Gastric dumping syndrome differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Umar Ahmad, M.D.[2]

Overview

Dumping syndrome may often be confused with other similar diseases that cause upper abdominal pain, nausea, and fatigue.

Differentiating from other Diseases

Diseases with similar symptoms

• Postgastrectomy complications:
  • Postvagatomy diarrhea
  • Small capacity syndrome
  • Short bowel syndrome
  • Afferent loop syndrome
  • Efferent loop syndrome
• Peptic ulcer disease
• Fistula
• Adhesion
• Stenosis
• Ischemia
• Gastritis
• Hernia
• Insulinoma
• Glucose-lowering medication abuse
• Symptomatic gallstone disease
• Postprandial Hypotension
• Short bowel syndrome
• Irritable bowel syndrome (IBS)

Differential Diagnosis of Dumping Syndrome based on Postvagotomy complications symptoms:

The differential diagnosis of dumping syndrome is based on the early dumping syndrome timeline.They are the following:

Differential Diagnosis for Postgastrectomy complications	Clinical features	Diagnosis
Small-capacity syndrome	Early satiety, malnutrition, weight loss	Clinical diagnosis with a history of surgery
Afferent loop syndrome	Upper abdominal pain, early satiety, relief after vomiting	Ultrasound, Barium enema
Efferent loop syndrome	Upper abdominal pain, distention, vomiting	CT scan, Upper GI series
Postvagotomy diarrhea	Diarrhea	Clinical diagnosis with a history of surgery
Short bowel syndrome	Upper abdominal pain, diarrhea, malnutrition, weight loss	LFTs, liver biopsy, Upper GI series, CT scan

Differential Diagnosis of Dumping Syndrome based on Early Dumping Syndrome symptoms:

The differential diagnosis of dumping syndrome is based on the early dumping syndrome timeline They are as follows:

Differential Diagnosis for Postgastrectomy complications	Clinical features	Diagnosis
Small-capacity syndrome	Early satiety, malnutrition, weight loss	Clinical diagnosis with a history of surgery
Afferent loop syndrome	Upper abdominal pain, early satiety, relief after vomiting	Ultrasound, Barium enema
Efferent loop syndrome	Upper abdominal pain, distention, vomiting	CT scan, Upper GI series
Postvagotomy diarrhea	Diarrhea	Clinical diagnosis with a history of surgery
Short bowel syndrome	Upper abdominal pain, diarrhea, malnutrition, weight loss	LFTs, liver biopsy, Upper GI series, CT scan

Differential Diagnosis of Dumping Syndrome based on Late Dumping Syndrome symptoms:

The differential diagnosis of dumping syndrome is based on the early dumping syndrome timeline.They are as follows:

Differential Diagnosis for Diarrhea predominant symptoms	Clinical features	Diagnosis
Crohn's disease	Diarrhea, abdominal pain	Colonoscopy, small bowel barium radiograph, CT enterography, magnetic resonance enterography
Ulcerative colitis	Present with abdominal pain, tenesmus, have diarrhea and rectal bleeding	Colonoscopy
Microscopic colitis	Watery diarrhea with nocturnal symptoms	Colonoscopy, flexible sigmoidoscopy and biopsy
Celiac disease	Diarrhea, steatorrhea, anemia	Endoscopy with small bowel biopsy, Tissue transglutaminase antibody
Neuroendocrine tumor	Gastrinoma, Carcinoid and VIP producing tumor	Urine 5HIAA, fasting gastritis(followed by secretin stimulation test), serum VIP
Hyperthyroidism	Increased appetite, insomnia, diarrhea, palpitations, heat intolerance, increased sweating	Serum TSH levels
Lactose intolerance	Flatulence, bloating with lactose consumption	Avoidance trial, lactose breath test
Infectious causes	Abdominal discomfort, diarrhea especially in the setting of recent travel	Stool for ova and parasites, stool Giardia antigen, stool culture, trial of metronidazole
Small bowel bacterial overgrowth	Bloating, diarrhea, abdominal distension	Jejunal aspirate, lactulose breath hydrogen test, antibiotic trial
Clostridium difficile infection(Psuedomembranous colitis)	Recent antibiotic treatment	Stool Polymerase Chain reaction

The diffrentials of chronic watery diarrhea are as follows:

Differential diagnosis of abdominal pain

The differential diagnosis based on abdominal pain are as follows:

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs The following is a list of diseases that present with acute onset severe lower abdominal pain: Disease Findings Ectopic pregnancy History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes. Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%. Ruptured ovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic. Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic. Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic. Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic. Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain. References