Gastric dumping syndrome differential diagnosis

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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

Dumping syndrome may often be confused with other similar diseases that cause upper abdominal pain, nausea, and fatigue.

Differentiating Dumping Syndrome from other Diseases

Diseases with similar symptoms

• Post-gastrectomy complications:
  • Post-vagotomy diarrhea
  • Small capacity syndrome
  • Short bowel syndrome
  • Afferent loop syndrome
  • Efferent loop syndrome
• Peptic ulcer disease
• Fistula
• Adhesion
• Stenosis
• Ischemia
• Gastritis
• Internal Hernia
• Insulinoma
• Glucose-lowering medication abuse
• Symptomatic gallstone disease
• Postprandial Hypotension
• Irritable bowel syndrome (IBS)

Differential diagnosis of dumping syndrome based on post-vagotomy complications:

They are the following:

Differential Diagnosis for Postgastrectomy complications	Clinical features	Diagnosis
Short bowel syndrome	Upper abdominal pain, diarrhea, malnutrition, weight loss	LFTs, liver biopsy, Upper GI series, CT scan
Small-capacity syndrome	Early satiety, malnutrition, weight loss	Clinical diagnosis with a history of surgery
Afferent loop syndrome	Upper abdominal pain, early satiety, relief after vomiting	Ultrasound, Barium enema
Efferent loop syndrome	Upper abdominal pain, distention, vomiting	CT scan, Upper GI series
Postvagotomy diarrhea	Watery Diarrhea	Clinical diagnosis with a history of surgery

Differential diagnosis of dumping syndrome based on early dumping syndrome symptoms:

Early dumping syndrome should be differentiated from other diseases presenting with abdominal pain, vomiting, nausea and early satiety. The differentials include the following::

Differential Diagnosis for Early Dumping Syndrome symptoms	Clinical features	Diagnosis
Adhesions	Upper abdominal pain, vomiting, distention	CT scan, Upper GI series
Internal hernia	Upper abdominal pain, vomiting, early satiety	CT scan, Diagnostic laproscopy
Fistula	Upper abdominal pain, relief after vomiting, early satiety	Fistuloscopy, Endoscopy, Colonoscopy, Dye injection, CT scan
Ischemia	Upper abdominal pain, vomiting, diarrhea, distention	CT Angiography
Ulcer	Upper abdominal pain with food, nausea, acid reflux	Gastroscopy
Stenosis	Upper abdominal pain with food, nausea, acid reflux, dysphagia	Gastroscopy, Gastrografin swallow

Differential Diagnosis of Dumping Syndrome based on Late Dumping Syndrome symptoms:

The differential diagnosis of dumping syndrome is based on the early dumping syndrome timeline.They are as follows:

Differential Diagnosis for Late Dumping Syndrome symptoms	Clinical features	Diagnosis
Insulinoma	Fasting hypoglycemia	After a 72 hour fast do labs: Serum Glucose, C-peptide, Insulin, Proinsulin
Glucose-lowering medication abuse	Hypoglycemia	Sulfonylurea and C-peptide assay
Postprandial Hypotension	Nausea, lightheadedness,	Blood pressure checked before and after a meal

Differential diagnosis of abdominal pain

The differential diagnosis based on abdominal pain are as follows:

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs The following is a list of diseases that present with acute onset severe lower abdominal pain: Disease Findings Ectopic pregnancy History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes. Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%. Ruptured ovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic. Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic. Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic. Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic. Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain. References