Post gastrectomy syndromes

Question 1

What is the post gastrectomy syndrome?

Answer 1

constellation of GI and cardiovascular symptoms that occur after removal of the stomach due to loss of reservoir function, interruption of pyloric sphincter and vagal nerve transection 25% develop some degree of post gastrectomy syndrome 1% disabled by it

Question 2

Name the post gastrectomy syndromes.

Answer 2

From Surgical Clinics of NA, 2017 paper 1) Dumping syndrome (early and late) 2) Afferent and efferent loop syndromes 3) nutritional/metabolic disturbances 4) Bile (alkaline) reflux gastritis 5) Roux stasis syndrome 6) post vagotomy diarrhea 7) Delayed gastric emptying (gastroparesis) 8) small gastric remnant

Question 3

What is dumping syndrome?

Answer 3

syndorme due to rapid gastric emptying of hyperosmolar contents (food) into small intestine. can be early or late Early- occurs 10-30 min after meal -rapid shift of water into small intestine from hyperosmolar stomach contents- causes diarrhea -GI symptoms predominate: cramping, abdo pain, explosive diarrhea, nausea, vomiting Late- occurs 2-4 hours after meal -get a big insulin spike and hypoglycemic after the big osmolar meal dump -adrenergic symptoms predominate: flushing, sweating, shaking

Question 4

How do you diagnose dumping syndrome?

Answer 4

history is consistent -nuclear medicine- Tc labelled gastric emptying study- eat radioactive eggs, look for rapid transit through stomach and intestine

Question 5

How do you treat dumping syndrome?

Answer 5

First line: change dietary habits- separate solids and liquids, frequent small meals, low carb meals (limit simple sugars), high protein and fat foods (fibre delays gastric emptying) Second line: Octreotide (if dietary modifications not helpful), short acting or long acting forms Third line: Convert to RXY (if you had BII or BI)

Question 6

What is bile (alkaline) reflux gastritis? b) Classic triad

Answer 6

excessive reflux of bile (duodenal contents) into stomach -frequently found after BII

Key is removal or bypass of pyloric sphincter

-Clinical triad: postprandial epigastric pain, reflux bile into stomach, histologic evidence of gastritis -usually symptoms occur 1-3 years after gastrectomy

Question 7

How do you distinguish alkaline reflux gastritis from afferent loop syndrome?

Answer 7

bilious reflux mixed with food without relief of pain after vomiting

Question 8

How to diagnose alkaline reflux gastritis?

Answer 8

-HIDA- can show pooling of bile in stomach and scintigraphy may reveal lack of gastric emptying -Endoscopy- assess anastomosis and gastric remnant (erthyema, bile in stomach, thickened gastric folds, atrophy, petechiae are signs of reflux)

Question 9

Treatment of alkaline reflux gastritis?

Answer 9

RXY with long intestinal limb (>60 cm)

Question 10

Afferent loop syndrome?

Answer 10

occurs after BII reconstruction (gastrojejunostomy) -partial obstruction of afferent duodenojejunal limb, which is unable to empty its contents (could be due to kinked loop, anastomotic narrowing, adhesions, intussusception, rarely anastomotic ulceration) -also thought to be due to long afferent limb (to minimize this, try to keep afferent limb <12-15 cm) -can occur as early as 1-2 weeks post-op and up to 40 years post-op 1% of Billroth II gastrojejunostomies

Question 11

Mechanism of ALS?

Answer 11

Food gets stuck in afferent limb due to some kind of obstruction (secondary to adhesions, long afferent limb, anastomotic narrowing, etc) -food stimulates secretion of bile and pancreatic secretions -bilious vomiting once intraluminal pressure increases enough -acute ALS is one of main reasons for duodenal stump blowout!

Question 12

Diagnosis of afferent loop syndrome?

Answer 12

CT scan- see distended afferent limb Endoscopy- can see mucosal sequelae of alkaline reflux from afferent limb

Question 13

Management of afferent limb syndrome?

Answer 13

OR- prevent duodenal stump necrosis and blowout long afferent limb is usually the problem- can shorten it surgically -can convert into Roux-en-Y procedure

Question 14

Efferent loop syndrome?

Answer 14

refers to jejunal segment distal to gastrojejunostomy that drains succus entericus away from stomach -50% develop within first month -obstruction could be due to any number of causes: adhesions, anastomotic strictures, retroanastomotic herniation in mesocolon

Question 15

Treatment?

Answer 15

like a SBO- if adhesive if require OR- retroanastomotic hernia reduction, close retroanastomotic space lyse adhesions, revise anastomosis RXY

Question 16

What are the metabolic disturbances you get with post gastrectomy?

Answer 16

Acronym: FIB (folate, iron, B12)

Iron- lack of absorption from decreased acid secretion, decreased intrinsic factor production from parietal cells (also produce HCl) found in fundus/body of stomach and also bypass of duodenum (usual spot of Fe absorption)

Vitamin B12- due to loss of intrinsic factor which is required to absorb B12

Folate- first site of absorption is duodenum- you bypass this in gastric resection

Calcium and Vitamin D- unknown mechanism, delayed complication usually 4-5 years after surgery

Question 17

How do you get delayed gastric emptying post gastrectomy?

Treatment?

Answer 17

with selective or truncal vagotomy, patients lose antral pump function and have reduced ability to empty solids

decreased motility problem after vagotomy

Treatment: medical- Metoclopramide, Erythromycin

Question 18

Bacterial overgrowth syndrome in post gastrectomy?

Answer 18

aka blind loop syndrome, small intestinal bacterial overgrowth (SIBO)

chronic obstruction in afferent limb causes bacterial stasis and overgrowth; bacteria can bind with B12 and deconjugated bile acids

Question 19

Small gastric remnant (early satiety syndrome)?

Answer 19

small gastric reservoir- get full easily, also from vagotomy resulting in loss of receptive relaxation and accommodation

-get epigastric pain from distension soon after eating

>80% of stomach removed is usual tipping point for symptoms

Treatment: small frequent meals

Question 20

Retained gastric antrum?

Answer 20

Rare condition, occurring in Billroth II gastrectomised patients, in which an ulcer recurs associated with high levels of circulating gastrin

-can occur if you divided stomach on wrong side of pylorus

Work-up: look at fasting serum gastrin levels (may be slightly elevated)

• Technetium study: shows retained antrum
• Secretin stimulation test: serum gastrin levels should fall, but in Zollinger Ellison syndrome, autonomous gastrin secretion so gastrin levels remain high

Treatment- Surgery: remove remaining antrum