Tirzepatide for refractory post-fundoplication dumping syndrome: A case report

Table 3 Timeline of clinical course from symptom onset through tirzepatide treatment and follow-up

Time point	Clinical phase	Key clinical & diagnostic details	Surgical context	Tirzepatide dose	Symptom status	BMI (kg/m2)
4 years prior	Index surgery	Laparoscopic paraesophageal herniorrhaphy for hiatal hernia and reflux	Toupet 270° fundoplication	N/A	Reflux symptoms present	36
Approximately 3.5 years prior (6 months post-procedure)	Symptom onset	Postprandial abdominal discomfort, diarrhea, generalized weakness, hunger pain; reflux improved	Post-fundoplication	N/A	DS symptoms (8-9/10)	36
3 months prior	Initial evaluation	Persistent symptoms despite dietary modification and proton pump inhibitor therapy	Post-fundoplication	N/A	DS symptoms (8-9/10)	36
2 months prior	Diagnostic work-up	CT abdomen/pelvis unremarkable; endoscopy with wireless pH showed intact fundoplication and reduced acid exposure (1.6%); gastric emptying study confirmed rapid emptying	Post-fundoplication	N/A	DS symptoms (8-9/10)	36
Month 0	Diagnosis & treatment initiation	Dumping syndrome diagnosed; tirzepatide initiated for obesity management	Post-fundoplication	2.5 mg weekly	Improving DS symptoms (6/10)	36
Month 2 (week 8)	Dose escalation	Dose increased due to good tolerability and partial symptom response	Post-fundoplication	5 mg weekly	Minimal DS symptoms (2/10)	34-35
Months 3-7	Maintenance phase	Continued therapy with progressive weight loss	Post-fundoplication	5 mg weekly	Minimal DS symptoms (1-2/10)	26-34
Month 7	Target BMI achieved	Approximately 50-lb weight loss achieved; target BMI reached	Post-fundoplication	5 mg weekly	Minimal DS symptoms (1-2/10)	26
Months 8-9	Dose tapering & discontinuation	Gradual dose reduction and discontinuation; symptoms gradually recurred despite stable weight	Post-fundoplication	5 mg to 2.5 mg to 0 mg	Progressive DS symptoms (2-6/10)	26 (stable)
Month 9	Post-discontinuation reassessment	Repeat endoscopy unremarkable; full symptom recurrence with stable BMI	Post-fundoplication	0 mg	Severe DS symptoms (8/10)	26.5 (stable)
Month 11	Treatment reinitiation	Tirzepatide restarted at lower maintenance dose	Post-fundoplication	2.5 mg weekly	Improving DS symptoms (2-6/10)	26 (stable)
Months 12-20	Follow-up/sustained remission	Sustained symptom resolution at 3- and 6-month follow-up; no adverse effects	Post-fundoplication	2.5 mg weekly	Minimal DS symptoms (1-2/10)	26 (stable)

BMI: Body mass index; N/A: Not available; DS: Dumping syndrome; CT: Computed tomography.