A 34-year-old woman comes to the office with dizzy spells. The patient had uncomplicated Roux-en-Y gastric bypass surgery 6 weeks ago. She has abdominal pain, nausea, diarrhea, and lightheadedness with palpitations 15-20 minutes after meals. Her symptoms are occasionally accompanied by profuse sweating. The patient has lost 3.6 kg (8 lb) since the surgery. She had type 2 diabetes mellitus before the operation. Her current medications include multivitamins and iron supplements.
Temperature is 36.7 C (98 F), blood pressure is 112/70 mm Hg, and pulse is 78/min. Physical examination is notable for an overweight woman in no acute distress. The abdomen shows well-healed surgical scars but is otherwise unremarkable. Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 34-year-old woman comes to the office with dizzy spells.  The patient had uncomplicated Roux-en-Y gastric bypass surgery 6 weeks ago.  She has abdominal pain, nausea, diarrhea, and lightheadedness with palpitations 15-20 minutes after meals.  Her symptoms are occasionally accompanied by profuse sweating.  The patient has lost 3.6 kg (8 lb) since the surgery.  She had type 2 diabetes mellitus before the operation.  Her current medications include multivitamins and iron supplements.
Temperature is 36.7 C (98 F), blood pressure is 112/70 mm Hg, and pulse is 78/min.  Physical examination is notable for an overweight woman in no acute distress.  The abdomen shows well-healed surgical scars but is otherwise unremarkable.  Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_981a_9849_853d_27ec542bcc76_MD0002_00 This patient likely has dumping syndrome, which occurs in up to 50% of patients after Roux-en-Y gastric bypass (RYGB) surgery. Dumping syndrome is subdivided into early or late based on the timing and etiology of postprandial symptoms. This patient's presentation is consistent with early dumping syndrome given the sudden onset of abdominal pain, diarrhea, and nausea within 15-30 minutes of eating. This is a consequence of rapid emptying of hypertonic gastric contents into the small intestine. Hypotension and tachycardia may also occur due to rapid fluid shifts between the plasma and high osmolality in the bowel. Roux-en-Y gastric bypass (RYGB) surgery In contrast, late dumping syndrome occurs 2-3 hours after eating and may present with dizziness/confusion, fatigue, and diaphoresis due to hypoglycemia (Choice B). Patients are initially hyperglycemic due to the speedy transit and absorption of simple carbohydrates in the small intestine; however, this is then countered by a surge of insulin causing hypoglycemia. Severe postprandial hypoglycemia may result in loss of consciousness or seizure. The initial management for both early and late dumping syndrome includes eating small/frequent meals, replacing simple sugars with complex carbohydrates, and incorporating high-fiber and protein-rich foods in the diet. (Choice C) Internal hernia (eg, through the transverse mesocolon) may complicate up to 5% of RYGB surgeries but usually presents with abdominal pain, small-bowel obstruction, and/or strangulation. (Choice D) Short bowel syndrome can occur after massive resection of the small bowel. Patients usually have malabsorptive diarrhea with nutrient deficiencies, dehydration, and weight loss. Sudden postprandial abdominal pain with dizziness/palpitations is not characteristic. (Choice E) Stomal stenosis can complicate 6%-20% of RYGB surgeries; however, patients typically present with nausea/vomiting, gastrointestinal reflux, and dysphagia several weeks after the procedure. Educational objective: Dumping syndrome is a common complication of Roux-en-Y gastric bypass surgery. Early dumping syndrome is characterized by abdominal pain, diarrhea, nausea, and hypotension/tachycardia 15-30 minutes after eating. Late dumping syndrome presents with symptoms of hypoglycemia (eg, dizziness/confusion, fatigue, diaphoresis) 2-3 hours after eating. __________ References: Pathophysiology, diagnosis and management of postoperative dumping syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19724252)

A 34-Year-Old Woman Comes to the Office with Dizzy Spells