Scintigraphic Gastric Emptying Test Research Articles

Does the Solid Meal Utilized in a Standard Scintigraphic Gastric Emptying Test Induce Symptoms That Correlate With the Degree of Delayed Gastric Emptying in Patients With Gastroparesis?: Presidential Poster Award

Introduction: A debated question in gastroparesis (GP) is whether the severity of isotope retention determines the variance in symptoms. Hence, our aim was to assess if the severity of symptoms induced by a standard radiolabeled eggbeater meal could distinguish the categories of food retention in GP. Methods: Patients with symptoms suggesting an upper GI motility disorder underwent a scintigraphic gastric emptying (GE) test. GP patients were categorized as mild, moderate, severe and very severe based on percent isotope retention at 4 hrs: 10-20%, 20-35%, 35-50% and >50%, respectively. Symptoms of nausea, fullness, bloating and abdominal pain were graded from 0-4 (none, minimum, mild, moderate and severe) by questioning the patient prior to, immediately after the meal, and hourly over the 4 hrs. Adjusted association between GP severity and symptoms were assessed using repeated logistic regression analysis. Results: 103 GP patients were recruited, average age of 50 [range: 18 - 86] and 75% females. The gastric retention in the majority of the patients was mild (36%) and very severe patient (33%), followed by moderate (23%) and severe (8%). Of the 103 GP patients, 42% had diabetes (DM) with the very severe gastric retention group having the highest percentage of DM (45%). After adjusting for diabetes, moderate retention patients were more likely to experience more nausea and bloating symptoms (Figures 1 and 2) (OR: 2.03, p=0.108; OR: 2.27, p=0.08), while very severe were less likely to experience bloating and abdominal pain (OR: 0.47, p=0.09; OR: 2.43, p=0.06) when compared to the mild gastric retention group. Moreover, DM patients had a statistical increase in the likelihood of experiencing nausea over nondiabetics (OR: 1.17, p=0.104; OR: 1.98, p=0.04). Fullness increased postprandially with no significant differences observed among the groups<./p>420_A Figure 1. Nausea in GP patients across the 4-hr meal420_B Figure 2. Bloating in GP patients across the 4-hr mealConclusion: We conclude that after a standard GE test meal: 1) nausea and bloating best correlate with a moderate gastric retention severity status (20-35%) and postprandial fullness is increased in all retention categories; 2) DM patients had greater nausea sensitivity; 3) There is disparity between very severe gastric retention (>50%) and decreased symptom severity, particularly with abdominal pain. Explanations include a chronically distended antrum being unable discriminate postprandial symptoms, the eggbeater test meal is insufficient in volume to provoke symptoms, and both DM and non-DM etiologies impair gastric neurosensory function.

The role of incongruence between the perceived functioning by patients and clinicians in the detection of psychological distress among functional and motor digestive disorders

ObjectivesPrevious research on gastrointestinal and other medical conditions has shown the presence of incongruence between self- and clinician-reported functioning and its relation with psychopathology. The main objective of this study was to test whether inconsistencies between clinician- and self-assessed functionality can be used to detect psychopathology among patients diagnosed of motor or functional gastrointestinal disorders. MethodsOne hundred and three patients from a gastroenterology inpatient unit were included in this study. All patients underwent clinical assessment, including intestinal manometry, Rome III criteria for functional gastrointestinal disorders, and psychological and psychiatric evaluation. Patients with suspected gastroparesis underwent a scintigraphic gastric emptying test. Definitive diagnoses were made at discharge. ResultsPatients with higher levels of incongruence differed in various sociodemographic (age, educational level, work activity and having children) and psychopathological (all SCL-90-R subscales except anxiety and hostility) characteristics. Using general lineal models, incongruence was found to be the variable with stronger relations with psychopathology even when controlling for diagnosis. Interactions were found between incongruence and diagnosis reflecting a pattern in which patients with functional disorders whose subjective evaluation of functioning is not congruent with that of the clinician, have higher levels of psychopathology than patients with motor disorders. ConclusionsIncongruence between clinician and self-reported functionality seems to be related to higher levels of psychopathology in patients with functional disorders. These findings underscore the need for routine psychosocial assessment among these patients. Gastroenterologists could use the concept of incongruence and its clinical implications, as a screening tool for psychopathology, facilitating consultation-liaison processes.

Mo1316 Two Hour Gastric Emptying Radionuclide Scintigraphy is Associated With False Diagnosis of Gastroparesis in Children

Introduction: Gastroparesis is a rare motor and sensory disorder of the stomach resulting in delayed gastric emptying in the absence of mechanical obstruction. Symptoms include nausea, vomiting, early satiety, bloating, abdominal pain, and weight loss. There is a paucity of data about the prevalence and etiology of gastroparesis in children, but the most common etiologies are post-viral, idiopathic and autonomic dysfunction disorders. Four hour radionuclide scintigraphic gastric emptying (GE) study is the recommended diagnostic study for gastroparesis. Many centers perform only a 2 hour GE study. There have been no comparison studies between these twomethods in pediatric patients. Methods:We conducted a retrospective review of the Mayo Clinic electronic data between April 2005 and June 2013. All children age (0-18) years diagnosed with gastroparesis, who underwent a 2 hour GE study, followed by 4 hour GE study were included. Children with history of gastric surgery (including gastric neurostimulator devices), diabetes, or on prokinetic medications were excluded. GE study was considered abnormal when GE was less than 7% at 1 hour, 31% at 2 hours and 81% at 4 hours. All demographic, symptoms and GE test results were recorded. This study was approved by the Mayo Clinic IRB. Results: A total 13 children (7 females, average age of 12 years) were identified. The most common reported symptoms at the time of both studies were abdominal pain (63%), nausea/ vomiting (38%), and bloating/ abdominal distention (16%). Many patients had multiple symptoms. Eighty five percent (n= 11) patients were diagnosed with gastroparesis using the 2 hour GE study. Out of 11 patients only 2 (18%) were confirmed with gastroparesis on the subsequent 4 hour GE study. Median time between the two studies was 6 months. None of the patients who had normal 2 hour study had an abnormal 4 hour study. Discussion: All patients who were diagnosed with gastroparesis by the 2 hours GE study continued to have symptoms despite trying different medications and diet modifications. Patients discontinued any prokinetic medications before repeating a 4 hour GE study. Most of the patients (85%) had a normal 4 hour GE study, despite persistence of their symptoms. These patients could have had GI symptoms due to a different etiology such as functional or other motility disorders (impaired accommodation). The improved GE results could be due to regression toward the mean, or true improvement in the gastric emptying function during the time elapsed between the two studies. Conclusion: The 2 hour radionuclide scintigraphic GE test is unreliable, and can result in false diagnosis of gastroparesis in children. Four hour GE radionuclide scintigraphy testing should be the standard practice.

Severity of Dyspeptic Symptoms Correlates with Delayed and Early Variables of Gastric Emptying

A simplified report of gastric retention values at select times is now recommended for scintigraphic gastric emptying test (GET). The purpose of this study was to assess correlation between severity of gastroparetic symptoms and all variables of GET, compared to select variables in clinical use. This was a prospective study of patients referred for scintigraphic GET. The Gastroparesis Cardinal Symptom Index questionnaire was obtained prior to the scintigraphy. Variables determined were lag time, half emptying time (T1/2), retention at 30 min, 1, 2 and 4 h. Statistical analysis was by Spearman rank correlation and Wilcoxon rank test with a significance set at p ≤ 0.05. Seven hundred seventeen patients had GET from 03/09 to 03/11. Results are from 325 patients who did not take medications known to affect GET were analyzed (64.9 % females, mean age 47 ± 18.9 years, 21.8 % diabetics, 78.2 % non-diabetic, of which 7.6 % were post-surgical, primarily post-fundoplication). Combined gastric retention at 2 and 4 h detected delayed GET in 83.5 % non-diabetics and 76.6 % of diabetics. Rapid GET was present in 11 % of patients at 30 min and 4 % at 1 h. Significant positive correlation was observed between nausea, vomiting, loss of appetite and variables of GET, but not with the half-time of emptying (T1/2). Bloating negatively correlated with retention at 2 h. There was no association between duration of symptoms and GET variables. Gastroparetic symptoms correlate with different retention times of GET, but not with T1/2. However, symptoms poorly distinguish between categories of gastroparesis or status of gastric emptying. Delayed GE is best detected by 2 and 4 h retention times, while 30 min and 1 h retention times detect rapid GE.

Can Gastrointestinal Clinical Presentation Predict Gastroparesis: Results From a Tertiary Referral Center

Background: Gastroparesis can have varied clinical presentation. There are no well defined clinical parameters for predicting gastroparesis in patients presentingwith different gastrointestinal symptoms. Aims: To assess clinical predictors of gastroparesis in a large cohort of patients undergoing gastric emptying test Methods: A retrospective chart review of patients referred to our tertiary care center with presumed diagnosis of gastroparesis and various combinations of abdominal symptoms (nausea, vomiting, abdominal pain, bloating, post parandial fullness and early satiety) were included. All patients underwent a standardized 4-hrs scintigraphic gastric emptying test (GET) consisting of low-fat (2%) isotope labeled egg beaters meal of 250 kcal at our center. Patient demographics, medical/surgical history, drug use (affecting gastric/GI motility), proton pump inhibitor (PPI) use, endoscopic findings and results of hydrogen breath test were noted. Patients with previous history of gastric or small bowel resection, IBD, significant co-morbidities (end stage liver, kidney disease) were excluded. A univariate analysis was performed using Fisher's exact to evaluate predictors of gastroparesis, variables with a significance (p<0.05) were further evaluated using a multivariate logistic regressions model to identify independent predictors for gastroparesis. Results: 217 patients (mean age 46 yrs, 77% females, 83% Caucasians, average BMI 29 kg/m2, 18% smoker and 32% alcohol use history) were included. The frequency of gastrointestinal symptoms were: nausea 70%, abdominal pain 54%, vomiting 45%, bloating 34%, early satiety 14%, constipation 35%, and associated heart burn or acid reflux 40% and weight loss 30%. Diabetes mellitus (DM type 1 and 2) were present in 25% patients, 30 % had cholecystectomy history and 37% carried a diagnosis of depression. A total of 42% (92) patients had DGE (mild = 53%, moderate = 31%, severe = 16%) and of these 33% had diabetic gastroparesis and rest had idiopathic gastroparesis. In univariate analysis presence of nausea, DM, chronic use of PPIs were significant predictors for delayed gastric emptying (DGE), however, in multivariate analysis there was no independent clinical variable that predicted DGE, Table 1. Similarly, in patients with DM no clinical predictors for presence of DGE were identified. The number of patients with moderate and severe delay in gastric emptying was comparable between diabetic gastroparesis and idiopathic gastroparesis patients: moderate 30% vs. 31% and severe 16% vs. 18 %, respectively. Conclusion: In a large cohort of patients presenting with varied gastrointestinal symptoms, there was no independent clinical factor that predicted gastroparesis. Future RCTs are needed to confirm these findings. Clinical parameters in patients with delayed and normal gastric emptying

Does Grading the Severity of Gastroparesis Based on Scintigraphic Gastric Emptying Predict the Treatment Outcome of Patients with Gastroparesis?

The objectives of this study were as follows: (1) Whether gastric emptying is different between gastroparesis (GP) patients responding or not responding to standard medical therapy; (2) Identifying if mild, moderate, and severe degrees of gastroparesis based on the scintigraphic gastric emptying test (GET) can predict treatment responses for GP of diabetic (DM) and idiopathic (ID) origin. A total of 165 patients (119 F) diagnosed with GP [126 (76%) DM, 39 (24%) ID etiology] failed medical treatment and required the gastric electrical stimulation (GES) device (GES group). In addition, 112 patients (89 F) [37 (33%) DM, 75 (67%) ID] with GP who symptomatically responded to medical therapies are the comparison group (MED GP). All patients underwent a standardized scintigraphic GET consisting of low-fat (2%) isotope labeled egg beaters meal of 250 kcal. We also analyzed the GET data to find cut-off points for different degrees of GP and identified mild (11-20% retention), moderate (21-35%), and severe gastroparesis (>35%) based on percent retention of isotope at 4 h. Overall gastric retention at 4 h was significantly greater in the GES group (45±1.9%) than MED GP (30±2%) (p<0.001). The distribution severity of the GET was different in GES-treated patients than MED treated (p<0.001). In the diabetics, 57% of GES patients retained >35% after 4 h (severe) similar to 43% in the DM MED group. However, 50% of the ID GES patients had retention>35% at 4 h significantly more than only 17% of ID MED GP. Significantly more ID patients who responded to medical therapy had mild gastroparesis and significantly more requiring GES had severe GET (p<0.05). (1) GET in patients whose GP symptoms were refractory to standard medical therapy and required GES was significantly slower than in GP patients whose symptoms responded to medical therapy. (2) Stratifying GET into mild, moderate, and severe degrees of gastric retention does not predict whether a medical or surgical approach will be better to control the symptoms of diabetic GP but does correlate with treatment for the idiopathic GP subgroup.

Clinical trial: effect of mitemcinal (a motilin agonist) on gastric emptying in patients with gastroparesis – a randomized, multicentre, placebo‐controlled study

Mitemcinal is an orally active motilin agonist that could potentially improve gastric emptying. To investigate the effect of mitemcinal on gastric emptying in patients with idiopathic and diabetic gastroparesis. In a randomized, double-blind design, 106 patients were randomized into four dosing regimens (22 to placebo and 21 each to mitemcinal 10 mg, 20 mg, 30 mg bid or 20 mg tid) for 28 days. A standardized scintigraphic gastric emptying test was performed at screening and again after completing the 4-week protocol. All doses of mitemcinal showed prokinetic activity. A significant improvement in meal retention at 240 min was noted even in the lowest dose group with the greatest improvement observed with 30 mg bid group (75% vs. 10% in placebo group). Diabetic patients responded better than the idiopathic subgroup. In diabetic patients, blood glucose at 1 h after a meal showed dose-dependent elevation. Although gastroparetic symptoms improved with both mitemcinal and placebo, the prominent placebo effect was not statistically exceeded by mitemcinal. Baseline scintigraphy results exhibited no clear correlation between the severity of gastroparetic symptoms and the status of gastric emptying. Mitemcinal is capable of accelerating gastric emptying in both diabetic and idiopathic patients with gastroparesis.

Retrograde Gastric Pacing Reduces Food Intake and Delays Gastric Emptying in Humans: A Potential Therapy for Obesity?

Obesity is one of the most prevalent health problems in the world with a lack of satisfactory therapies and gastric electrical stimulation has recently been proposed for the treatment of obesity. The aim of this study was to investigate the effects of retrograde gastric pacing (RGP) on food and water intake, and gastric emptying in humans. RGP with a tachygastrial frequency of 9 cycles/min was performed via a pair of submucosal gastric electrodes implanted 5 cm above the pylorus in 12 subjects. The water load test, food intake test and scintigraphic gastric emptying test were performed to assess the efficacy of RGP. RGP resulted in a 13% reduction in the consumption of water, a 16% reduction in food intake and a 15% increase in gastric retention of a solid meal. No significant symptoms were recorded with RGP using the parameters used for the water-load, food intake and scintigraphic gastric emptying tests. Acute RGP at a tachygastrial frequency results in a significant reduction of water and food intake and a delay in gastric emptying without inducing any unacceptable symptoms. It is worthy to explore its therapeutic potential for obesity.

Persistence of abnormal gastrointestinal motility after operation for Hirschsprung’s disease

OBJECTIVE: Recent studies in patients with Hirschsprung’s disease (HD) suggest that morphological abnormalities of the intramural intestinal plexuses are not restricted to the colon. In this report, symptoms and objective tests of gastrointestinal (GI) motor dysfunction were determined long after operative treatment to see whether evidence of a more widespread and relevant motility disturbance could be detected. METHODS: Twenty-one children were available for study an average of 6.6 yr after surgery for HD. All of these patients underwent evaluation of bowel frequency per week, total GI transit time (TGTT), and a scintigraphic gastric emptying test using solid food; anorectal manometry and segmental colonic transit times were performed in a subset of patients. Results were compared with findings in appropriately matched controls. RESULTS: Frequency of defecation per week in patients with HD after surgery was not different from that in control children, but TGTT was significantly longer ( p < 0.01). Percentage retention of gastric isotope at 60 min exceeded the normal range in 12 of 21 (57.1%) patients, and colonic transit was abnormal in all six children studied. Symptoms persisted in two-thirds of patients postoperatively, and transit abnormalities were more common in the symptomatic subset ( p = 0.026). CONCLUSIONS: Our data show that, in a subset of patients with HD, GI motor dysfunction persists long after surgical correction. The heterogeny of basic defects responsible for HD could provide the substrate for these motor abnormalities that, in turn, seem at least partially responsible for continuation of the symptomatic state.

Persistence of abnormal gastrointestinal motility after operation for Hirschsprung's disease.

Recent studies in patients with Hirschsprung's disease (HD) suggest that morphological abnormalities of the intramural intestinal plexuses are not restricted to the colon. In this report, symptoms and objective tests of gastrointestinal (GI) motor dysfunction were determined long after operative treatment to see whether evidence of a more widespread and relevant motility disturbance could be detected. Twenty-one children were available for study an average of 6.6 yr after surgery for HD. All of these patients underwent evaluation of bowel frequency per week, total GI transit time (TGTT), and a scintigraphic gastric emptying test using solid food; anorectal manometry and segmental colonic transit times were performed in a subset of patients. Results were compared with findings in appropriately matched controls. Frequency of defecation per week in patients with HD after surgery was not different from that in control children, but TGTT was significantly longer (p < 0.01). Percentage retention of gastric isotope at 60 min exceeded the normal range in 12 of 21 (57.1%) patients, and colonic transit was abnormal in all six children studied. Symptoms persisted in two-thirds of patients postoperatively, and transit abnormalities were more common in the symptomatic subset (p = 0.026). Our data show that, in a subset of patients with HD, GI motor dysfunction persists long after surgical correction. The heterogeny of basic defects responsible for HD could provide the substrate for these motor abnormalities that, in turn, seem at least partially responsible for continuation of the symptomatic state.

A scintigraphic study on gastric emptying in patients with non-ulcer dyspepsia

Solid gastric emptying rates (GER) were determined with scintigraphic techniques in 20 patients with non-ulcer dyspepsia (NUD) and 9 healthy volunteers. GER were significantly decreased in NUD patients compared with controls, especially 45 min (P < 0.05), 60 and 90 min (P < 0.01) and 120 min (P < 0.05) after ingestion. In 13 out of 20 NUD patients who demonstrated lower GER, only 4 cases gave a lower GER at all stages throughout the determination, the other 9 showed their abnormal GER only after 60 min. In 3 cases who received repeated GER studies after cisapride therapy, 2 patients showed symptomatic relief accompanied by GER improvement. It is concluded that gastric emptying delay may be present with a high percentage in patients with non-ulcer dyspepsia. Scintigraphic gastric emptying test is a safe and reliable technique with good reproducibility. It may be helpful in quantitative study about gastric motion disorders.

Long-term results of subtotal colectomy and evidence of noncolonic involvement in patients with idiopathic slow-transit constipation.

Patients with chronic idiopathic constipation can be difficult to manage either medically or surgically. We report our experience of long-term follow-up of 21 patients who had undergone colectomy with ileorectal anastomosis for difficult chronic idiopathic constipation. The patients (19 female, 2 male) were aged 26-68 (median = 46) years and had undergone subtotal colectomy 5-12 (median = 8) years before their assessment. They answered a questionnaire about severity of abdominal pain, bloating, urgency, and straining. They also completed the hospital anxiety and depression questionnaire. Fifteen ulcerative colitis patients with panproctocolectomy and 13 colon cancer patients with colonic resection who had a similar follow-up period served as control groups. The following assessments were performed in chronic idiopathic constipation patients with subtotal colectomy: a) oesophageal manometry; b) scintigraphic gastric emptying test; c) review of barium follow-through; d) glucose H2 breath test; e) urodynamic studies; and f) autonomic function tests. Twenty-four per cent of patients with chronic idiopathic constipation had a family history of difficult constipation requiring hospital investigations and treatment. At the time of assessment abdominal pain, bloating, urgency, and straining at defecation were all significantly more frequent in patients with chronic idiopathic constipation with colectomy than in the control groups with colectomy. Seventy-one per cent of chronic idiopathic constipation patients had at least one episode of intestinal obstruction after subtotal colectomy, which is significantly higher (P < 0.01) than in the control groups (ulcerative colitis, 13%; colonic carcinoma, 8%). In patients with chronic idiopathic constipation, among those studied, 68% had some oesophageal motor dysfunction: 19% delayed gastric emptying; 10%, prolonged small-bowel transit on barium follow-through; 54%, abnormal urodynamic variables; and 14%, abnormal autonomic function tests. This study shows considerable morbidity in a selected cohort of patients with chronic idiopathic constipation who were sufficiently disabled by their symptoms to undergo subtotal colectomy. They had more abdominal and rectal symptoms and more frequent intestinal obstructive episodes than control groups with colonic resection. Evidence of generalized smooth-muscle dysfunction and familial occurrence of constipation suggests a primary chronic intestinal pseudo-obstruction-like disorder in some of these patients.

Scintigraphic test of gastric emptying and motility: preliminary results in patients with chronic gastritis

To record gastric peristalsis using a conventional scintigraphic gastric emptying test the frame rate was increased to 1 frame per 3 s at 10, 30, and 50 min postprandially. The gastric contraction frequency was obtained from the first harmonic of a Fourier transform of a gastric region of interest (ROI) curve. The propagation of gastric contractions was better revealed from computed functional images of the phase and amplitude distribution as compared with the multiple scintigraphic images. The maximal count-rate changes per pixel were calculated as an estimate of the most prominent regional contractile activity of the gastric wall. Among 12 patients with chronic gastritis the group with more severe dyspeptic complaints (n = 6) had significantly higher count-rate changes per pixel when compared with the group with minor complaints (20.0, 21.1 and 14.2 vs 12.9, 12.0, and 10.4 counts/pixel × s at 10, 30, and 50 min, respectively; p < 0.05). The mean half-times of gastric emptying (61, SD 11 vs 54, SD 13 min) and the mean gastric contraction frequencies (2.99, SD 0.19; 3.09, SD 0.33; 3.07, SD 0.10 vs 3.15, SD 0.15; 3.17, SD 0.13; 3.23, SD 0.20 cycles/min at 10, 30, and 50 min, respectively) did not show significant differences between both groups. Our preliminary results agree with the hypothesis of the occurrence of more powerful, nonexpulsive gastric-wall contractions in patients with more severe dyspeptic complaints. Hence, additional quantification of gastric motility allowed a more detailed evaluation of gastric-motor-activity disorders that were for so long not accessible to conventional gastric-emptying tests.