Bev's sCARE page - Postgastrectomy Syndrome


- - - - -		DISCLAIMER: The information contained and presented herein is intended for informational purposes only. It has been researched as thoroughly as possible, but it should not and cannot replace the advice or care of a physician or other qualified medical professional. We are not doctors and do not assume responsibility for any inaccuracy of information presented anywhere in this website, nor do we aim to diagnose or treat. Consult your doctor for specific concerns; each individual case is unique and must be treated accordingly. The following information has been reproduced with permission from the Twin Cities District Dietetic Association Manual of Clinical Nutrition, 4th edition, 1994. POSTGASTRECTOMY SYNDROME Scroll down or click on the links to read more about aspects of postgastrectomy syndrome: small stomach syndrome, dumping syndrome (early postprandial and late postprandial), weight loss, malabsorption syndrome, change in bowel habits, iron-deficiency anemia, vitamin B-12 deficiency anemia, bezoars, metabolic bone disease, and milk intolerance. Click here for postgastrectomy syndrome diet guidelines. Small Stomach Syndrome This syndrome is associated with symptoms such as an unpleasant feeling of fullness and abdominal distention. Nausea, vomiting, and gastric delay may occur. The syndrome occurs secondary to a decreased stomach reservoir and possibly from an inflamed gastric outlet which may result from postoperative recovery. Over time, the reservoir (or pouch) should enlarge from stretching, and the syndrome may spontaneously resolve itself. Nutritional Guidelines Eat small, frequent meals (six or more feedings per day is common) Sip liquids between meals - quick consumption may cause vomiting Eat slowly Sit up when eating, using gravity as an aid Eat nutrient-dense foods since total quantity of foods is limited Dumping Syndrome - Early Postprandial Subjective symptoms include an unpleasant feeling of fullness, excessive heart rate, diarrhea, abdominal distention, weakness, cold sweat (especially on the forehead), sensation of warmth and/or chilliness, and sometimes flushing. Symptoms usually occur during the meal or 10 to 15 minutes after eating. They consist of feelings of pressure, sounds of rumbling and movement, and some epigastric pain. The reason for dumping is thought to be due to rapid gastric emptying of foodstuffs into the jejunum (intestine), resulting in diarrhea. The syndrome is seen especially when concentrated carbohydrates are consumed - these tend to create a hyperosmotic environment in the intestine. Fluid is then pulled from the tissues into the intestine, causing a decrease in plasma volume in the blood. This accounts for the systemic symptoms. The high fluid volume and rapid transit time in the intestine result in the diarrhea. Certain humoral agents (serotonin, bradykinin, enteroglucagon, prostaglandin) are being researched for their relationship to a possible cause of dumping. Nutritional Guidelines Limit concentrated carbohydrates (e.g., cookies, cake, syrup) Include a moderate fat intake (40 to 40% of toal calories). Fat tends to retard gastric emptying and can be a good calorie source if weight loss is a concern Protein intake should be at least 20% of total calories. Protein is needed for tissue repair and can supply energy. Include some protein in each meal Eat smaller, more frequent meals (6 or more feedins per day) Eat slowly Consuming fluids (slowly) between meals may be helpful. Waiting at least 30 minutes to drink fluids after eating a meal may slow intestinal transit time. Low-carbohydrate beverages are preferable Moderate temperatures may be tolerated better than extreme hot or cold temperatures. Cold drinks may contribute to increased gastric motility Dumping Syndrome - Late Postprandial (alimentary hypoglycemia) Alimentary hypoglycemia may develop 1.5 to 3 hours after eating. Gastrointestinal disturbances are not involved. The symptoms experienced are weakness, hunger, perspiration, nausea, anxiety, and tremors. The syndrome results from rapid digestion and absorption of foodstuffs, especially of carbohydrate, in the intestine, which causes a rapid rise in blood sugar. This leads to increased insulin secretion. The end result is a fall in the blood glucose levels from insulin's action causing hypoglycemia. Nutritional Guidelines Eliminate concentrated sweets Eat small, frequent meals (6 or more per day) Eat protein foods throughout the day Concentrated carbohydrates may be helpful in alleviating an attack once it is occurring, because sugar will help raise the low blood glucose quickly. For example, drink a small glass of juice, or eat hard candy Weight Loss After surgery, weight loss is very common. Weight loss can be attributed to a small dietary intake secondary to the small storage capacity of the stomach and a rapid feeling of satiety. Malabsorption may also be a factor in weight loss. Nutritional Guidelines Eat small, frequent meals Drink high-calorie liquids between meals, as tolerated. Use non-dairy liquids if required A vitamin/mineral supplement should be considered Malabsorption Syndrome Surgery may cause anatomic changes that affect the availability of bile and pancreatic enzymes. There may be a lack of coordination between gastric emptying, gallbladder secretions, and pancreatic secretions. This may result in an inadequate mixing of food and enzymes. There may also be rapid upper intestinal transit, which may result in defective digestion of foodstuffs. If the duodenum (upper small intestine) is bypassed (Billroth II), absorption of iron and calcium are initially decreased, since the duodenum is their major absorption site. In time, the remainder of the intestine will absorb these two minerals. Steatorrhea is the malabsorption of fats (frequent, bulky, pale-colored, floating stools), which results in loss in fat-soluble vitamins, calcium, zinc, magnesium, and iron. Nutritional Guidelines High-protein intake Limit fat intake. The amount of restriction depends on the severity of the malabsorption of fat Medium-chain triglyceride supplementaion may be appropriate if weight loss is a concern Vitamin/mineral supplementation Change in Bowel Habits A change in bowel function after surgery can range from severe diarrhea to constipation. Nutritional Guidelines Small, frequent feedins and fluids between meals may be helpful for mild diarrhea Increasing dietary fiber intake can be helpful for both mild diarrhea and constipation. Increase fluid intake when increasing fiber Anemia Different types of anemias can be seen as a late complication of gastrectomy surgery. It may be several years before anemic is noticed. The incidence and degree of anemia varies. Iron-deficiency anemia can result from nondietary factors (e.g., bleeding from recurrent ulcers or further surgery) or from inadequate food intake, impaired iron absorption, or bypass of the duodenum (absorption site). Lack of gastric acid and decreased mixing of acid with the food prevents proper absorption. Vitamin B-12 deficiency results when there is not enough intrinsic factor (found in the stomach), which is essential for Vitamin B-12 absorption in the lower small intestine. Bacterial overgrowth in part of the intestine that is not used (afferent loop) competes with the Bitamin B-12 absorption. This can contribute to the deficiency. Nutritional Guidelines - Iron-deficiency anemia Eat foods high in iron. A Vitamin C source will help with iron absorption. Liver, beef, and green vegetables are good iron sources Oral (inorganic iron salts) or parenteral supplementation may be indicated Nutritional Guidelines - Vitamin B-12 deficiency This is best treated with intramuscular B-12 injections Nutritional Guidelines - Folacin deficiency Eat folacin-containing foods like liver, green leafy vegetables, and nuts Vitamin supplementation may be indicated Bezoars Phytobezoars (formed from plant fibers) can result from decreased gastric motility, decreased mixing and churning in the stomach, delayed gastric emptying, and reduced gastric secretions. Nutritional Guidelines Digestive agents (papain, cellulese, pancreatic enzymes) can be used in treating gastric phytobezoars Limit intake of oranges, persimmons, coconut, berries, green beans, figs, apples, sauerkraut, brussel sprouts, and potato peelings Metabolic Bone Disease Osteomalacia and osteoporosis (softening of the bones) may occur after many years following certain types of gastric surgery. It is most commonly seen with total gastrectomies. It will be important to consume adequate ammounts of calcium-containing foods. Otherwise, supplementation with Vitamin D and calcium may be necessary. Milk Intolerance There are several reasons that people do not drink milk including dislike for the taste and gastrointestinal upset (bloating, diarrhea, et cetera). Milk may not be tolerated postoperatively owing to lactose intolerance (the body's failure to break down the sugar in milk to absorb it) or to inadequate breakdown of casein (milk protein) owing to lack of digestive enzymes, lack of gastric acid, and other factors. A person's tolerance for milk should be tested, and if it is well tolerated, milk can slowly be added to the diet. Milk is a great source of protein, calcium, and Viatmin D. Once bowel function resumes postoperatively, it will be important to slowly advance dietary intake and not overburden the gastrointestinal system. It must be remembered that each patient should be evaluated individually, because food tolerance can vary greatly. Many patients, over time, can enjoy a regular diet.