Gastric dumping syndrome diagnostic study of choice

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Gastric dumping syndrome Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Gastric dumping syndrome from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
X Ray
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Gastric dumping syndrome diagnostic study of choice On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Gastric dumping syndrome diagnostic study of choice All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Gastric dumping syndrome diagnostic study of choice
CDC on Gastric dumping syndrome diagnostic study of choice
Gastric dumping syndrome diagnostic study of choice in the news
Blogs on Gastric dumping syndrome diagnostic study of choice
Directions to Hospitals Treating Gastric dumping syndrome
Risk calculators and risk factors for Gastric dumping syndrome diagnostic study of choice

Overview

• The page name should be "Diagnostic study of choice for [disease name]", with only the first letter of the title capitalized. Note that the page is called "Diagnostic study of choice."
• Goal:
  • To describe the most efficient/sensitive/specific test that is utilized for diagnosis of [disease name].
  • To describe the gold standard test for the diagnosis of [disease name].
  • To describe the diagnostic criteria, which may be based on clinical findings, physical exam signs, pathological findings, lab findings, findings on imaging, or even findings that exclude other diseases.
• As with all microchapter pages linking to the main page, at the top of the edit box put {{CMG}}, your name template, and the microchapter navigation template you created at the beginning.
• Remember to create links within WikiDoc by placing [[square brackets]] around key words which you want to link to other pages. Make sure you makes your links as specific as possible. For example, if a sentence contained the phrase anterior spinal artery syndrome, the link should be to anterior spinal artery syndrome not anterior or artery or syndrome. For more information on how to create links, click here.
• Remember to follow the same format and capitalization of letters as outlined in the template below.
• You should include the name of the disease in the first sentence of every subsection.

Diagnostic Study of Choice

Population at risk

Dumping syndrome should be suspected based on the concurrent presentation of multiple suggestive symptoms in patients who have undergone gastric or esophageal surgery [1]. A carefully obtained medical history and thorough symptom evaluation are very important for the accurate diagnosis of dumping syndrome. Profound fatigue after meal ingestion, with the need to lie down, is an important clinical clue. Various approaches can be used to confirm the presence of dumping syndrome, including symptom-based questionnaires, glycemia monitoring, oral glucose challenge testing and gastric emptying studies. An additional diagnostic evaluation may also be necessary to exclude conditions that can present with similar symptoms (e.g. postoperative complications, strictures, adhesions and insulinoma). Hypoglycemia unawareness may develop as a result of recurrent hypoglycemia, making it even more difficult to diagnose late dumping syndrome in patients who have undergone gastric bypass surgery [20]. Symptom-based questionnaires

Symptom-based questionnaires, such as the Sigstad's score and the Arts' dumping questionnaire can be used to identify patients with clinically meaningful dumping symptoms. Sigstad's score was developed to separate patients with or without postoperative dumping syndrome in the era of peptic ulcer surgery [17], while Arts' dumping questionnaire was designed to differentiate between early and late dumping symptoms. The Sigstad's scoring system assigns points to each dumping symptom, and the total points are used to calculate a diagnostic index [31]. A diagnostic index >7 is suggestive of dumping syndrome whereas a score <4 suggests that other diagnoses should be considered. Patients receive an oral glucose tolerance test (OGTT) prior to using the Sigstad's scoring system to score and grade symptom severity. The primary focus of the Sigstad's scoring system is to identify early dumping by diagnosing signs and symptoms such as a high pulse rate or increased haematocrit indicative of hypovolemia. The diagnostic accuracy of the Sigstad's scoring questionnaire in bariatric patients or after upper GI cancer surgery has not been established [7]. Arts et al. developed a dumping-severity score in which symptoms of early and late dumping (eight and six symptoms, respectively) were scored on a 4-point Likert scale [15]. This questionnaire has been tested on patients with early and late dumping, and was shown to be effective at discriminating between the two sets of symptoms and was responsive to somatostatin analogue therapy, but was never formally validated [15]. A relatively recent report also describes the use of a visual analogue scale (VAS) survey to evaluate early and late dumping syndromes in more than 1,000 patients after gastrectomy for gastric cancer [32]. This survey used a very low cutoff for dumping complaints (VAS score >10 mm), and a single item on the questionnaire was sufficient to label patients as symptomatic for late dumping [32]. Glycemia measurements

Single plasma glucose measurements, whether scheduled or random, can be performed during clinic visits after gastric or esophageal surgery. Although the diagnostic value of a single glucose measurement is low, its clinical value increases when evaluated in conjunction with late dumping symptoms. To date, no definitive guidance regarding cutoff values for plasma glucose has been established, but some clinicians consider plasma glucose concentrations <2.8 mmol/L (50 mg/dL) to be indicative of post-gastric bypass hypoglycemia, whereas others regard levels <3.3 mmol/L (60 mg/dL) diagnostic of hypoglycemia [33]. Capillary glucose measurements (finger prick) are not considered valid because of their lack of accuracy in the hypoglycemic range. Continuous glucose monitoring may be beneficial in complex cases of dumping syndrome [34-36]. Provocative testing

Clinical suspicion of dumping syndrome can be confirmed using provocative tests such as the OGTT or mixed-meal tolerance test [37]. In the glucose tolerance test, patients with suspected dumping syndrome ingest 50 g or 75 g of glucose in solution after an overnight fast. Blood glucose concentrations, haematocrit, pulse rate and blood pressure are measured before and at 30-min intervals up to 180 min after ingestion. The OGTT is considered positive for early dumping based on the presence of an early (30 min) increase in haematocrit >3% or an increase in pulse rate >10 beats/min after 30 min, the latter being regarded as the most sensitive indicator of early dumping syndrome [1]. Test results are positive for late dumping based on the development of late (60–180 min postingestion) hypoglycemia [1]. In the mixed-meal tolerance test, patients with suspected dumping syndrome ingest a mixed meal containing carbohydrates, fats and proteins after an overnight fast [18, 38]. Blood samples are collected before meal ingestion and at 30-min intervals for up to 2 h afterward to monitor glycemic and insulin profiles. The mixed-meal tolerance test is considered positive for late dumping syndrome in patients who develop hypoglycemia between 60 and 180 min after meal ingestion.

The use of provocative testing to diagnose dumping syndrome is associated with several challenges. Provocative testing can be difficult in patients with small gastric pouches as a result of gastric or bariatric surgical procedures. Furthermore, the OGTT frequently detects post-gastric bypass hypoglycemia in patients with and without symptoms, as well as in healthy individuals [20]. Therefore, the diagnostic accuracy of this test is low and normative values have not been firmly established [20]. As a result, clinical practice guidelines for adult hypoglycemic disorders developed by the Endocrine Society do not support the use of the OGTT for diagnosing postprandial hypoglycemia [39]. The mixed meal tolerance test holds promise as a more physiologic stimulation test for the detection of post-gastric bypass hypoglycemia [20, 40]. Some studies demonstrate improved specificity of this test in asymptomatic patients; however, normative values have not been established for healthy individuals [20]. Further validation of the mixed meal tolerance test is needed in patients with and without hypoglycemia symptoms, as well as in healthy individuals. Because there is currently no optimal approach for the diagnosis of dumping syndrome, [20] provocative testing is still commonly used in some countries to diagnose hypoglycemia in the safety of a medical testing facility. Gastric emptying studies

The rate of gastric emptying may also be used to confirm a diagnosis of dumping syndrome. A gastric emptying scintigraphy test involves eating a bland meal that contains a small amount of radioactive material, and measuring the rate of gastric emptying at hourly intervals until 4 h after the meal. However, gastric emptying studies generally have low sensitivity and specificity, probably because the process of rapid gastric emptying occurs soon after ingestion, a phase that is not adequately assessed in most studies. Furthermore, the duration of the entire study of up to 4 h is integrated into a single value (half emptying time), which may neutralize the rapid initial emptying effect [3, 15, 37].

Gold standard/Study of choice:

• [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
• The following result of [gold standard test] is confirmatory of [disease name]:
  • Result 1
  • Result 2
• The [name of investigation] should be performed when:
  • The patient presented with symptoms/signs 1. 2, 3.
  • A positive [test] is detected in the patient.
• [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
• The diagnostic study of choice for [disease name] is [name of investigation].
• There is no single diagnostic study of choice for the diagnosis of [disease name].
• There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
• [Disease name] is mainly diagnosed based on clinical presentation.
• Investigations:
  • Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
  • Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
  • Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.

The comparison table for diagnostic studies of choice for [disease name]

	Sensitivity	Specificity
Test 1	✔	...%
Test 2	...%	✔

✔= The best test based on the feature

Diagnostic results

The following result of [investigation name] is confirmatory of [disease name]:

• Result 1
• Result 2

Sequence of Diagnostic Studies

The [name of investigation] should be performed when:

• The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
• A positive [test] is detected in the patient, to confirm the diagnosis.

Diagnostic Criteria

• Here you should describe the details of the diagnostic criteria.
• Always mention the name of the criteria/definition you are about to list (e.g. modified Duke criteria for diagnosis of endocarditis / 3rd universal definition of MI) and cite the primary source of where this criteria/definition is found.
• Although not necessary, it is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.
• Be very clear as to the number of criteria (or threshold) that needs to be met out of the total number of criteria.
• Distinguish criteria based on their nature (e.g. clinical criteria / pathological criteria/ imaging criteria) before discussing them in details.
• To view an example (endocarditis diagnostic criteria), click here
• If relevant, add additional information that might help the reader distinguish various criteria or the evolution of criteria (e.g. original criteria vs. modified criteria).
• You may also add information about the sensitivity and specificity of the criteria, the pre-test probability, and other figures that may help the reader understand how valuable the criteria are clinically.
• [Disease name] is mainly diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
• There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
• The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].

• [Disease name] may be diagnosed at any time if one or more of the following criteria are met:
  • Criteria 1
  • Criteria 2
  • Criteria 3

IF there are clear, established diagnostic criteria:

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
• The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
• The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

IF there are no established diagnostic criteria: 

• There are no established criteria for the diagnosis of [disease name].

References

• References should be cited for the material that you have put on your page. Type in {{reflist|2}}.This will generate your references in small font, in two columns, with links to the original article and abstract.
• For information on how to add references into your page, click here.