MEDizzy - A 65-year-old man presented to the hospital 2 weeks ago with

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A 65-year-old man presented to the hospital 2 weeks ago with an acute abdomen, hypotension, anemia, and respiratory failure. His past medical history was notable for hypertension and hypercholesterolemia for which he took enalapril and atorvastatin. At laparotomy, he was found to have a perforated duodenal ulcer with peritonitis and hemoperitoneum. A vagotomy and Billroth I anastomosis were performed. He has improved gradually and is increasing his oral intake and ambulation. His white blood cell (WBC) count and hemoglobin are normal. This afternoon approximately 3 hours after lunch, he reported the acute onset of lightheadedness, confusion, palpitations, and diaphoresis. His temperature is 36.0°C, heart rate is 110 bpm, blood pressure is 120/70 mmHg, and oxygen saturation is 95% on room air. Which of the following is most likely present?

ExplanationSurgical intervention in PUD can be viewed as being either elective, for the treatment of medically refractory disease, or as urgent/emergent, for the treatment of an ulcer-related complication. The development of pharmacologic and endoscopic approaches for the treatment of PUD and its complications has led to a substantial decrease in the number of operations needed for this disorder, with a decrease of over 90% for elective ulcer surgery over the last four decades. Refractory ulcers are an exceedingly rare occurrence. Surgery is more often required for the treatment of an ulcer-related complication. Free peritoneal perforation occurs in ~2%–3% of DU patients. As in the case of bleeding, up to 10% of these patients will not have antecedent ulcer symptoms. Concomitant bleeding may occur in up to 10% of patients with perforation, with mortality being increased substantially. The procedure that provides the lowest rates of ulcer recurrence (1%) but has the highest complication rate is vagotomy (truncal or selective) in combination with antrectomy. Antrectomy is aimed at eliminating an additional stimulant of gastric acid secretion, gastrin. Two principal types of anastomoses are used after antrectomy: gastroduodenostomy (Billroth I) and gastrojejunostomy (Billroth II). Dumping syndrome consists of a series of vasomotor and GI signs and symptoms and occurs in patients who have undergone vagotomy and drainage (especially Billroth procedures). Two phases of dumping, early and late, can occur. Early dumping takes place 15–30 minutes after meals and consists of crampy abdominal discomfort, nausea, diarrhea, belching, tachycardia, palpitations, diaphoresis, light-headedness, and, rarely, syncope. These signs and symptoms arise from the rapid emptying of hyperosmolar gastric contents into the small intestine, resulting in a fuid shift into the gut lumen with plasma volume contraction and acute intestinal distention. The release of vasoactive GI hormones (vasoactive intestinal polypeptide, neurotensin, motilin) is also theorized to play a role in early dumping. The late phase of dumping typically occurs 90 minutes to 3 hours after meals. Vasomotor symptoms (light-headedness, diaphoresis, palpitations, tachycardia, and syncope) predominate during this phase. This component of dumping is thought to be secondary to hypoglycemia from excessive insulin release. Dumping syndrome is most noticeable after meals rich in simple carbohydrates (especially sucrose) and high osmolarity. Ingestion of large amounts of fluids may also contribute. Up to 50% of postvagotomy and drainage patients will experience dumping syndrome to some degree early on. Signs and symptoms often improve with time, but a severe protracted picture can occur in up to 1% of patients. Although this patient is certainly at risk of pulmonary embolism and myocardial infarction, his symptoms are typical of hypoglycemia due to dumping syndrome.