Post gastrectomy syndromes Flashcards
What is the post gastrectomy syndrome?
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
Name the post gastrectomy syndromes.
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
What is dumping syndrome?
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
How do you diagnose dumping syndrome?
history is consistent -nuclear medicine- Tc labelled gastric emptying study- eat radioactive eggs, look for rapid transit through stomach and intestine
How do you treat dumping syndrome?
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)
What is bile (alkaline) reflux gastritis? b) Classic triad
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
How do you distinguish alkaline reflux gastritis from afferent loop syndrome?
bilious reflux mixed with food without relief of pain after vomiting
How to diagnose alkaline reflux gastritis?
-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)
Treatment of alkaline reflux gastritis?
RXY with long intestinal limb (>60 cm)
Afferent loop syndrome?
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
Mechanism of ALS?
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!
Diagnosis of afferent loop syndrome?
CT scan- see distended afferent limb Endoscopy- can see mucosal sequelae of alkaline reflux from afferent limb
Management of afferent limb syndrome?
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
Efferent loop syndrome?
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
Treatment?
like a SBO- if adhesive if require OR- retroanastomotic hernia reduction, close retroanastomotic space lyse adhesions, revise anastomosis RXY
What are the metabolic disturbances you get with post gastrectomy?
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
How do you get delayed gastric emptying post gastrectomy?
Treatment?
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
Bacterial overgrowth syndrome in post gastrectomy?
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
Small gastric remnant (early satiety syndrome)?
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
Retained gastric antrum?
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
