclude conditions that can present with similar symptoms (e.g. postoperative complications, strictures, adhesions and insulinoma). Hypoglycemia unawareness may develop as a result of recurrent hypoglycemia, making it even more difficult to diagnose late dumping syndrome in patients who have undergone gastric bypass surgery [20].
* A mixed-meal tolerance [[test]] is the study of choice for the [[diagnosis]] of late [[Gastric dumping syndrome|dumping syndrome]].<ref name="pmid243159902">{{cite journal |vauthors=Salehi M, Gastaldelli A, D'Alessio DA |title=Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass |journal=Gastroenterology |volume=146 |issue=3 |pages=669–680.e2 |year=2014 |pmid=24315990 |pmc=3943944 |doi=10.1053/j.gastro.2013.11.044 |url=}}</ref><ref name="pmid24315990">{{cite journal |vauthors=Salehi M, Gastaldelli A, D'Alessio DA |title=Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass |journal=Gastroenterology |volume=146 |issue=3 |pages=669–680.e2 |year=2014 |pmid=24315990 |pmc=3943944 |doi=10.1053/j.gastro.2013.11.044 |url=}}</ref><ref name="pmid23787216">{{cite journal |vauthors=Khoo CM, Muehlbauer MJ, Stevens RD, Pamuklar Z, Chen J, Newgard CB, Torquati A |title=Postprandial metabolite profiles reveal differential nutrient handling after bariatric surgery compared with matched caloric restriction |journal=Ann. Surg. |volume=259 |issue=4 |pages=687–93 |year=2014 |pmid=23787216 |pmc=3901799 |doi=10.1097/SLA.0b013e318296633f |url=}}</ref>
Symptom-based questionnaires
 
Symptom-based questionnaires, such as the Sigstad's score and the Arts' dumping questionnaire can be used to identify patients with clinically meaningful dumping symptoms. Sigstad's score was developed to separate patients with or without postoperative dumping syndrome in the era of peptic ulcer surgery [17], while Arts' dumping questionnaire was designed to differentiate between early and late dumping symptoms. The Sigstad's scoring system assigns points to each dumping symptom, and the total points are used to calculate a diagnostic index [31]. A diagnostic index >7 is suggestive of dumping syndrome whereas a score <4 suggests that other diagnoses should be considered. Patients receive an oral glucose tolerance test (OGTT) prior to using the Sigstad's scoring system to score and grade symptom severity. The primary focus of the Sigstad's scoring system is to identify early dumping by diagnosing signs and symptoms such as a high pulse rate or increased haematocrit indicative of hypovolemia. The diagnostic accuracy of the Sigstad's scoring questionnaire in bariatric patients or after upper GI cancer surgery has not been established [7]. Arts et al. developed a dumping-severity score in which symptoms of early and late dumping (eight and six symptoms, respectively) were scored on a 4-point Likert scale [15]. This questionnaire has been tested on patients with early and late dumping, and was shown to be effective at discriminating between the two sets of symptoms and was responsive to somatostatin analogue therapy, but was never formally validated [15]. A relatively recent report also describes the use of a visual analogue scale (VAS) survey to evaluate early and late dumping syndromes in more than 1,000 patients after gastrectomy for gastric cancer [32]. This survey used a very low cutoff for dumping complaints (VAS score >10 mm), and a single item on the questionnaire was sufficient to label patients as symptomatic for late dumping [32].
Glycemia measurements
 
Single plasma glucose measurements, whether scheduled or random, can be performed during clinic visits after gastric or esophageal surgery. Although the diagnostic value of a single glucose measurement is low, its clinical value increases when evaluated in conjunction with late dumping symptoms. To date, no definitive guidance regarding cutoff values for plasma glucose has been established, but some clinicians consider plasma glucose concentrations <2.8 mmol/L (50 mg/dL) to be indicative of post-gastric bypass hypoglycemia, whereas others regard levels <3.3 mmol/L (60 mg/dL) diagnostic of hypoglycemia [33]. Capillary glucose measurements (finger prick) are not considered valid because of their lack of accuracy in the hypoglycemic range. Continuous glucose monitoring may be beneficial in complex cases of dumping syndrome [34-36].
Provocative testing
 
Clinical suspicion of dumping syndrome can be confirmed using provocative tests such as the OGTT or mixed-meal tolerance test [37]. In the glucose tolerance test, patients with suspected dumping syndrome ingest 50 g or 75 g of glucose in solution after an overnight fast. Blood glucose concentrations, haematocrit, pulse rate and blood pressure are measured before and at 30-min intervals up to 180 min after ingestion. The OGTT is considered positive for early dumping based on the presence of an early (30 min) increase in haematocrit >3% or an increase in pulse rate >10 beats/min after 30 min, the latter being regarded as the most sensitive indicator of early dumping syndrome [1]. Test results are positive for late dumping based on the development of late (60–180 min postingestion) hypoglycemia [1]. In the mixed-meal tolerance test, patients with suspected dumping syndrome ingest a mixed meal containing carbohydrates, fats and proteins after an overnight fast [18, 38]. Blood samples are collected before meal ingestion and at 30-min intervals for up to 2 h afterward to monitor glycemic and insulin profiles. The mixed-meal tolerance test is considered positive for late dumping syndrome in patients who develop hypoglycemia between 60 and 180 min after meal ingestion.
 
The use of provocative testing to diagnose dumping syndrome is associated with several challenges. Provocative testing can be difficult in patients with small gastric pouches as a result of gastric or bariatric surgical procedures. Furthermore, the OGTT frequently detects post-gastric bypass hypoglycemia in patients with and without symptoms, as well as in healthy individuals [20]. Therefore, the diagnostic accuracy of this test is low and normative values have not been firmly established [20]. As a result, clinical practice guidelines for adult hypoglycemic disorders developed by the Endocrine Society do not support the use of the OGTT for diagnosing postprandial hypoglycemia [39]. The mixed meal tolerance test holds promise as a more physiologic stimulation test for the detection of post-gastric bypass hypoglycemia [20, 40]. Some studies demonstrate improved specificity of this test in asymptomatic patients; however, normative values have not been established for healthy individuals [20]. Further validation of the mixed meal tolerance test is needed in patients with and without hypoglycemia symptoms, as well as in healthy individuals. Because there is currently no optimal approach for the diagnosis of dumping syndrome, [20] provocative testing is still commonly used in some countries to diagnose hypoglycemia in the safety of a medical testing facility.
Gastric emptying studies
 
The rate of gastric emptying may also be used to confirm a diagnosis of dumping syndrome. A gastric emptying scintigraphy test involves eating a bland meal that contains a small amount of radioactive material, and measuring the rate of gastric emptying at hourly intervals until 4 h after the meal. However, gastric emptying studies generally have low sensitivity and specificity, probably because the process of rapid gastric emptying occurs soon after ingestion, a phase that is not adequately assessed in most studies. Furthermore, the duration of the entire study of up to 4 h is integrated into a single value (half emptying time), which may neutralize the rapid initial emptying effect [3, 15, 37].
 
===== Template statements =====
 
=== Gold standard/Study of choice: ===
* [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
* The following result of [gold standard test] is confirmatory of [disease name]:
** Result 1
** Result 2
* The [name of investigation] should be performed when:
** The patient presented with symptoms/signs 1. 2, 3.
** A positive [test] is detected in the patient.
* [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
* The diagnostic study of choice for [disease name] is [name of investigation].
* There is no single diagnostic study of choice for the diagnosis of [disease name].
* There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
* [Disease name] is mainly diagnosed based on clinical presentation.
* Investigations:
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.


==== The comparison table for diagnostic studies of choice for [disease name] ====
==== The comparison table for diagnostic studies of choice for dumping syndrome ====
{|
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background: #FFFFFF; color: #FFFFFF; text-align: center;" |
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Test characteristic
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
! style="background: #696969; color: #FFFFFF; text-align: center;" |<small>✔ </small>Oral glucose provocation
| style="background: #DCDCDC; padding: 5px; text-align: center;" |✔
| style="background: #DCDCDC; padding: 5px; text-align: center;" |100%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |92%
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
! style="background: #696969; color: #FFFFFF; text-align: center;" |Hydrogen breath
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |100%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |✔
| style="background: #DCDCDC; padding: 5px; text-align: center;" | -
|}
|}
<small> ✔= The best test based on the feature </small>
<small> ✔= The best test based on the feature </small>


===== Diagnostic results =====
===== Diagnostic results =====
The following result of [investigation name] is confirmatory of [disease name]:
{| class="wikitable"
* Result 1
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Test
* Result 2
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Confirmatory result
|-
|'''[[Glucose tolerance test|Oral glucose tolerance test]]'''
|An increase in the [[heart rate]] by 10 beats per minute or more in the first hour after an oral [[glucose]] challenge of 50 grams [[glucose]] after fasting for 10 hours.
|-
|'''Mixed-meal tolerance test'''
|[[Hypoglycemia]] between 60 to 180 minutes, after a mixed-meal ([[Lipid|lipids]], [[Carbohydrate|carbohydrates]], [[Protein|proteins]]) after fasting for 10 hours.
|-
|'''[[Hydrogen Breath Test|Hydrogen breath test]]'''
|A positive [[Hydrogen Breath Test|hydrogen breath test]] (a rise of 10 to 15 parts per million) after [[glucose]] [[ingestion]].
|}


===== Sequence of Diagnostic Studies =====
=== Diagnostic criteria ===
The [name of investigation] should be performed when:
{| class="wikitable mw-collapsible"
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Oral glucose tolerance test
* A positive [test] is detected in the patient, to confirm the diagnosis.
|-
|
* The patient fasts overnight
* An oral [[glucose]] load of 50 grams to 75 grams in [[solution]] is given
* Readings of the [[heart rate]] and [[blood pressure]] are taken before the [[ingestion]]
* [[Blood]] is drawn before the [[ingestion]]
* After [[ingestion]], every 30 minutes until 180 minutes, readings and [[blood]] are taken
* After [[ingestion]], a [[hematocrit]] >3% before 30 minutes is diagnostic (less [[Sensitivity (tests)|sensitive]])
OR
* After [[ingestion]], a [[pulse]] increase of 10 beats per minute after 30 minutes is diagnostic (most [[Sensitivity (tests)|sensitive]])
OR
* After [[ingestion]], induction of [[Symptom|symptoms]] of [[Gastric dumping syndrome|dumping syndrome]] is diagnostic (more specifically) for late [[Gastric dumping syndrome|dumping syndrome]]
|}
{| class="wikitable mw-collapsible"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Mixed-meal tolerance test
|-
|
* The patient fasts overnight
* A meal consisting of [[Lipid|lipids]], [[Protein|proteins]] and [[Carbohydrate|carbohydrates]] is given
* Readings of the [[heart rate]] and [[blood pressure]] are taken before the [[ingestion]]
* [[Blood]] is drawn before the [[ingestion]]
* After [[ingestion]], every 30 minutes until 2 hours, readings and [[blood]] are taken
* After [[ingestion]], [[hypoglycemia]] between 60 to 180 minutes is [[diagnostic]]
|}
{| class="wikitable mw-collapsible"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hydrogen breath test
|-
|
* The patient is given an [[Mouth|oral]] [[glucose]] load of 50 grams to 75 grams
* After [[ingestion]], differences in the rise in breath [[hydrogen]] support upper [[Gastrointestinal tract|gut]] [[Small bowel bacterial overgrowth syndrome|bacterial overgrowth]] (a rise of 10 to 15 parts per million). This is evidence for [[Small intestine|small intestinal]] [[malabsorption]] of [[glucose]]
|}


=== Diagnostic Criteria ===
==References==
* Here you should describe the details of the diagnostic criteria.
{{Reflist|2}}
*Always mention the name of the criteria/definition you are about to list (e.g. modified Duke criteria for diagnosis of endocarditis / 3rd universal definition of MI) and cite the primary source of where this criteria/definition is found.
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*Be very clear as to the number of criteria (or threshold) that needs to be met out of the total number of criteria.
*Distinguish criteria based on their nature (e.g. clinical criteria / pathological criteria/ imaging criteria) before discussing them in details.
*To view an example (endocarditis diagnostic criteria), click [[Endocarditis diagnosis|here]]
*If relevant, add additional information that might help the reader distinguish various criteria or the evolution of criteria (e.g. original criteria vs. modified criteria).
*You may also add information about the sensitivity and specificity of the criteria, the pre-test probability, and other figures that may help the reader understand how valuable the criteria are clinically.
* [Disease name] is mainly diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
* There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
 
* The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
* The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
 
* [Disease name] may be diagnosed at any time if one or more of the following criteria are met:
** Criteria 1
** Criteria 2
** Criteria 3


IF there are clear, established diagnostic criteria:
[[Category:Gastroenterology]]
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
*The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
*The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
IF there are no established diagnostic criteria: 
*There are no established criteria for the diagnosis of [disease name].


 
{{WH}}
==References==
{{WS}}
* References should be cited for the material that you have put on your page. Type in <nowiki>{{reflist|2}}</nowiki>.This will generate your references in small font, in two columns, with links to the original article and abstract.
* For information on how to add references into your page, click [[Adding References to Articles|here]].

Latest revision as of 22:11, 18 December 2017


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

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Overview

The two most sensitive and specific tests used in confirming the clinical suspicion and in diagnosing dumping syndrome are the oral glucose tolerance test and the hydrogen breath test.

Diagnostic Study of Choice

Study of choice:

The comparison table for diagnostic studies of choice for dumping syndrome

Test characteristic Sensitivity Specificity
✔ Oral glucose provocation 100% 92%
Hydrogen breath 100% -

✔= The best test based on the feature

Diagnostic results
Test Confirmatory result
Oral glucose tolerance test An increase in the heart rate by 10 beats per minute or more in the first hour after an oral glucose challenge of 50 grams glucose after fasting for 10 hours.
Mixed-meal tolerance test Hypoglycemia between 60 to 180 minutes, after a mixed-meal (lipids, carbohydrates, proteins) after fasting for 10 hours.
Hydrogen breath test A positive hydrogen breath test (a rise of 10 to 15 parts per million) after glucose ingestion.

Diagnostic criteria

Oral glucose tolerance test

OR

OR

Mixed-meal tolerance test
Hydrogen breath test

References

  1. ↑ van der Kleij FG, Vecht J, Lamers CB, Masclee AA (1996). "Diagnostic value of dumping provocation in patients after gastric surgery". Scand. J. Gastroenterol. 31 (12): 1162–6. PMID 8976007.
  2. ↑ van der Kleij FG, Vecht J, Lamers CB, Masclee AA (1996). "Diagnostic value of dumping provocation in patients after gastric surgery". Scand. J. Gastroenterol. 31 (12): 1162–6. PMID 8976007.
  3. ↑ Emous M, Ubels FL, van Beek AP (2015). "Diagnostic tools for post-gastric bypass hypoglycaemia". Obes Rev. 16 (10): 843–56. doi:10.1111/obr.12307. PMID 26315925.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Khoo CM, Muehlbauer MJ, Stevens RD, Pamuklar Z, Chen J, Newgard CB, Torquati A (2014). "Postprandial metabolite profiles reveal differential nutrient handling after bariatric surgery compared with matched caloric restriction". Ann. Surg. 259 (4): 687–93. doi:10.1097/SLA.0b013e318296633f. PMC 3901799. PMID 23787216.

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