The sites in the duodenum of receptor areas which affect abomasal emptying in the calf

Calves were prepared with abomasal and duodenal cannulae to assess the effects on abomasal emptying of duodenal infusates at different rates and different sites. In two calves infusions of isotonic NaHCO3 or 60 mM HCl 30 cm distal to the pylorus were as effective in controlling abomasal emptying as infusions of the duodenum from 5 cm distal to the pylorus, and in three other calves they were as effective as perfusing the whole duodenum including the most proximal 5 cm. Reducing the rate of duodenal infusion of 60 mM HCl from 10 to 2.5 ml/min diminished its effect from total inhibition of gastric emptying to slight or negligible inhibition. The stimulation of gastric emptying by duodenal infusion of isotonic NaHCO3 solution was undiminished by reduced rates of infusion. It is proposed that in the calf receptors which activate and inhibit gastric emptying are present throughout the duodenum.

Intact removal of phytobezoar using fibreoptic endoscope in patient with gastric atony

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Antroduodenal motor response to solid-liquid and homogenized meals

The effect of the physical state of food on antroduodenal motor activity and the pattern of the emptying of an aqueous phase marker were examined in 6 healthy volunteers using an intestinal perfusion technique and intraluminal pressure transducers. Ingestion of a solid-liquid meal produced marked phasic changes in pressure in the distal antrum, lasting 92 +/- 10 min (mean +/- SE), while, in contrast, ingestion of the same nutrients in a homogenized state resulted in complete absence of distal antral changes in pressure lasting 133 +/- 12 min. The motor responses of the proximal antrum and duodenum were similar for the two meals. Both meals emptied during a 3-hr period, the pattern of emptying of the aqueous phase marker being similar for the two meals except for the first 40 min, when emptying was more rapid after the solid-liquid meal. The homogenized meal emptied despite the absence of changes in distal antral pressure. The gastrin response was similar for the two meals and is therefore not responsible for the different patterns of antral motility and gastric emptying.

Calories and gastric emptying: a regulatory capacity with implications for feeding

Gastric emptying in four unanesthetized male Macaca mulatta was studied with the serial test meal method of Hunt and Spurrell. Liquid meals were infused into the stomach through a chronic indwelling Silastic cannula. Saline meals empty rapidly and exponentially. Doubling the volume of saline from 150 to 300 ml increased the emptying rate so that the half-life remained unchanged (15 min). The 150-ml glucose meals (0.05, 0.125, and 0.25 g/ml) emptied more slowly than saline, progressively more slowly with increasing concentrations (0.05--1.8, 0.125--0.78, and 0.25--0.37 ml/min) and linearly through most of their course. Doubling the volume of 0.125 g/ml-glucose meal did not change the rate of emptying. Converting grams of glucose to their caloric content, the emptying rate in kcal/min becomes constant (approx 0.4 kcal/min) in this range of concentrations. Isocaloric casein hydrolysate and medium-chain triglyceride oil meals at 0.5 kcal/ml empty at the same rate as glucose. The precision of this regulation is sufficient to give it a role in preabsorptive satiety and the control of caloric intake.

Effect of selective proximal vagotomy on food-stimulated gastric acid secretion and gastrin release in patients with duodenal ulcer

We studied effects of selective proximal vagotomy on food-stimulated acid secretion and gastrin release in 7 duodenal ulcer patients. Food-stimulated acid secretion was evaluated by sham feeding patients and by infusing food directly into their stomachs. Vagotomy reduced sham feeding-stimulated acid secretion from 28.2 +/- 4.6 to 1.2 +/- 0.7 meq/hr (95% reduction) whereas infused food-stimulated secretion was decreased from 36.1 +/- 4.6 to 17.9 +/- 5.5 meq/hr (50% reduction). In contrast to the reductions in acid secretion, the gastrin response to infused food doubled after surgery. Although selective proximal vagotomy reduced the rate of acid secretion in response to infused food and also reduced by 64% the peak secretory capacity (peak acid output to pentagastrin), fractional secretion (i.e., the secretion rate in response to infused food expressed as a percentage of the peak secretory capacity) increased significantly after vagotomy from 63 +/- 7% to 91 +/- 11%. This increased fractional secretion in response to infused food was probably a result of exaggerated gastrin release after vagotomy.

Proximal gastric vagotomy and suprapyloric antrectomy. Experimental evaluation in dogs

In five dogs with Heidenhain pouches, proximal gastric vagotomy and suprapyloric antrectomy did not alter the rate of gastric emptying of 300 mL of 1% dextrose or of 40 plastic spheres, or disrupt the barricade preventing duodenogastric reflux. However, the operation did slow gastric emptying of 50 g of cubed liver and increase the postprandial secretion of hydrochloric acid from the pouch. We concluded that suprapyloric antrectomy can be combined with proximal gastric vagotomy without disturbing the gastric emptying of liquids and indigestible solids or resulting in increased duodenogastric reflux. However, the operation does slow gastric emptying of digestible solids.

Reconstruction after total gastrectomy: construction of a Hunt-Lawrence pouch using Auto Suture staples

A simple gastric reservoir using autosuture staples can be constructed rapidly after total gastrectomy. The importance of both a reservoir capacity and delayed evacuation was supported by the clinical course of most of the patients. All 18 patients had improved nutrition. Patients resected for cure tended to have greater weight gain and less abdominal discomfort. Occasionally patients who underwent only palliative resection were long-term survivors with a clinical course similar to that of patients resected for cure. On the basis of these results, it is unfair not to consider this type of reconstruction in patients who have undergone a total gastrectomy because it adds little to the operating time, yet it provides better palliation in terms of nutrition and abdominal comfort on both a short- and long-term basis.

Aspects of the control of feeding: application of quantitation in psychobiology

In rhesus monkeys equipped with indwelling gastric cannulae and studied in the unanesthetized state, it is possible to demonstrate that their feeding is a precisely regulated behavior functioning to maintain caloric intake quite constant. The infusion of nutrients into the stomach through the cannula results in a reduction in their feeding by an amount that is equivalent to the caloric value of the infusion. A similar precise recovery from caloric deficits by overeating can also be demonstrated. One means of controlling intake of food may derive from a remarkable change in gastric function that occurs with feeding. If the stomach is filled with non-nutrient saline it functions like a physiological "pump" expelling its contents into the small bowel in an exponential fashion--more rapidly with increasing volume. If the stomach is filled with nutrients then it functions like a precise "valve," delivering its contents at a constant and linear rate of 0.4 kcal/min to the duodenum regardless (within limits) of the volume, concentration or character (carbohydrate, fat, protein) of the nutrient meal. This change in gastric activity is provoked by the calories that are passed into the duodenum and sustained for a period depending on the amount of calories in the duodenum. The relation of these physiological events to the control of feeding is discussed.

Barium and isotope studies]

The study of gastric emptying by isotopic and barium feeding, in 43 patients, before and 6 months after highly selective vagotomy, showed no retention after this type of operation. Whereas during the first 45 minutes following ingestion of the test meal, there was no modification of emptying, a significant acceleration thereafter was demonstrated by both methods. The isotopic meal allows continuous study of gastric emptying which appears to be more regular after the operation. There was no difference in gastric emptying between patients suffering from post-prandial gastric fullness, mild diarrhea or dumping syndrome.

Proximal stomach and antrum in stomach emptying

In a series of measurements of liquid-phase gastric emptying using a radionuclide marker on 35 subjects, five were identified in whom the proximal stomach and antrum were clearly distinguishable. Three of these subjects were normal controls and two suffered from systemic sclerosis. In the three normal subjects, analysis of the movement of the liquid showed the expected movement from fundus to antrum and thence through the pylorus. In the two patients with systemic sclerosis, there was, in contrast, evidence of mass retropulsion of the contents of the antrum into the fundus. In such cases, the measurement of stomach emptying based on the assumption of a single-compartment system in likely to be misleading.

Sieving of solid food by the canine stomach and sieving after gastric surgery

Present concepts on the gastric emptying of solid materials derive from experiments with plastic spheres now known to be emptied differently than food. Accordingly, experiments were undertaken with radiolabeled chicken liver to assess (a) the size of meat particles passed by the normal canine stomach and (b) the effects of ulcer surgery on the rate of emptying and the size of emptied meat particles. Control or ulcer-operated dogs were prepared with chronic duodenal fistulas from which chyme was collected after a standard meal of beefsteak + radioliver + water. Collected chyme was sieved over a stack of sieves of decreasing pore size, and the percent of radioactivity recovered on each sieve was determined each postcibal hour for 5 hr. Control dogs emptied the meal slowly, and virtually all recovered meat was emptied in particles equal to or less than 2.0 mm. Dogs with vagotomy (V), pyloroplasty (P), vagotomy + pyloroplasty (V + P), or antrectomy with end-to-end (A-BI) or end-to-side (A-BII) gastroduodenostomy did not empty the meal faster than the control dogs. In all ulcer-operated dogs except those with P, there were significant upward shifts in the size of meat particles emptied from the stomach; but changes were marked only dogs with V + P or A-BII. Although the experiments verify the antral sieving mechanism noted in earlier work with plastic spheres, the trituration of solid food is probably more complex than previously envisioned.

Effect of posture on the pattern of stomach emptying in the newborn

To determine the effect of posture on the pattern of neonatal stomach emptying, 56 test meals of a 10% dextrose were given to 14 healthy infants over a period of two or three consecutive days. The infants, whose postnatal age ranged between 5 and 27 days, were studied in each of four positions. The emptying pattern was determined by the double-sampling dye-technique. The results indicate that there are no significant postural differences in the pattern of stomach emptying. They also indicate that neonatal and adult patterns are similar.

[Gastric emptying in patients with ulcus ventriculi (author's transl)]

The half life time (T 1/2) of gastric emptying was measured in 53 patients suffering from atrophic gastritis or gastric ulceration, by use of a radiolabelled standardized test-meal. In healthy controls the T 1/2 was 58.8 +/- 9.1 min (median 59 min). In 35 gastric ulcer patients the T 1/2 of median 85 min was significantly slowed if compared to the normal value (2 p less than 0.01). After healing of the ulcer in 12 patients this value returned to normal. In 8 patients with diffusely atrophic gastritis the T 1/2 value was slowed significantly (median 123 min), if the gastritis was confined to the antrum, gastric emptying was accelerated (median 48 min).

Postprandial gastric function in pancreatic insufficiency

Abnormalities in postprandial gastric function could contribute to the maldigestion of pancreatic insufficiency. To measure simultaneously postprandial gastric secretion and emptying and correlate these measurements with intraluminal duodenal changes, we performed intestinal intubation and duodenal perfusion during feeding of a solid-liquid test meal in 10 healthy controls and 10 patients with documented pancreatic insufficiency before and after replacement therapy. In pancreatic insufficiency, intraduodenal pH was significantly decreased late in the postprandial period while simultaneously measured duodenal acid loads were normal, confirming that reduced bicarbonate output rather than increased acid delivery was responsible for higher duodenal acidity in these patients. Significant (P less than 0.05) reductions in postprandial acid, pepsin, and total secretory outputs were noted in untreated patients only during the first postprandial hour. Absolute gastric emptying rates were lower in patients (P less than 0.05) than in healthy subjects, but fractional rates of emptying were similar. Fasting and postprandial hypergastrinaemia were consistently observed in the patients with pancreatic disease. There are postprandial disturbances of secretory function but no primary gastric motor defect in patients with exocrine pancreatic insufficiency.

Interrelations between serum gastrin levels, gastric emptying and acid output before and after proximal gastric vagotomy and truncal vagotomy and antrectomy

In a prospective study of proximal gastric vagotomy and truncal vagotomy and antrectomy measurements were made, before and after operation, of acid output, gastrin output and gastric emptying of a solid and a liquid meat extract meal. No relationships were demonstrable between acid output and gastrin output. Truncal vagotomy and antrectomy (TVA) produced rapid early emptying of both meals combined with gross prolongation of the overall emptying of the solid meal. Truncal vagotomy and antrectomy reduced the intergrated gastrin output after either meal. Proximal gastric vagotomy (PGV) produced rapid early emptying of the liquid meal with no alteration in the early emptying of the solid meal; however, overall solid meal emptying was delayed. Proximal gastric vagotomy increased basal, peak and integrated gastrin output. In preoperative patients slow solid meal emptying was associated with higher gastrin output but after PGV the reverse was found, the slowest emptiers having the lowest gastrin output. These findings do not support the contention that a pyloroplasty should be added to PGV to reduce the hypergastrinaemia produced by the operation.

[Experimental study on canine gastric motility following selective proximal vagotomy (author's transl)]

Electromyographical studies were made on the gastric motility of dogs following selective vagotomy (SV) and selective proximal vagotomy (SPV) as the subsequent studies on the changes after truncal vagotomy (TV) after which gastric motility is fairly disturbed, and the influence of pyloroplasty additionally performed to SPV. Gastric discharge frequency was suppressed by SV similar to that by TV. Dysrhythmia of motility occurred after gastric vogotomy. Restoration to the normal was the fastest after SPV. Changes in the discharge frequency after SPV did not differ much from those in the normal stomach and other types of vagotomy. With SPV, the decrease in the propagation velocity of basic electrical rhythms (BER) was mild, and a pattern similar to the control was shown compared with TV and SV. The antiperistaltic discharge was observed even with SPV, but the frequency was low compared with TV and SV. The frequency of peristaltic discharge was the highest when pyloroplasty was performed in addition to SPV. The responses to vagostigmine, insulin tetragastrin in SPV were similar to those in the normal stomach. During the gastric emptying time, there was neither difference before and after SPV, nor any significant difference due to the presence or absence of pyloroplasty. The above data show that SPV is advantageous for retaining the function of gastric peristalsis, also for gastric secretion, but the addition of pyloroplasty will not be advantageous for the elimination of gastric content.

Study by a radio-isotopic method (author's transl)]

A radio-isotopic method was used to study the gastric emptying of an ordinary meal in 15 control subjects. The technique developed may be used for direct measurement of the early phase of gastric emptying and a simultaneous study of emptying of liquid and solid phases, respectively labelled with Tc99m and Cr51. Emptying of the liquid phase of the meal takes place in accordance with a mono-exponential curve in relation to time, the T 1/2 of which is 54 min +/- 6 (MSD). Emptying of the solid phase is significantly slower than that of the liquid phase. The reproductibility of the method was confirmed and the imprecision of each measurement does not exceed 5%.

[Formula diets in gastroenterology]

Elemental diets are in use for therapy of intestinal fistulas, diarrhoe of unknown etiology, short-bowel-syndrom and chronic inflammatory bowel diseases.

[Drug interactions]

Every alteration of the effect of a drug within the human body due to substances introduced from outside are considered drug interactions. Several types of these mutual actions are differentiated. They can be influenced with varying success according to the site of the interaction. An unusual variant of the interactions sometimes appears in genetically induced disturbances in the metabolism of drugs.

[Gastroparesis diabeticorum and bezoar (author's transl)]

Gastroparesis diabeticorum has been isolated by Kassander in 1958. Since that time, 65 well documented cases have been published. Very often the patients are asymptomatic and the disorder is discovered by an occasional X-ray examination of the G-I tract. But, sometimes, the diabetes of these patients becomes brittle and they loose weight; bezoar, gastroplegia and hemorrhages may occur. We report two additional cases with severe undernutrition and bezoar. The gastroparesis may be related to a vagal neuropathie. The treatment is disappointing; metoclopramide gives the best improvement.

Different gastric, pancreatic, and biliary responses to solid-liquid or homogenized meals

We have compared responses to an ordinary solid-liquid (S) meal and to a homogenized (H) meal of identical composition (sirloin steak, bread, butter, ice cream with chocolate syrup, and water) by measuring simultaneously postprandial gastric, pancreatic, and biliary functions by marker-perfusion techniques. Responses to each (S or H) meals differed strikingly both in magnitude and pattern. S meals elicited a stronger early gastric secretory response (acid, pepsin, and volume) which compensated for faster initial emptying and resulted in higher gastric acidity and volume than after H meals. Further, nutrients ingested with S meals were emptied at a slower rate than H (as evidenced by a more gradual decline in intragastric buffer and osmolality, as well as time required for complete emptying of the meal). This, in turn, prolonged pancreatic and biliary responses since stimulation of these organs continued for as long as meal was delivered into the duodenum. However, early biliary outputs (gallbladder response) were less after S than H, probably because nutrients entered the duodenum more slowly and were initially diluted by rapidly emptying water. The physical characteristics of each meal (encompassing appearance, taste, and form of ingestion) probably accounted for early differences in digestive responses. Later, interactions between gastric (motor and secretory), pancreatic, and biliary functions played a major role. Our findings suggest that gastric, pancreatic, and biliary responses to liquid test meals introduced into the stomach may differ substantially from the presumably more physiological response to ordinary solid-liquid meals.

Gastric emptying in normal subjects and patients with peptic ulcer: a study using the acetaminophen method

Gastric emptying in patients with peptic ulcer and normal subjects was studied using the acetaminophen method. The subjects consisted of 15 normal subjects, 52 gastric ulcer patients and 65 duodenal ulcer patients, who were studied in active stage of the ulcer. As an indicator of gastric emptying, the plasma acetaminophen concentration was measured by dye method (diphenylhydrazyl), as mcg/ml, at 45 minutes after ingestion of a high calory pasty test meal (200 ml) with 1.5 gr of acetaminophen. In normal subjects, the plasma acetaminophen concentration was 9.4 +/- 3.6 mcg/ml. In gastric ulcer patients, the concentration was 7.4 +/- 3.2 mcg/ml, which showed significantly delayed gastric emptying (P less than 0.05). In duodenal ulcer patients, the concentration was 11.6+/-3.3 mcg/ml, which suggested significantly rapid gastric emptying (P less than 0.05). In consideration of gastric secretion, gastric ulcer cases with lower acid secretion have more delayed gastric emptying. In duodenal ulcer cases with hypersecretion, gastric emptying is more rapid than normo-and/or hyposecretory cases (P less than 0.005). The delayed gastric emptying may play a role in etiology of gastric ulcer. On the other hand, the rapid gastric emptying with gastric acid hypersecretion may be important in the pathogenesis of duodenal ulcer.

The pathophysiology of gastric surgery

Gastric surgery may be followed by mechanical postoperative problems, usually due to impaired gastric emptying or the afferent loop syndrome, recurrent dyspepsia, the early or late dumping syndrome, diarrhoea, or nutritional disturbances. The pathophysiological basis of these disorders is discussed and their clinical features are briefly considered.

A preliminary report

Using a radioisotope technique, gastric emptyping of a solid meal was measured in 10 pre-operative duodenal ulcer (DU) patients, 10 post-operative truncal vagotomy and pyloroplasty (TV+P), and 8 post-operative truncal vagotomy and pyloric stretch (TV+S) patients. Results show that after the first 20 min, although gastric emptyping after TV+S shows a tendency to reduction in rate compared with TV+P, the difference never reaches statistical significance (p greater than 0.01). When compared with control DU patients, the TV+S group again exhibits a statistically insignificant (p greater than 0.10) tendency to reduction in rate after the first 20 min, whereas the TV+P group shows no such tendency. The significance of these findings is discussed in relation to the use of a pyloric ring stretch as an alternative to pyloroplasty.