Case 7 question 1

Try again! The patient is likely experiencing symptoms of early Dumping syndrome. Early dumping can occur after gastric surgery, when there is rapid gastric emptying resulting in hyperosmolar chyme entering the jejunal lumen. This results in intra-luminal sequestration of fluid, which causes vasomotor symptoms like palpitations, lightheadedness and sweating, as well as bloating, abdominal pain and diarrhea. Simple sugars are likely to worsen osmolar shifts, and liquids which empty rapidly from the stomach increase fluid sequesteration in the gut lumen, and exacerbate the symptoms of dumping syndrome. Small frequent meals, containing fiber, complex carbohydrates, protein and fat are recommended.

Good choice! Performing  upper endoscopy to evaluate the stomach and anastomoses to rule out an anastomotic ulcer or stricture is a reasonable next step in evaluation of this patient’s weight loss. Risk factors for anastomotic ulceration include current smoking, NSAID use, H pylori infection and local ischemia at the anastomotic site.

Try again! It is premature to consider enteral nutrition in this patient, who has not yet tried dietary modifications for dumping syndrome. A standard enteral formula that is delivered into the stomach may not resolve the patient’s symptoms.

Good choice! Contrast imaging, including a CT scan with oral and IV contrast or an upper GI series, is a useful way to assess for anastomotic leaks , stenoses or fistulae and is an appropriate next step.