Gastric dumping syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Medical Therapy

• Dumping syndrome is largely avoidable by avoiding certain foods which are likely to cause it, therefore having a balanced diet is important. Treatment includes changes in eating habits and medication. People who have gastric dumping syndrome need to eat several small meals a day that are low in carbohydrates, especially omitting simple sugars (candy, desserts, ice cream), and should drink liquids between meals, not with them.
• People with severe cases take medicine such as cholestyramine or proton pump inhibitors (such as pantoprazole) to slow their digestion.
• Treatment – Most patients with dumping can be treated conservatively with dietary changes (frequent small meals that are high in fiber and protein and low in carbohydrates, separation of liquid from solid during meals) [9,10]. Symptoms tend to resolve in most patients as they learn to avoid foods that aggravate the problem (eg, simple sugar).
• Octreotide may also help in severe cases of dumping but is rarely required [8]. A study of 30 patients with dumping treated with either subcutaneous octreotide, administered three times a day, or its long-acting formulation (Octreotide LAR), which is given monthly, reported that both significantly reduced dumping symptoms and improved quality of life [12].
• Patients preferred monthly treatment.
• The rare patient with intractable dumping symptoms who fails dietary and medical therapy may require reoperation [9,10]. In patients who had a distal gastrectomy, conversion from a loop gastrojejunostomy to a Roux-en-Y reconstruction is the procedure of choice. This operation slows gastric emptying by impairing motility of the Roux loop. Thus, gastric remnant of no more than 25 percent should be left to avoid postoperative Roux stasis syndrome (see 'Roux stasis syndrome' below).
• In patients who had a prior loop gastrojejunostomy without gastrectomy, simple takedown of the gastrojejunostomy usually resolves dumping syndrome, provided that normal antropyloric and duodenal functions are maintained.

Clinicians treat dumping syndrome through dietary alterations by encouraging patients to reduce simple carbohydrate intake. Patients must avoid forbidden foods and change their eating behaviors (patients should cut food into small pieces, chew thoroughly, eat slowly, and wait 1 hour after a meal before drinking beverages).7,8

Patients whose symptoms persist often respond to octreotide 25 to 100 mcg subcutaneously 30 minutes before meals or long-acting depot injections of octreotide 10 to 20 mg/month. This somatostatin analogue slows gastric emptying, delays small bowel transit, and inhibits vasoactive peptide release.13,14

For late dumping syndrome, administering acarbose 25 mg before breakfast, lunch, and dinner often alleviates rebound hypoglycemia. Acarbose inhibits carbohydrate absorption in the small intestine, prevents postprandial hyperinsulinemia, and reduces insulin concentrations. Acarbose alleviates postprandial hypotension and tachycardia by slowing the gastric empting rate and subsequently delivering high-osmolality nutrients to the duodenum in a more measured way.14,15

Considerations for Oral Dosing after Bariatric Surgery · Procedures that truncate the stomach reduce gastric mixing, which is important in the disintegration process of oral forms of medication. · RYGB increases the stomach’s pH and may decrease solubility of weakly acidic drugs. · RYGB surgery reduces drug (and food)/biliopancreatic secretion mixing; therefore, drugs that depend on bile salts to enhance their solubility (eg, cyclosporine, phenytoin, levothyroxine, tacrolimus) may be compromised after RYGB. · RYGB bypasses the duodenum and the proximal jejunum and may shorten passage time through the intestine. Drugs with poor water solubility and extended-release formulations may have inadequate transit time for dissolution and absorption. · Studies have documented decreased bioavailability for several drugs after RYGB surgery (eg, amoxicillin, azithromycin, cyclosporine A, levothyroxine, nitrofurantoin, mycophenolic acid, phenytoin, phenobarbital sirolimus, tacrolimus, tamoxifen). · Procedures that reduce the stomach size may increase mucosal toxicity of nonsteroidal anti-inflammatory drugs, salicylates, oral bisphosphonates, and oral iron tablet formulations. · Any procedure that causes dumping increases gut transit time and may decease drug absorption.

RYGB = Roux-en-Y gastric bypass. Adapted from references 17- 21.