Effect of Insulin on the Dumping Syndrome

Abstract

The dumping syndrome is the commonest cause of distress after partial gastrectomy, and may also occur after total gastrectomy, after gastro-enterostomy, and after pyloroplasty. For many years it has been known that if patients with this syndrome drink a hypertonic solution of glucose their usual post-cibal symptoms will be provoked (Machella, 1949 al., 1960), and this observation was later repeated with a similar nmeal preceded by a suitably adjusted dose of insulin. On each occasion the test was performed between 8 and 9 a.m., with the patient sitting at a table, having taken nothing by mouth for the previous 12 hours. A precisely similar meal was served to each patient. In five instances, at the first test the patients were persuaded and cajoled into eating as much as they possibly could, despite the onset of symptoms which would normally have caused them to stop eating: fro.m the amount of food left their intake was then calculated, and at the second test they were given exactly what they had eaten on the first occasion. The other two patients were allowed to eat as much as they wanted on each occasion.The results are set out in detail in Table I. In all seven patients the first meal provoked marked typical dumping symptoms, whereas after the second meal these symptoms were either absent or greatly reduced. In all seven patients the fall in plasma volume after the second meal was smaller than after the first (t=7.95; P<O.001). A typical result is shown in Fig.

Predicting the dumper.

“…Increased motility of the small bowel was later observed,3 4 and stretching of the unsupported gastric remnant has also been shown to produce symptoms.' 6 A reduction in plasma volume occurs, after eating, in most patients who have undergone partial gastrectomy7 8 whether they have severe postcibal symptoms or not. Similar changes are observed in normal persons when hypertonic glucose is instilled into the duodenum.9 This reduction in plasma volume almost certainly results from the passage of fluid into the gut lumen to establish iso-osmolarity.…”

“…If they are successful there is a change in distribution of unbound bilirubin, and it may in consequence pass into the brain, causing kernicterus. It has been observed in premature infants that sulphafurazole (sulfisoxazole) reduces the concentration of plasma bilirubin and at the same time increases the incidence of kernicterus.4 Likewise, jaundice may follow treatment with novobiocin because it competes with bilirubin for the limited amount of glucuronyl transferase in the liver of the newborn baby.5 6 The readily absorbable sulphonamides traverse the inflamed blood-brain barrier in high concentration, so they have been popular in the treatment of meningococcal meningitis. In relation to a blood level of unity the levels in the cerebrospinal fluid and bile are about the same, whereas in serous cavities and the placenta they are about one-half.…”

Surgical treatment of duodenal ulceration.

“…A. Williams,' in a most detailed study, point out the high incidence of impaired nutrition and anaemia,3 4 loss of weight, and occasional osteomalacia as sequels to gastrectomy, while about 10% of patients who have undergone the operation suffer such unpleasant and persistent syndromes as vomiting of bile and " dumping." Attempts to overcome the last by treatment with insulin' 6 and tolbutamide7 have been reported. Subacute combined degeneration of the cord is also known.8 The recognition and treatment of pulmonary disorders after these operations was discussed in this journal two weeks ago by K. N. V. Palmer and A. J. S. Gardiner.9…”