A 59-year-old man comes to the office for postoperative follow-up. He underwent a partial (distal) gastrectomy for a perforated peptic ulcer 3 weeks ago. The patient also received an extended course of antibiotics, with the last dose taken 2 weeks ago. For the past 10 days, he has had intermittent abdominal cramps and diarrhea. Symptoms begin 20-30 minutes after the patient eats and are associated with nausea, weakness, palpitations, light-headedness, and diaphoresis. He has no symptoms overnight, and there is no associated fever or weight loss. Medical history is notable for hypertension. The patient has a 20-pack-year smoking history but quit after the recent hospitalization. Temperature is 36.7 C (98 F), blood pressure is 130/65 mm Hg, pulse is 80/min, and respirations are 18/min. BMI is 26 kg/m². On examination, the abdomen is soft and nontender with normal bowel sounds. The surgical wound is healing well and has no erythema or discharge. Cardiopulmonary examination is normal. Complete blood count is normal. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec25c8_d8ec_3c37_bc81_f3b779b7178a_MD0003_00 This patient has typical clinical features of early dumping syndrome (DS), including gastrointestinal (eg, nausea, diarrhea, abdominal cramps) and vasomotor (eg, palpitations, diaphoresis) symptoms. DS is a common postgastrectomy complication, occurring in up to 50% of patients. It is caused by loss of the normal action of the pyloric sphincter due to injury or surgical bypass and leads to rapid emptying of hypertonic gastric contents into the duodenum and small intestine. This causes fluid shifts from the intravascular space to the small intestine, leading to hypotension, stimulation of autonomic (sympathetic) reflexes, and release of intestinal vasoactive polypeptides. The diagnosis of DS is based primarily on clinical features, although an upper gastrointestinal x-ray series or gastric emptying studies may be helpful if the diagnosis is unclear (Choice E). The following dietary modifications are recommended for most patients: Consume small, frequent meals, and eat slowly Avoid simple sugars Increase fiber and protein intake Drink fluids between rather than during meals Symptoms of DS usually diminish over time. A minority of patients with refractory symptoms may benefit from a trial of octreotide or require reconstructive surgery, but this is uncommon (Choice C). (Choice B) Endoscopy would confirm the postsurgical anatomy but would not otherwise contribute to the diagnosis of DS. (Choice D) This patient has no fever or leukocytosis to suggest antibiotic-associated colitis, and the postprandial onset of gastrointestinal and vasomotor symptoms with resolution overnight is more consistent with DS. Many patients (20%) are carriers of Clostridioides difficile, and false-positive results can occur with highly sensitive PCR tests, which do not differentiate toxin-producing from non-toxin-producing organisms; testing should be used only in the appropriate clinical context (eg, profuse watery diarrhea with an elevated white blood cell count). Educational objective: Dumping syndrome is a common postgastrectomy complication characterized by gastrointestinal (eg, nausea, diarrhea, abdominal cramps) and vasomotor (eg, palpitations, diaphoresis) symptoms. The diagnosis is primarily clinical. The symptoms can be controlled with dietary modification (eg, avoiding simple sugars) and usually diminish over time.

A 59-Year-Old Man Comes to the Office for Postoperative Follow-Up