Guideline sources The following summarized guidelines for the evaluation and management of dumping syndrome (DS) are prepared by our editorial team based on guidelines from the Dumping Syndrome Consensus Group (DS-CG 2020), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), and the European Association for the Study of Obesity (EASO 2017). 1 2 3 Guidelines 1. Screening and diagnosis Clinical presentation: Recognize that: DS is a complication of esophageal or gastric surgery that can comprise both early and late DS symptoms B early DS is the typical and most frequent manifestation of DS and can occur in isolation or in association with late symptoms B DS affects the quality of life and can be associated with weight loss B symptoms of early DS are driven by rapid delivery of nutrients to the small bowel, which triggers the release of several gastrointestinal hormones, including vasoactive agents, incretins, and glucose modulators B https://web.pathway.md/diseases/recaTzMBAx5lBjH1o 1/4 6/29/23, 10:23 PM Dumping syndrome Pathway hypoglycemia is the main symptom of late DS and is driven by a hyperinsulinemic response and GLP-1 release B DS can contribute to weight loss after bariatric surgery. B Diagnosis: Suspect DS based on clinical history. Recognize that currently available dumping questionnaires have no proven diagnostic value. B Suspect late DS in patients with spontaneous hypoglycemia < 2.8 mmol/L (50 mg/dL). B 2. Diagnostic investigations Oral glucose tolerance test: obtain a modified oral glucose tolerance test for the diagnosis of DS. Regard the test results as positive for early DS in case of an early (30 minutes) increase in hematocrit > 3% or in pulse rate > 10 bpm. Regard the test results as positive for late DS in case of late (60-180 minutes after ingestion) hypoglycemia (< 50 mg/dL). B Mixed meal tolerance test: do not obtain mixed meal tests over modified glucose tolerance test. D Continuous glucose monitoring: insufficient evidence regarding the usefulness of continuous glucose monitoring for diagnosing DS. I Gastric emptying testing: insufficient evidence regarding the usefulness of gastric emptying tests in diagnosing DS. I 3. Medical management Acarbose: offer acarbose for the treatment of patients with DS symptoms, especially symptoms of late DS. B Diazoxide: insufficient evidence regarding the usefulness of diazoxide in the treatment of patients with DS. I Octreotide: As per DS-CG 2020 guidelines, offer somatostatin analogs for the treatment of patients with DS. Recognize that short-acting analogs have greater efficacy but require multiple injections. B As per EASO 2017 guidelines, consider offering octreotide in patients failed to be controlled with dietary modifications. B 4. Nonpharmacologic interventions Dietary modifications: As per AACE 2020 guidelines, eliminate concentrated sweets from the diet after Roux-en-Y gastric bypass to minimize symptoms of DS, as well as after any bariatric procedure to reduce caloric intake. B As per DS-CG 2020 guidelines: https://web.pathway.md/diseases/recaTzMBAx5lBjH1o 2/4 6/29/23, 10:23 PM Dumping syndrome Pathway Initiate dietary interventions with eliminating rapidly absorbable carbohydrates as the first- line treatment approach in patients with DS. B Advise patients to consume high fiber and protein-rich foods, eat slowly, and chew well. B As per EASO 2017 guidelines, initiate nutritional manipulations as the first-line treatment to control DS. B Dietary supplements: insufficient evidence regarding the usefulness of agents increasing meal viscosity in the management of patients with DS. I Continuous enteral feeding: insufficient evidence regarding the usefulness of continuous enteral or gastric feeding in the treatment of patients with DS. I 5. Surgical interventions Indications for reoperation: insufficient evidence to recommend surgical interventions (or re- interventions) in patients with DS. I Clinical findings Symptoms Past medical history Abdominal cramps Orthostatic hypotension Bloating Vital signs Borborygmi Diarrhea Signs of shock Dizziness Tachycardia Early satiety Lab findings Epigastric pain Fatigue Hyperglycemia Headache blood glucose Increased appetite Lightheadedness Diagnostic procedures Malaise modified oral glucose tolerance test Nausea Palpitations Restlessness Shortness of breath Skin flushing Sleepiness Syncope Tremor Trouble concentrating Vomiting Past surgical history Recent bariatric surgery https://web.pathway.md/diseases/recaTzMBAx5lBjH1o 3/4 6/29/23, 10:23 PM Dumping syndrome Pathway Recent gastrectomy Recent gastrointestinal surgery Integument exam Diaphoresis Pallor Hematological findings References 1. Emidio Scarpellini, Joris Arts, George Karamanolis et al. International consensus on the diagnosis and management of dumping syndrome. Nat Rev Endocrinol. 2020 Aug;16 8 448 466. Open 2. Busetto L, Dicker D, Azran C et al. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obes Facts. 2017;10 6 597 632. Open 3. Jeffrey I Mechanick, Caroline Apovian, Stacy Brethauer et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity Silver Spring). 2020 Apr;28 4 O1 O58. Open https://web.pathway.md/diseases/recaTzMBAx5lBjH1o 4/4