# Dumping syndrome and other gastric bypass maladies



## mycrofft (May 1, 2012)

Annually we are creating tens of thousands of gastric-malabsorptive patients through bariatric gastric bypass surgeries. Are we being educated well enough about them? Is enough research being conducted and communicated about their conditions? 
Start with dumping syndrome.What do we know?


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## Dwindlin (May 1, 2012)

Not much to say in terms of EMS treatment.  Treat it as any other form of diarrhea and provide supportive therapy.


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## mycrofft (May 1, 2012)

Dumping syndrome is not just diarrhea, and sometimes doesn't include it. My understanding is blood glucose drops, but oral glucose only makes it worse.
PLUS: chronically abnormal and exam, obstructions, etc.


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## jwk (May 1, 2012)

Dwindlin's got it right - it's not really an EMS issue.  This is not an acute problem - it's chronic and a very common side effect of bariatric surgery that all bariatric patients and their surgeons are aware of.


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## EpiEMS (May 1, 2012)

Not strictly a gastric bypass issue, but a GI surgery one: how would you deal with a nauseated patient who has had a fundoplication? If he/she cannot vomit, but feels nauseated, would you consider Zofran?


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## Aidey (May 2, 2012)

What is interesting about dumping syndrome is that it is very often caused by not following the post surgery diet. So we've taken a bunch of people who have proven that they can't follow a healthy diet and put them in a situation where they will make themselves sick if they don't follow a strict diet. Perfectly logical.


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## Handsome Robb (May 2, 2012)

EpiEMS said:


> Not strictly a gastric bypass issue, but a GI surgery one: how would you deal with a nauseated patient who has had a fundoplication? If he/she cannot vomit, but feels nauseated, would you consider Zofran?



Absolutely I would consider zofran. Unless there's some obscure contraindication that I have never heard of. 

Just because you can't puke doesn't mean you can't feel like you are going to puke. 

Generally zofran is more effective for those who are nauseated but aren't actively vomiting. Great at suppressing nausea, not so great at stopping active vomiting. Unfortunately we can only use phenergan if they are allergix to zofran. 

I admittedly know very little about the above mentioned beyond what they are.


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## mycrofft (May 2, 2012)

Thanks for the considered inputs. 

As for it not being an emergency situation, diabetes and medical allergies are not emergencies, but have a great deal of bearing upon how such patients are approached. 

An altered absorptive status can affect medications prescribed, how medications (as well as vital is and proteins etc) are absorbed and utilized. There are also the shorter term issues of postop conditions (prolonged wound healing, anticoagulant therapy, potential acute abdomen due to dehiscence of the anatomosis), and longer term issues (current thought takes them off NSAIDS for life, _H. pylori_ infections are more severe). What if such a pt becomes pregnant, or a drug addict, or just goes off the rails diet-wise and suffers an esophageal insult because the stomach simply can't accept that much food?

Dumping syndrome is not just a punishment for the sin of eating sugar (although on casual comparison it does resemble Antabvuse and alcohol) , it is an agonizing reaction, sometimes to sugar not revealed in ingredients lists or included by a restaurant or barrista (was that Starbucks order for Splenda or not? Hmmmmm...). 

This is a suddenly enlarging class of patients which the medical community is creating and then not following on.


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## jwk (May 4, 2012)

mycrofft said:


> This is a suddenly enlarging class of patients which the medical community is creating and then not following on.



I'm not sure where you get this idea that the "medical community" is somehow not dealing with this.  There are significant benefits AND SIGNIFICANT RISKS to bariatric surgery.  They're covered pretty well with the patient pre-operatively, but unfortunately, a LOT of patients simply don't follow their instructions for the length of time they're supposed to follow them.  As with many things, they're looking for a quick fix.  

What I think is sad is that bariatric surgery used to be reserved for massively obese patients - the 5' 350# women, or 6' 500# men.  It used to come with required counseling and psychological testing.  Such is not the case any more.  I put a lot of people to sleep for bariatric surgery that are barely at the usual 35 BMI cutoff, so that means a lot of folks in the 220# range.  They can do well - IF they follow their instructions with behavior modification including exercise.  Most will lose the weight, and gain it back within five years.  Sad.


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## bigbaldguy (May 4, 2012)

EpiEMS said:


> Not strictly a gastric bypass issue, but a GI surgery one: how would you deal with a nauseated patient who has had a fundoplication? If he/she cannot vomit, but feels nauseated, would you consider Zofran?



They can't puke? Who says they can't puke?


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## mycrofft (May 4, 2012)

I get the idea the medical community drops the ball because the definitive studies are not being published (where I can find them), and after the procedure is done, the surgeon says "My part is done" and the GP says "The isn't my bailiwick, see the surgeon".<_<

Yeah, I hate going to Los Angeles and seeing all the before and after billboards for surgery (usually for lap band, but...). It's a real money maker, especially when you add the highly probable cholecystectomy afterwards. And doing unnecessary ones (cosmetic and due to neurotic body image troubles) can often have a very "easy" pt on the table, not as large.

I've had to case manage a number of cases where the pt was never a good candidate (alcoholics?) and tried to get around the surgery by, say, eating mashed potatoes with lots of fluids (that one dehisced and took pain meds for the bellyache...) or drinking beer the carbonation had been shaken out of (sayWHAT?:wacko.

Ask some questions, like "How long after surgery can a pt [or why can't a patient] resume taking NSAIDS?" or  "Why do some patients get dumping syndrome, some apparently don't, and most who do get it sporadically?", and the answer is usually tap-dancing or a stare. Not their job.

But EMS, as evidenced by some of the responses so far, is NOT prepared for some of the niceties and potential pitfalls of treating such patients. 

Ten thousand more a year.


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## Aidey (May 4, 2012)

Definitive studies on what? And treating them for what?


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## NomadicMedic (May 4, 2012)

Dumping syndrome is a dietary issue, not an acute medical emergency. Now, if they've had diarrhea for a couple of days, they may be dehydrated or hypokalemic... But that's a matter of fluid in the field. How do you feel EMS should be treating these patients.


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## mycrofft (May 4, 2012)

DKA is a dietary issue by that argument. 

Quote from NIH article with nice clinical definition 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015671/


"Dumping syndrome falls into 2 types, early (osmotic) and late (hypoglycemic). ...
Symptoms can broadly be divided into vasomotor (including tachycardia, sweating, palpitations, flushing, and dizziness) and gastrointestinal (nausea, cramping abdominal pain, and diarrhea). Early dumping, which occurs up to 45 minutes after a meal, is thought to result from the passage of a large volume of osmotic material into the small bowel, causing an influx of fluid from the intravascular space. The subsequent reduction in circulating volume, combined with the release of vasoactive substances, such as vasoactive intestinal polypeptide, causes the symptoms.
In late dumping, a similar set of symptoms occurs. However, they do not arise until 2 hours to 4 hours after a meal and are due to an entirely different mechanism. Here, a rapid delivery of sugars into the duodenum and consequent rise in blood sugar causes an excessive serum insulin response with subsequent rebound hypoglycemia. ..Symptoms of late dumping tend to be much more subtle and nonspecific than in the early syndrome, and the diagnosis may not always be considered. Confirmation is made by demonstrating a rebound hypoglycemia following a prolonged oral glucose tolerance test."

So, get a lowered blood sugar, and administer more oral glucose per protocol? Don't recommend it.

 And how would these symptoms be interpreted if dumping syndrome wasn't known and treatment not accommodated to it? Could Rx be given for vasoactive stage, then the pt recovers and cardiovascular situation degrades thanks to medication delivered, as the hypoglycemia is kicking in. If you gave beta blockers, not only will there be cardiovascular issues, but you will be masking the presenting signs of hypoglycemia.

What if the pt is pregnant? Or vomiting and not very far postop?

Vitamin B 12 has to be continuously supplemented; if it is not absorbed properly or the supplements are ineffective (has to be "melt in your mouth" type for many pts) or not taken at all, red cell counts will be low, and microcytic. CNS symptoms present including  paresthesias and possibly psychiatric/psychological manifestations.

And on and on. A post-gastric bypass pt is eligible for medic alert status for a reason.


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## EpiEMS (May 5, 2012)

bigbaldguy said:


> They can't puke? Who says they can't puke?



Pt said so. Admittedly, I didn't believe her 100%, and I've yet to ask a gastroenterologist or surgeon, but I looked around on PubMed. I did find, based on a few studies I located, many patients find it difficult — if not impossible — to vomit after a fundoplication. I found a 1999 study comparing open and laparoscopic fundoplication outcomes, and for both methods, only about 15% reported a normal ability to vomit (http://archsurg.ama-assn.org/cgi/reprint/134/3/240.pdf). I also located (but don't have full text access to) a 2011 study out of Sweden published in the Annals of Surgery, which indicated that "[t]wenty-three percentage of the patients in the total fundoplication group noted some ability to vomit compared with 31% in the partial posterior fundoplication group" (http://www.ncbi.nlm.nih.gov/pubmed/21451393).


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## mycrofft (May 6, 2012)

I know for a fact people post-Roux-en-Y (aka gastric bypass ) surgery can and do vomit.


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## EpiEMS (May 7, 2012)

mycrofft said:


> I know for a fact people post-Roux-en-Y (aka gastric bypass ) surgery can and do vomit.



I was addressing a different (I think?) procedure, Nissen fundoplication, where the fundus is wrapped around the esophagus, reducing reflux by making the lower esophageal sphincter stronger (if I'm understanding it correctly).


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## Handsome Robb (May 7, 2012)

So it's funny that this came up, I just had a patient with dumping syndrome the day after this thread started. 

The abd pain lead to anxiety and ended with carpal pedal spasms and a near syncope. 

From that experience I learned that the only real thing we can do is manage symptoms as they are presented. 

I couldn't get a whole lot of info from the patient but they had a gastric bypass a couple years back and went in for a glucose test at a satellite lab site and it ended badly.


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## Sam Adams (May 7, 2012)

Absolutely fascinating. Didn't know there was a name for it. Seen it first hand w/ a colleague. 

He had the surgery 5-10 years ago, had his gall bladder out shortly there after, had problems w/ his inability to eat healthy and has been going up and down w/ his weight ever since. However, once or twice a week, while working, he would get very cranky, start looking dusky and start acting weird. I and some of his friends soon figured out he would become hypoglycemic (rebound) after eating the fecal matter that had lead to his weight issue in the first place.

We pieced together a theory that w/ full (relative) stomach, he'd be releasing the same amount of insulin as his pre-op self. I guess we were sort of correct. Never noticed whether or not he vomits.

You're all correct though. Not very much education pre-hospitally about this.


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