Update on gastrointestinal scintigraphy

A hypoallergenic solid meal for gastric emptying scintigraphy based on mediterranean diet. "One diet to empty almost everyone"

AIM

We aim to establish normal values and standardize a hypoallergenic and mediterranean diet for gastric emptying scintigraphy (GES).

MATERIAL AND METHODS

In a prospective cohort of healthy volunteers, we performed GES of a [99Tc]TcDTPA2 labelled hypoallergenic meal (egg, potato, rice and olive oil). Anterior and posterior images were simultaneously acquired at 0, 30, 60, 110, 120, 130, 180, 230, 240 and 250 min. Cross-sectional analysis was performed between demographic data and gastric retention values. A score covariance analysis model was used to observer changes between measurements over time.

RESULTS

50 participants (29 women) were included. Mean values and standard deviation (5-95th) for gastric retention percentages at 60, 120, 180, 240 min were 51.40 ± 8.63 (36.5-66.1), 21.66 ± 9.40 (6.5-38.2), 7.58 ± 5.77 (1.5-19.1) and 2.94 ± 2.08 (1-7.3), respectively. Male participants had a significative faster gastric emptying compared to women in practically all the acquisitions. Male participants and smoker participants generated a significative decrease of gastric retention values in generalized linear model (male coefficient -4.818, IC95% -7.24 to -2.39, P-value < .001; and smoker coefficient of -3.484, IC95% -6.29 to -0.67, P-value < .05).

CONCLUSION

This study standardizes and establishes normal values for GES with the first hypoallergenic solid meal based on consensus recommendations and a mediterranean diet; suitable for most patients with allergic or sensitive-conditions to other meal components.

Clinical issues and challenges in imaging of gastrointestinal diseases: A minireview and our experience

Imaging techniques play a crucial role in the modern era of medicine, particularly in gastroenterology. Nowadays, various non-invasive and invasive imaging modalities are being routinely employed to evaluate different gastrointestinal (GI) diseases. However, many instrumental as well as clinical issues are arising in the area of modern GI imaging. This minireview article aims to briefly overview the clinical issues and challenges encountered in imaging GI diseases while highlighting our experience in the field. We also summarize the advances in clinically available diagnostic methods for evaluating different diseases of the GI tract and demonstrate our experience in the area. In conclusion, almost all imaging techniques used in imaging GI diseases can also raise many challenges that necessitate careful consideration and profound expertise in this field.

Gastric Emptying Scintigraphy Protocol Optimization Using Machine Learning for the Detection of Delayed Gastric Emptying

PURPOSE

The purpose of this study is to examine the feasibility of a machine learning (ML) system for optimizing a gastric emptying scintigraphy (GES) protocol for the detection of delayed gastric emptying (GE), which is considered a primary indication for the diagnosis of gastroparesis.

METHODS

An ML model was developed using the JADBio AutoML artificial intelligence (AI) platform. This model employs the percent GE at various imaging time points following the ingestion of a standardized radiolabeled meal to predict normal versus delayed GE at the conclusion of the 4 h GES study. The model was trained and tested on a cohort of 1002 patients who underwent GES using a 70/30 stratified split ratio for training vs. testing. The ML software automated the generation of optimal predictive models by employing a combination of data preprocessing, appropriate feature selection, and predictive modeling analysis algorithms.

RESULTS

The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was employed to evaluate the predictive modeling performance. Several models were developed using different combinations of imaging time points as input features and methodologies to achieve optimal output. By using GE values at time points 0.5 h, 1 h, 1.5 h, 2 h, and 2.5 h as input predictors of the 4 h outcome, the analysis produced an AUC of 90.7% and a balanced accuracy (BA) of 80.0% on the test set. This performance was comparable to the training set results (AUC = 91.5%, BA = 84.7%) within the 95% confidence interval (CI), demonstrating a robust predictive capability. Through feature selection, it was discovered that the 2.5 h GE value alone was statistically significant enough to predict the 4 h outcome independently, with a slightly increased test set performance (AUC = 92.4%, BA = 83.3%), thus emphasizing its dominance as the primary predictor for delayed GE. ROC analysis was also performed for single time imaging points at 1 h and 2 h to assess their independent predictiveness of the 4 h outcome. Furthermore, the ML model was tested for its ability to predict "flipping" cases with normal GE at 1 h and 2 h that became abnormal with delayed GE at 4 h.

CONCLUSIONS

An AI/ML model was designed and trained for predicting delayed GE using a limited number of imaging time points in a 4 h GES clinical protocol. This study demonstrates the feasibility of employing ML for GES optimization in the detection of delayed GE and potentially shortening the protocol's time length without compromising diagnostic power.

Chronic constipation that resulted in fecal impaction and colon perforation: A case report

RATIONALE

Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ.

PATIENT CONCERNS

A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids.

DIAGNOSIS

An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying.

INTERVENTIONS

Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed.

OUTCOMES

The patient had an uneventful postoperative course and was discharged in good condition.

LESSONS

Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

Three-dimensional semiquantitative analysis of gastric emptying SPECT

OBJECTIVE

We used dynamic single-photon emission computed tomography (D-SPECT) to overcome the interference of the planar dynamic imaging due to the overlap of internal organs, thus more accurate physiological function can be obtained.

METHODS

3D printed gastric phantom was used to simulate gastric emptying (GE). First, the planar dynamic liquid GE procedure was used and served as the reference value; second, D-SPECT followed by repeated liquid GE procedures with three gamma cameras were used. The emptying flow rate of the gastric phantom simulated three flow rates of liquid, semisolid and solid. Third, we simulated the intestinal activity that interfered with the residual value obtained by 2D dynamic imaging, which was compared with D-SPECT. Then, we brought the 3D VOI data into the postprocessing program to obtain the residual activity curve and residual percentage.

RESULTS

The residual amount obtained in the phantom at 60th minutes in the first stage is 14.57%; the residual amount of liquid emptying are Siemens: 3.33%, GE: 15.06%, PHILIPS: 1.12%; residual amount for semisolid are Siemens: 47.36%, GE: 54.25%, PHILIPS: 51.57%; residual amount for solids are Siemens: 63.98%, GE: 66.88%, PHILIPS: 63.76%. All values are within the normal range. Then, we simulated the intestinal activity that interfered with the residual value obtained by 2D dynamic imaging: 75-90 min: 10.42, 19.48, 19.51 and 11.02%; however, the residual values obtained with 3D SPECT VOI data: 75-90 min: 1.42, 1.41, 1.35 and 1.02%. These results show that the emptying data errors caused by intestinal overlap can be effectively corrected (P = 0.017).

CONCLUSION

D-SPECT imaging can overcome the interference in the semiquantitative data of residual GE caused in 2D mode.

Early steps of an alternative test meal for gastric emptying scintigraphy

Background/Aim. Gastric emptying (GE) scintigraphy provides a physiologic and noninvasive measurement of GE. Although GE scintigraphy has been standardized, preparing a meal is still complex and not practical in daily routine. The aim of the study was to prepare a simple, practical, and easily standardizable semisolid meal and investigate its role in estimating the GE function in of rabbits. Methods. In the first part of the study (basal condition), the mixture of the macroaggregated albumin (MAA) labeled with 37 MBq (1 mCi) of technetium-99m (99mTc) and 40 g of barium sulfate (1g/mL) was applied to animals via a nasogastric catheter. A series of images (frame/min, 60 min) in the anterior and posterior projections were dynamically acquired, and the motion was corrected after the radiopharmaceutical application. A few days later, the same rabbits were scanned under the same protocol after a 1 mg atropine injection to simulate gastroparesis condition. Eleven rabbits were included according to inclusion and exclusion criteria, and a total of twenty-two imaging data sets were analyzed for quantification. Results. In the basal study, total counts of the mixture decreased from 87,800.83 ? 12,622.76 to 42,733.14 ? 6,591.53 at 30 min and to 13,684.19 ? 1,774.90 at 60 min, and these decreases were statistically significant (p = 0.003). Emptying percentages were 51.39 ? 0.78% at 30 min and 84.32 ? 1.56 at 60 min and were statistically significant (p = 0.003). After intravascular atropine sulfate injection, total counts of the mixture decreased from 84,508.78 ? 11,871.48 to 64,995.18 ? 9,298 at 30 min and to 53,507.17 ? 7,258.98 at 60 min, and these decreases were statistically significant (p = 0.003). Emptying percentages were 23.10 ? 1.11% at 30 min and 36.63 ? 1.42 at 60 min and were statistically significant (p = 0.003). The difference between basal and post-atropine sulfate gastric emptying percentage at 30th (p = 0.003) and 60th (p = 0.003) min was statistically significant. Conclusion. The meal, used in this study, is non-nutrient, fatty-free, and semisolid and is easy to prepare and administer. Due to its semisolid nature, it offers a chance to evaluate the quantification of regional and total GE as well as the separate roles of the fundus and antrum.

The Utility of Adding a Liquid-Nutrient Meal to Aid Interpretation of Small-Bowel Transit Scintigraphy

Small-bowel transit scintigraphy (SBTS) evaluates the accumulation of a radiolabeled meal in the terminal ileal reservoir (TIR) 6 h after ingestion. The location of the TIR may be difficult to determine because anatomic information is limited; for equivocal studies, the patient is asked to return the next day to help determine the TIR location by potential transit into the colon. The purpose of this study was to evaluate whether administration of an additional liquid-nutrient meal (LNM) at 6 h can promote movement of the radiolabeled meal to aid in the interpretation of SBTS and eliminate the need for the patient to return. Methods: This retrospective study reviewed 117 SBTS studies from February 2017 to September 2019. Patients were fed a standardized mixed radiolabeled solid-liquid meal for gastric emptying with SBTS according to Society of Nuclear Medicine and Molecular Imaging practice guidelines. An additional LNM was given at 6 h, and post-LNM images were obtained at least 20 min after the LNM. Two board-certified nuclear medicine physicians independently evaluated all images as equivocal or diagnostic at 6 h. Results: Of the 117 patients (71.8% female; median age, 42.0 y) undergoing SBTS, 37 were equivocal cases at 6 h before the LNM (31.6%; 95% CI, 23.3%-40.9%), compared with 12 equivocal cases after the LNM (10.3%; 95% CI, 5.4%-17.2%). Of the equivocal cases, 25 (69.4%; 95% CI, 51.9%-83.7%) had a definitive result after the LNM, whereas 11 (30.6%; 95% CI, 16.4%-48.1%) remained equivocal and 1 showed rapid transit. Among the 23 patients with gastroparesis, only 13 (57%) responded to the LNM, and none of the 3 patients with irritable bowel syndrome responded. Conclusion: The number of equivocal SBTS cases decreased after administration of an LNM at 6 h, converting to a definitive result. This suggests that with use of an LNM, most patients can complete SBTS in 1 d without the need for repeat imaging at 24 h. Administering an LNM appears to be less effective for patients with gastric disorders. However, the clinical significance remains to be explored, and it is unclear whether such patients have both a gastric and a small-bowel disorder, hence reducing any motility-promoting effect of the LNM.

Colonic transit in patients after anterior resection: prospective, comparative study using single-photon emission CT/CT scintigraphy

BACKGROUND

Bowel dysfunction after anterior resection is well documented, but its pathophysiology remains poorly understood. No study has assessed whether postoperative variation in colonic transit contributes to symptoms. This study measured colonic transit using planar scintigraphy and single-photon emission CT (SPECT)/CT in patients after anterior resection, stratified according to postoperative bowel function.

METHODS

Symptoms were assessed using the low anterior resection syndrome (LARS) score. Following gallium-67 ingestion, scintigraphy was performed at predefined time points. Nine regions of interest were defined, and geometric centre (GC), percentage isotope retained, GC velocity index and colonic half-clearance time (T½ ) determined. Transit parameters were compared between subgroups based on LARS score using receiver operating characteristic (ROC) curve analyses.

RESULTS

Fifty patients (37 men; median age 72·6 (range 44·4-87·7) years) underwent planar and SPECT scintigraphy. Overall, 17 patients had major and nine had minor LARS; 24 did not have LARS. There were significant differences in transit profiles between patients with major LARs and those without LARS: GCs were greater (median 5·94 (range 2·35-7·72) versus 4·30 (2·12-6·47) at 32 h; P = 0·015); the percentage retained isotope was lower (median 53·8 (range 6·5-100) versus 89·9 (38·4-100) per cent at 32 h; P = 0·002); GC velocity indices were greater (median 1·70 (range 1·18-1·92) versus 1·45 (0·98-1·80); P = 0·013); and T½ was shorter (median 38·3 (17·0-65·0) versus 57·0 (32·1-160·0) h; P = 0·003). Percentage tracer retained at 32 h best discriminated major LARS from no LARS (area under curve (AUC) 0·828).

CONCLUSION

Patients with major LARS had accelerated colonic transit compared with those without LARS, which may help explain postoperative bowel dysfunction in this group. The percentage tracer retained at 32 h had the greatest AUC value in discriminating such patients.

Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis

BACKGROUND AND AIMS

Gastroparesis (GP) is a chronic debilitating condition. Prior pyloric-targeted procedures are either invasive or have questionable efficacy. Gastric peroral pyloromyotomy (G-POEM) has been proposed as a minimally invasive approach. We performed a pooled analysis to evaluate the efficacy and safety of G-POEM for GP.

METHODS

Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2019. Studies including patients who underwent G-POEM for GP were eligible. Procedural, clinical, and safety outcomes were assessed by pooling data with a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval.

RESULTS

Ten studies were eligible for inclusion (292 patients), and 2 of the 10 studies were prospective. Seven studies were performed in the United States, 2 in France, and 1 in China. Endoscopic pyloromyotomy was feasible in all patients. Significant symptomatic improvement was achieved after 83.9% of procedures (mean follow-up, 7.8 ± 5.5 months). When comparing the mean values of pre- and postprocedural scintigraphic evolution, there was a significant decrease of the residual percentage at 2 and 4 hours. The overall adverse events rate was 6.8%.

CONCLUSIONS

G-POEM appears to be a promising approach for GP in terms of safety and efficacy outcomes in the short term.

Esophageal Clearance in Laryngopharyngeal Reflux Disease: Correlation of Reflux Scintigraphy and 24-hour Impedance/pH in a Cohort of Refractory Symptomatic Patients

Objectives

The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD.

Methods

A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies.

Results

The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. LOS tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration.

Conclusion

Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.

The Effects of a Whey Protein and Guar Gum-Containing Preload on Gastric Emptying, Glycaemia, Small Intestinal Absorption and Blood Pressure in Healthy Older Subjects

A whey protein/guar gum preload reduces postprandial glycaemia in type 2 diabetes through slowing gastric emptying. However, gastric emptying has previously been assessed using a stable isotope breath test technique, which cannot discriminate between slowing of gastric emptying and small intestinal absorption. This preload also may be useful in the management of postprandial hypotension. We evaluated the effects of a whey protein/guar preload on gastric emptying, glucose absorption, glycaemic/insulinaemic and blood pressure (BP) responses to an oral glucose load. Eighteen healthy older participants underwent measurements of gastric emptying (scintigraphy), plasma glucose and insulin, glucose absorption, superior mesenteric artery (SMA) flow, BP and heart rate (HR) after ingesting a 50 g glucose drink, with or without the preload. The preload reduced plasma glucose (p = 0.02) and serum 3-O-methylglucose (3-OMG) (p = 0.003), and increased plasma insulin (p = 0.03). There was no difference in gastric emptying or BP between the two days. The reduction in plasma glucose on the preload day was related to the reduction in glucose absorption (r = 0.71, p = 0.002). In conclusion, the glucose-lowering effect of the preload may relate to delayed small intestinal glucose absorption and insulin stimulation, rather than slowing of gastric emptying.

Association between duration or etiology of gastroparesis and clinical response after gastric per-oral endoscopic pyloromyotomy

BACKGROUND AND AIMS

Gastric per-oral endoscopic pyloromyotomy (GPOEM) is a novel procedure with promising potential for the treatment of gastroparesis but with limited data regarding predictors of clinical response. This study aims to evaluate the safety and efficacy of the procedure and explore the impact of duration and etiology (diabetic vs nondiabetic) of gastroparesis on clinical outcome as measured by the Gastroparesis Cardinal Symptom Index (GCSI).

METHODS

A single-center retrospective longitudinal study at a tertiary care hospital was performed over an 18-month period. Forty patients with refractory gastroparesis (25 nondiabetic and 15 diabetic patients) were included.

RESULTS

GCSI significantly improved throughout the study period (F[2.176, 17.405] = 10.152, P = .001). The nausea/vomiting subscale showed sustained improvement through 18 months (F[2.213, 17.704] = 15.863, P < .00001). There was no significant improvement in bloating (F[2.099, 16.791] = 1.576, P = .236). Gastric scintigraphy retention was significantly reduced by 41.7% (t = -7.90; P < .00001). Multivariate linear regression modeling revealed a significant correlation between the duration of disease and a GCSI improvement at 12 months (P = .02), with a longer duration of disease associated with a poorer long-term response. The etiology of gastroparesis was not associated with clinical improvement (P = .16). Adverse events (7.5%) included 1 capnoperitoneum, 1 periprocedure chronic obstructive pulmonary disease exacerbation, and 1 mucosotomy closure site disruption.

CONCLUSIONS

GPOEM appears to be a safe and effective minimally invasive therapy for refractory gastroparesis, especially for patients with predominant nausea/vomiting and shorter duration of disease, regardless of the etiology. We propose the clinical criteria for undergoing GPOEM should be a GCSI of at least 2.0 and a gastric retention of greater than 20%.

Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide

Per oral endoscopic pyloromyotomy (POP), also known as gastric per-oral endoscopic myotomy (GPOEM), is a novel procedure with promising potential for the treatment of gastroparesis. As more data emerge and the procedure is becoming more recognized in clinical practice, its safety and efficacy need to be carefully evaluated. Appropriate patient selection for favorable clinical success prediction after GPOEM also needs additional research. This review aims to systemically summarize the existing data on clinical outcomes of POP. Symptomatologic responses to the procedure, its adverse effects, procedural techniques, and predictive factors of clinical success are also discussed.

Gastric Peroral Endoscopic Pyloromyotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use For Patients With Gastroparesis

BACKGROUND & AIMS

Gastric peroral endoscopic pyloromyotomy (GPOEM) is becoming a promising treatment option for patients with refractory gastroparesis. We aimed to systematically assess the efficacy of GPOEM and its effects on health care use.

METHODS

We performed a retrospective study on 30 patients with refractory gastroparesis who underwent GPOEM from June 2015 through July 2017 at a tertiary center. We compared outcomes with those of 7 patients with refractory gastroparesis who did not undergo the procedure (controls). The primary outcomes were patient-reported reductions in symptoms, based on the gastroparesis cardinal symptom index (GCSI), and increases in 8 aspects of quality of life, based on Short Form 36 (SF-36) scores. Data were collected on the day of the procedure (baseline) and at 1 month, 6 months, 12 months, and 18 months afterward. Secondary outcomes included visits to the emergency department or hospitalization for gastroparesis-related symptoms.

RESULTS

GPOEM was technically successful in all patients and significantly reduced GCSI scores in repeated-measure analysis of variance (F_{2.044, 38.838} = 22.319; P < .0005). The mean score at baseline was 3.5 ± 0.6, at 1 month after GPOEM was 1.8 ± 1.0 (P < .0005), at 6 months after was 1.9 ± 1.2 (P < .0005), at 12 months after was 2.6 ± 1.5 (P < .026), and at 18 months after was 2.1 ± 1.3 (P < .016). GPOEM was associated with improved quality of life: 77.8%, 76.5%, and 70% of patients had significant increases in SF-36 scores, compared with baseline, at 1 month, 6 months, and 12 months after GPOEM, respectively (F_1.71,18.83 = 14.16; P < .0005). Compared with controls, patients who underwent GPOEM had significant reductions in GCSI, after we controlled for baseline score and duration of the disease (F_1,31 = 9.001; P = .005). Patients who received GPOEM had significant reductions in number of emergency department visits (from 2.2 ± 3.1 times/mo at baseline to 0.3 ± 0.8 times/mo; P = .003) and hospitalizations (from 1.7 ± 2 times/mo at baseline to 0.2 ± 0.4 times/mo; P = .0002).

CONCLUSIONS

In a retrospective study of patients who underwent GPOEM for refractory gastroparesis, we found the procedure significantly improved symptoms, increased quality of life, and reduced health care use related to gastroparesis.

Outcomes of Per Oral Endoscopic Pyloromyotomy in the United States

Per oral endoscopic pyloromyotomy (POP) has emerged as an endoscopic intervention for refractory gastroparesis. Early experience in the United States showed exciting clinical response rate, reduced gastroparesis symptoms, improved quality of life, and decreased gastric-emptying time during midterm follow-up up to 18 months. One recent study also showed that the number of patient emergency room visits and hospitalizations decreased significantly after POP. The procedure is technically feasible and safe. As more data become available, it is important to identify patients who would benefit most from this novel procedure.

Chronic constipation

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

Effect of Acupuncture on Postoperative Ileus after Distal Gastrectomy for Gastric Cancer

Purpose

Acupuncture has recently been accepted as a treatment option for managing postoperative ileus (POI) and various functional gastrointestinal disorders. Therefore, we conducted a prospective randomized study to evaluate the effect of acupuncture on POI and other surgical outcomes in patients who underwent gastric surgery.

Materials and Methods

Thirty-six patients who underwent distal gastrectomy for gastric cancer from March to December 2015 were randomly assigned to acupuncture or non-acupuncture (NA) groups at 1:1 ratio. The acupuncture treatment was administered treatment once daily for 5 consecutive days starting at postoperative day 1. The primary outcome measure was the number of remnant sitz markers in the small intestine on abdominal radiograph. The secondary outcome measure was the surgical outcome, including the times to first flatus, first defecation, start of water intake, and start of soft diet, as well as length of hospital stay and laboratory findings.

Results

The acupuncture group had significantly fewer remnant sitz markers in the small intestine on postoperative days 3 and 5 compared to those in the NA group. A significant difference was observed in the numbers of remnant sitz markers in the small intestine with respect to group differences by time (P<0.0001). The acupuncture group showed relatively better surgical outcomes than those in the NA group, but the differences were not statistically significant.

Conclusions

In this clinical trial, acupuncture promoted the passage of sitz markers, which may reflect the possibility of reducing POI after distal gastrectomy.

Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes

BACKGROUND

Gastroparesis is a poorly understood, chronic, debilitating motility disorder with very limited medical therapeutic options. Gastric peroral endoscopic pyloromyotomy (G-POEM) is an emerging novel endoscopic technique as an incisionless pyloroplasty for refractory cases. Effective information of G-POEM on different types of gastroparesis is sparse.

METHODS

Cases of G-POEM using selective circular myotomy as a salvage therapy for refractory symptoms were retrospective studied. The G-POEM procedures were performed by a single expert endoscopist under a certain protocol. Gastroparesis Cardinal Symptoms Index (GCSI) and gastric emptying scintigraphy (GES) were evaluated before and after the procedure. Procedures related adverse event were also recorded.

KEY RESULTS

All procedures were successfully completed without complications. Each case in this series was different in demography and etiology of gastroparesis, namely postsurgical, postinfectious, and idiopathic gastroparesis in an elderly male and two young female adults. All cases were refractory to conventional treatment but demonstrated obvious success after G-POEM as a salvage therapy both clinically and on GES.

CONCLUSIONS & INFERENCES

G-POEM as a salvage therapy improves symptoms and gastric emptying in patients with different types of refractory gastroparesis. Our cases are also the firsts to show success of G-POEM in postinfectious gastroparesis and in elderly male patient. More data are needed to determine which subgroup of patients would benefit most from this novel procedure.

Effect of Acupuncture on Reducing Duration of Postoperative Ileus After Gastrectomy in Patients with Gastric Cancer: A Pilot Study Using Sitz Marker

OBJECTIVES

Postoperative ileus (POI) is a common problem after abdominal surgery. Acupuncture is being accepted as an option for reducing POI and managing various functional gastrointestinal disorders. Therefore, this pilot study was conducted to evaluate the effect of acupuncture on reducing duration of POI and other surgical outcomes in patients who underwent gastric surgery.

DESIGN

A prospective, randomized, controlled pilot study was conducted on patients who underwent gastric cancer surgery from January 2013 to December 2013. Ten patients were randomly assigned into the acupuncture (A) or nonacupuncture (NA) groups at a 1:1 ratio.

INTERVENTIONS

The acupuncture treatment was performed by Korean traditional medicine doctors (KMDs). The style of acupuncture was Korean. In the A group, acupuncture treatment was given once daily for 5 consecutive days starting on postoperative day 1. Each patient received acupuncture at 16 acupoints based on expert consensus provided by qualified and experienced KMDs. No acupuncture treatment was performed in the NA group.

OUTCOME MEASURES

The primary outcome measure was the number of remnant Sitz markers in the small intestine on abdominal radiography. Secondary outcome measures were time to first flatus, start of sips water, start of soft diet, hospital stay, and laboratory findings.

RESULTS

The A group had significantly fewer remnant Sitz markers in the small intestine on postoperative days 3 and 5 compared with those in the NA group (p = 0.025 and 0.005). A significant difference was observed in the numbers of remnant Sitz marker in the small intestine with respect to time difference by group (p = 0.019). The A group showed relatively better surgical outcomes, but without statistical significance.

CONCLUSIONS

Although further studies are warranted, acupuncture may reduce duration of POI after gastric surgery and could be a potential factor in enhanced recovery after surgery protocols.

Application Failure Mode and Effects Analysis Reveals Failure Modes for Interferential Stimulation Therapy in Treating Chronic Constipation

Transcutaneous electrical stimulation (TES) is used to treat chronic constipation in the home environment. Incorrect application of TES may lead to ineffective therapy. We used an application failure mode and effects analysis (AFMEA) to analyze and rank problems. In developing mitigation options to minimize or eliminate failure modes, we identified design and engineering requirements for a new, simple-to-use stimulation system to deliver TES at home for treating chronic constipation, and educational material required to train clinicians, patients, and users. This provided a structured approach to the analysis and design of an improved device for treating chronic constipation.

A novel dynamic scintigraphic technique for assessing duodenal contractions during gastric emptying in humans: a feasibility study

Duodenal contractions are thought to play a role in the control of gastric emptying. Although noninvasive techniques, such as ultrasonography and MRI, have been proposed for studying duodenal contractile activity in humans, there are no reports on the use of scintigraphy for this purpose. This work aimed to describe a novel scintigraphic technique for assessing duodenal contractility during gastric emptying in humans, and to present preliminary data on the frequency and amplitude of contractions detected in three different duodenal segments. Fasted young healthy volunteers (N=12) were given either a liquid or a solid test meal of similar calorie content (400 kcal) labeled with 99mTc-phytate. Static images were collected to determine gastric emptying. Dynamic images of the anterior aspect of the abdomen (1 frame/s) were also acquired periodically in a standard position for 256 s at 15-30 min intervals. 'Activity versus time' curves were generated for regions of interest corresponding to the proximal, middle, and distal duodenal segments. Curves were digitally filtered and processed to estimate both dominant frequency (fast Fourier transform) and amplitude (mean ejection fraction) of postprandial duodenal contractions. There were no significant differences regarding dominant frequency among proximal, middle, and distal duodenal regions of interest. In addition, there were no significant differences between the liquid and the solid meal in terms of either frequency or amplitude of duodenal contractions. Characterization of duodenal contractions in humans using scintigraphy is feasible and yields consistent data for both the frequency and the amplitude of postprandial contractions, which seems to be rather independent of meal consistency.

Colonic transit in children and adolescents with chronic constipation

OBJECTIVE

The aim of this study was to assess clinical features and colonic transit patterns in Brazilian children with refractory constipation.

METHODS

From 2010 to 2013, 79 constipated patients received follow-up care in a tertiary hospital. Of these patients, 28 (aged 8-14 years) were refractory to conventional therapy and underwent a simplified visual method of nuclear colonic transit study, by ingestion of a liquid meal containing 9.25 MBq/kg of (99m)Tc-phytate. Abdominal static images were taken immediately and at two, six, 24, 30, and 48h after ingestion for qualitative analysis of the radio marker progression through the colon.

RESULTS

Two patterns of colonic transit were found: slow colonic transit (SCT, n=14), when images at 48h showed a larger part of the tracer remained in proximal and transverse colon, and distal retention (DR, n=14), when after 30h, the radio isotope passed the transverse colon and was retained in the rectosigmoid up to 48h. The SCT and DR group included, respectively, nine and ten males; median ages in the nuclear study of 11 and 10 years, p=0.207; median duration of constipation of seven and six years, p=0.599. Constipation appearing during first year age (p=0.04) and report of soft stools (p=0.02) were more common in SCT patients. Palpable abdominal fecal impaction was found only in DR group. Appendicostomy for antegrade continence enema was successful in 4/12 (30%) of SCT patients (median follow-up: 2.4 years).

CONCLUSION

Nuclear transit study distinguished two colonic dysmotility patterns and was useful for guiding refractory patients to specific therapies.

Scintigraphy in laryngopharyngeal and gastroesophageal reflux disease: A definitive diagnostic test?

AIM: To investigate the utility of scintigraphic studies in predicting response to laparoscopic fundoplication (LF) for chronic laryngopharyngeal reflux symptoms.

METHODS: Patients with upper aero-digestive symptoms that remained undiagnosed after a period of 2 mo were studied with conventional pH and manometric studies. Patients mainly complained of cough, sore throat, dysphonia and globus. These patients were imaged after ingestion of 99m-technetium diethylene triamine pentaacetic acid. Studies were quantified with time activity curves over the pharynx, upper and lower oesophagus and background. Late studies of the lungs were obtained for aspiration. Patients underwent LF with post-operative review at 3 mo after surgery.

RESULTS: Thirty four patients (20 F, 14 M) with an average age of 57 years and average duration of symptoms of 4.8 years were studied. Twenty four hour pH and manometry studies were abnormal in all patients. On scintigraphy, 27/34 patients demonstrated pharyngeal contamination and a rising or flat pharyngeal curve. Lung aspiration was evident in 50% of patients. There was evidence of pulmonary aspiration in 17 of 34 patients in the delayed study (50%). Pharyngeal contamination was found in 27 patients. All patients with aspiration showed pharyngeal contamination. In the 17 patients with aspiration, graphical time activity curve showed rising activity in the pharynx in 9 patients and a flat curve in 8 patients. In those 17 patients without pulmonary aspiration, 29% (5 patients) had either a rising or flat pharyngeal graph. A rising or flat curve predicted aspiration with a positive predictive value of 77% and a negative predictive value of 100%. Over 90% of patients reported a satisfactory symptomatic response to LF with an acceptable side-effect profile.

CONCLUSION: Scintigraphic reflux studies offer a good screening tool for pharyngeal contamination and aspiration in patients with gastroesophageal reflux disease.

Identification of clinical outcome measures for recovery of gastrointestinal motility in postoperative ileus

OBJECTIVE

To identify clinical hallmarks associated with recovery of gastrointestinal transit.

BACKGROUND

Impaired gastrointestinal transit or postoperative ileus largely determines clinical recovery after abdominal surgery. However, validated clinical hallmarks of gastrointestinal recovery to evaluate new treatments and readiness for discharge from the hospital are lacking.

METHODS

Gastric emptying and colonic transit were scintigraphically assessed from postoperative day 1 to 3 in 84 patients requiring elective colonic surgery and were compared with clinical parameters. The clinical hallmark that best reflected recovery of gastrointestinal transit was validated using data from a multicenter trial of 320 segmental colectomy patients.

RESULTS

Seven of 84 patients developed a major complication with paralytic ileus characterized by total inhibition of gastrointestinal motility and were excluded from further analysis. In the remaining patients, recovery of colonic transit (defined as geometric center of radioactivity ≥2 on day 3), but not gastric emptying, was significantly correlated with clinical recovery (ρ = -0.59, P < 0.001). Conversely, the combined outcome measure of tolerance of solid food and having had defecation (SF + D) (area under the curve = 0.9, SE = 0.04, 95% CI = 0.79-0.95, P < 0.001), but not time to first flatus, best indicated recovery of gastrointestinal transit with a positive predictive value of 93% (95% CI = 78-99). Also in the main clinical trial, multiple regression analysis revealed that SF + D best predicted the duration of hospital stay.

CONCLUSIONS

Our data indicate that the time to SF + D best reflects recovery of gastrointestinal transit and therefore should be considered as primary outcome measure in future clinical trials on postoperative ileus.(Netherlands National Trial Register, number NTR1884 and NTR222).

Evaluation of gastroesophageal reflux before and after sleeve gastrectomy using symptom scoring, scintigraphy, and endoscopy

BACKGROUND

The effect of laparoscopic sleeve gastrectomy (SG) on gastroesophageal reflux disease (GERD) has been a controversial issue. There have been limited studies on this aspect and most of the published studies are retrospective. Therefore, a prospective study was designed to objectively assess the problem. The objective of this study was to assess the impact of SG on symptoms of gastroesophageal reflux using questionnaire, endoscopy, and radionuclide scintigraphy.

METHODS

Thirty-two patients undergoing laparoscopic sleeve gastrectomy were assessed for gastroesophageal reflux using Carlsson Dent Questionnaire and GERD questionnaire before and after surgery at three monthly intervals. They were also subjected to upper GI endoscopy (UGIE) and radionuclide scintigraphy both pre- and postoperatively.

RESULTS

Mean preoperative weight and body mass index were 126.5 kg and 47.8 kg/m2, respectively. Mean percent excess weight loss at 12 months was 64.3 ± 18.4. Both the Carlsson Dent Score (CDS) and Severity Score (SS) exhibited a decline from 2.88 to 1.63 (p<0.05) and 2.28 to 1.06 (p<0.05), respectively after 12 months. Radionuclide scintigraphy revealed a significant rise of GERD from 6.25% to 78.1% in the postoperative period (p<0.001). UGIE showed a rise in incidence of esophagitis from 18.8% to 25%; however, there was improvement in all patients except one in terms of reduction of severity of esophagitis.

CONCLUSION

Presence of GERD may not be considered as a contra-indication for sleeve gastrectomy. There is improvement of GERD as assessed by symptom questionnaires, as well as improvement in grade of esophagitis. The new onset GERD detected on scintigraphy may not be pathologic as there is a decrease in total acid production postsurgery; however, it still remains an important issue and needs long-term follow-up.

Nausea predicts delayed gastric emptying in children

OBJECTIVES

To assess whether the gastroparesis cardinal symptom index (GCSI), or any individual symptom, is associated with delayed gastric emptying in children, and to assess understanding of symptoms associated with delayed gastric emptying.

STUDY DESIGN

Fifty children (36 F), 5-18 years of age, undergoing gastric emptying scintigraphy (GES) at Lurie Children's Hospital in Chicago, Illinois, completed Likert-type GCSI and symptom comprehension questionnaires. Correlation of GES results (normal or abnormal) with questionnaire results using the Wilcoxon rank sum test.

RESULTS

Seventy percent of subjects had a normal GES. Children reported understanding most terms of GCSI (average score 2.59, range 0-3). The GCSI was not associated with delayed gastric emptying. Nausea was associated with delayed gastric emptying only (numerical P = .04, word P = .02). Results were not altered when poorly understood terms were excluded.

CONCLUSIONS

The GCSI is not associated with delayed gastric emptying in children. Lack of association does not seem to be related to lack of understanding. Nausea alone was the only symptom that showed an association with delayed gastric emptying on GES.

Delayed small bowel transit in children with cystic fibrosis and pancreatic insufficiency

OBJECTIVE

Gastrointestinal disturbances are common in people with cystic fibrosis (CF); however, motility studies in this population have yielded inconsistent results. This study examined gastric emptying (GE) and small bowel transit (SBT) time in children with CF and pancreatic insufficiency compared with a healthy adult reference group.

METHODS

Participants consumed an 8-ounce liquid test meal (approximately 550 calories, 32 g of fat) labeled with 300 μCi 99m technetium (Tc) sulfur colloid. Subjects with CF received a standard dose of pancreatic enzymes before consuming the test meal. GE and SBT were measured using a standard nuclear medicine scan. GE was determined after correcting for 99mTc decay in both anterior and posterior images. SBT was determined by following the movement of the tracer from the stomach to the cecum. The percentage arrival of total small bowel activity at the terminal ileum and cecum/ascending colon at 6 hours was used as an index of SBT. A 1-way analysis of covariance was performed for comparisons between groups after adjustment for age, sex, and body mass index.

RESULTS

Subjects with CF (n = 16) had similar GE compared with the healthy reference group (n = 12); however, subjects with CF had significantly prolonged SBT time. At 6 hours, 37.2% ± 25.4% (95% CI 23.7-50.7) of the tracer reached the terminal ileum and colon compared with 68.6% ± 13.1% (95% CI 60.2-76.9) for the reference group (P < 0.001). After controlling for sex, age, and body mass index, this difference remained statistically significant (F = 12.06, adjusted R = 0.44, P < 0.002).

CONCLUSIONS

Children with CF and pancreatic insufficiency had unaltered GE but delayed SBT time when taking pancreatic enzymes.

Gastric emptying of water in children with severe functional fecal retention

The objective of this study was to evaluate gastric emptying (GE) in pediatric patients with functional constipation. GE delay has been reported in adults with functional constipation. Gastric emptying studies were performed in 22 children with chronic constipation, fecal retention and fecal incontinence, while presenting fecal retention and after resuming regular bowel movements. Patients (18 boys, median age: 10 years; range: 7.2 to 12.7 years) were evaluated in a tertiary pediatric gastroenterology clinic. Gastric half-emptying time of water (reference range: 12 ± 3 min) was measured using a radionuclide technique immediately after first patient evaluation, when they presented fecal impaction (GE₁), and when they achieved regular bowel movements (GE₂), 12 ± 5 weeks after GE₁. At study admission, 21 patients had reported dyspeptic symptoms, which were completely relieved after resuming regular bowel movements. Medians (and interquartile ranges) for GE₁ and GE₂ were not significantly different [27.0 (16) and 27.5 (21) min, respectively (P = 0.10)]. Delayed GE seems to be a common feature among children with chronic constipation and fecal retention. Resuming satisfactory bowel function and improvement in dyspeptic symptoms did not result in normalization of GE data.

Comparison of continuous breath test and gastric scintigraphy for the measurement of gastric emptying rate in healthy and dyspeptic individuals

OBJECTIVE

To determine normative gastric emptying rates for the continuous breath test and to compare its findings with gastric scintigraphy in healthy volunteers and dyspeptic patients.

METHODS

A standard 250 kcal meal double-labeled with 1 mCi 99mTc colloid and 100 μg nonradioactive 13C-octanoic acid was administered to 20 healthy individuals and 22 dyspeptic patients attending a tertiary medical center in 2009-2010. Gastric emptying rate was measured simultaneously with sequential gastric scintigraphy and the continuous breath test. The results of the healthy controls were used as a normative reference. The findings of the two tests were analyzed by linear regression and κ statistics. In addition, the gastric half-emptying times (T ½) were compared by a κ test for evaluating the agreement of normal/abnormal results in both methods.

RESULTS

Background features were as follows: healthy individuals - 15 men/5 women, mean age 44.9 ± 14 years and mean BMI 26.8 ± 3.5; dyspeptic patients - 5 men/17 women, mean age 58.0 ± 13 years and mean BMI 25.3 ± 5.5. The upper limit of normal for gastric half-emptying time (T ½) was 140 min by the breath test. The linear correlation of T ½ between the methods was 0.64. The agreement of normal/abnormal T ½ between the methods was 0.65.

CONCLUSION

The continuous breath test may be a suitable method for the evaluation of gastric emptying. A larger study is required to determine its feasibility as the standard of care in dyspeptic patients.

Use of scintigraphy to evaluate gastric accommodation and emptying: comparison with barostat

BACKGROUND AND AIM

Scintigraphy is a useful noninvasive technique for assessment of gastric motility, especially emptying, but there is little knowledge of use of the technique to assess gastric accommodation. Therefore, to clarify the usefulness of scintigraphy as a technique for assessing gastric accommodation, we compared scintigraphy with barostat, the gold standard modality.

METHODS

Twenty healthy volunteers (14 men, six women; mean age, 28.5 ± 5.4 years) were enrolled in the study. The volunteers ingested a radiolabeled ((99m) Tc) test meal and scintigraphic images were recorded. Radioactivity in the upper third and whole stomach was calculated to evaluate accommodation. In the barostat procedure, gastric accommodation was evaluated by measuring the maximum volume of the distended balloon. Thereafter, correlation between scintigraphic and barostat accommodation was investigated. Intra-and inter-observer variation of the scintigraphic test results were also assessed. Finally, the diagnostic performance of scintigraphy was evaluated by using sumatriptan as a positive control.

RESULTS

Measurements of accommodation by scintigraphy and barostat correlated (r = 0.524, P < 0.05). Sumatriptan significantly increased scintigraphically measured gastric accommodation (with sumatriptan, 51.5 ± 16.4%; without sumatriptan, 38.4 ± 13.8%) (P < 0.01), and had significantly (P < 0.05) delayed 50% half emptying time at 60, 90, 120, and 150 min after the start of the experiment. The data from repeated scintigraphic tests were highly reproducible (r = 0.804) with significant differences not observed among the investigators (inter-observer variation = 0.932, intra-observer variation = 0.898).

CONCLUSION

Gastric scintigraphy is a useful technique for assessing gastric accommodation and emptying.

Interferential therapy: a new treatment for slow transit constipation. a pilot study in adults

AIM

The study aimed to assess, for the first time, the effectiveness of interferential therapy (IFT) in the treatment of slow transit constipation in adults and its impact on the quality of life.

METHOD

All consecutive patients with slow transit constipation diagnosed by symptomology and a colonic transit time (CTT) of > 100 h measured with radiopaque markers were included in this prospective study. IFT was performed for 1 h/day over 3 months. Clinical improvement was based on the stool diary and the Knowles-Eccersley-Scott Symptom and Cleveland Clinic Constipation Scores. Quality of life was assessed with the Gastrointestinal Quality of Life Index questionnaire.

RESULTS

Eleven patients with a median age of 51 years were included. At the end of the follow-up period, seven (63.6%) had significantly improved after IFT with a median of 0.66 stools per week [interquartile range (IQR) 0.33-0.66] before treatment and 1.66 (IQR 1.33-1.66) after (P = 0.007). The Knowles-Eccersley-Scott Symptom score changed from 30 (IQR 27-33) before treatment to 19 (IQR 17-26) after treatment (P = 0.005) and the Cleveland Clinic Constipation Score from 26 (IQR 25-28) to 17 (IQR 13-24; P = 0.005). The CTT improved from 103 h (IQR 101-113) to 98 h (IQR 94-107; P = 0.02). The Gastrointestinal Quality of Life Index score improved from 60 (IQR 57-63) to 95 (IQR 68-100; P = 0.005).

CONCLUSION

IFT is a new non-invasive treatment for slow transit constipation. Further studies to confirm these results with longer follow-up are necessary.

Ileal and faecal protein digestibility measurement in humans and other non-ruminants – a comparative species view

A comparative non-ruminant species view of the contribution of the large intestinal metabolism to inaccuracies in nitrogen and amino acid absorption measurements is provided to assess potential implications for the determination of crude protein/amino acid digestibility in adult humans consuming lower digestible protein sources. Most of the amino acids in the hindgut are constituents of the microorganisms and significant microbial metabolism of dietary and endogenous amino acids occurs. Bacterial metabolism of nitrogen-containing compounds leads to a significant disappearance of nitrogen in the large intestine. Literature data show that some 79 % of the nitrogen entering the large intestine of the horse is absorbed. For dogs, sows, and growing pigs these estimates are 49, 34 and 16 %, respectively. The coefficient of gut differentiation of humans compares closely to that of dogs while the coefficient of fermentation in humans is the lowest of all non-ruminant species and closest to that of cats and dogs. Large intestinal digesta transit times of humans compare closest to adult dogs. Significant amino acid metabolism has been shown to occur in the large intestine of the adult dog. Use of the growing pig as an animal model is likely to underestimate the fermentation of amino acids in the human large intestine. Based on the significant degree of fermentation of nitrogen-containing components in the large intestine of several non-ruminant species, it can be expected that determination of amino acid digestibility at a faecal level in humans consuming low quality proteins would not provide accurate estimates of the amino acids absorbed by the intestine.

Planar scintigraphic imaging of the gastrointestinal tract in clinical practice

In the last 30 years, nuclear medicine has paralleled other imaging fields with the development of 3-dimensional techniques, including single-photon emission computed tomography and positron emission tomography. However, conventional nuclear medicine planar scintigraphy remains a common procedure at most imaging centers. Gastrointestinal studies constitute a significant portion of these planar procedures. The most common gastrointestinal studies, including hepatobiliary, gastric emptying, and gastrointestinal bleeding evaluations, resemble their original protocol. However, serial improvements have optimized the diagnostic efficacy of these procedures. Conventional Technetium-99m sulfur colloid liver/spleen imaging and hepatic blood pool imaging with labeled red blood cells now mainly serve an adjunctive role in the evaluation of equivocal findings on computed tomography. Salivary gland imaging is a less commonly requested evaluation, but can be used to evaluate functional capacity in some disease entities.

Assessment of gastric motor function in childhood functional dyspepsia and obesity

BACKGROUND

The aim was to compare gastric emptying rate and nutrient tolerance during a satiety drinking test in children with functional dyspepsia (FD) and obesity and to study the relationship between daily caloric intake and the satiety drinking test.

METHODS

A total of 28 dyspeptic children (22 girls, mean age 12.5 ± 3.1 years) and 15 obese children (five girls, 13.3 ± 1.8 years) were studied. The patients underwent an octanoic acid gastric emptying breath test and a satiety drinking test. Prior to both tests, a dyspepsia questionnaire was filled out to calculate the mean calorie intake.

KEY RESULTS

The most prevalent dyspeptic symptoms were early satiety (96.4%), postprandial fullness (89.2%), and epigastric pain (78.6%), followed by nausea (50%). All dyspeptic and obese children (n = 43) started the satiety drinking test and 41 children completed the test until a score of 5 was reached. The maximum ingested volume in FD was significantly lower than in obesity or in age-matched healthy controls (252 ± 85 vs 479 ± 199 and 359 ± 29 mL respectively, both P < 0.05). As a group, dyspeptic children had significantly slower gastric emptying than obese children (89.7 ± 54.8 min vs 72.5 ± 26.0 min, P = 0.05). Daily calorie intake was significantly higher in obese children than that in dyspeptic children (2325 ± 469 vs 1503 ± 272 cal, P < 0.0001). The endpoint of the satiety drinking test was significantly correlated with body weight or BMI (both R = 0.41, P = 0.04), but not with daily calorie intake, gastric emptying rate or age.

CONCLUSIONS & INFERENCES

The satiety drinking test is a potentially useful non-invasive tool in the investigation of children with FD and obesity.

How to interpret a functional or motility test - colon transit study

Measurement of colon transit time is the most basic and primary tool in evaluating disorders of colonic motility. In particular, it is helpful in pathologic diagnosis and for planning management in patients with constipation. Several techniques for measuring colon transit time currently exist. The standard measurement of colon transit time has been performed using radioopaque marker test. The radioopaque marker test is the most widely used method; it is simple to perform as well as being cost effective. But, this technique produces radiation exposure. Radionuclide scintigraphy and wireless motility capsules are other techniques used to measure colon transit time. In radionuclide scintigraphy, the transit of radioisotope is viewed by gamma camera; this approach has an advantage in that it uses minimal radiation and it allows a physiological assessment of gastrointestinal transit. Wireless motility capsules have been validated most recently, but this technique is not useful in Korea. This review presents the techniques used to measure colon transit time and the interpretations provided in different colon transit studies.

Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery

BACKGROUND & AIMS

Postoperative ileus is characterized by delayed gastrointestinal (GI) transit and is a major determinant of recovery after colorectal surgery. Both laparoscopic surgery and fast-track multimodal perioperative care have been reported to improve clinical recovery. However, objective measures supporting faster GI recovery are lacking. Therefore, GI transit was measured following open and laparoscopic colorectal surgery with or without fast-track care.

METHODS

Patients (n = 93) requiring elective colonic surgery were randomized to laparoscopic or conventional surgery with fast-track multimodal management or standard care, resulting in 4 treatment arms. Gastric emptying and colonic transit were scintigraphically assessed from days 1 to 3 in 78 patients and compared with clinical parameters such as time to tolerance of solid food and/or bowel movement and time until (ready for) discharge.

RESULTS

A total of 71 patients without mechanical bowel obstructions or surgical complications requiring intervention were available for analysis. No differences in gastric emptying 24 hours after surgery between the different groups were observed (P = .61). However, the median colonic transit of patients undergoing laparoscopic/fast-track care was significantly faster compared with the laparoscopic/standard, open/fast-track, and open/standard care groups. Multiple linear regression analysis showed that both laparoscopic surgery and fast-track care were significant independent predictive factors of improved colonic transit. Both were associated with significantly faster clinical recovery and shorter time until tolerance of solid food and first bowel movement.

CONCLUSIONS

Colonic transit recovers significantly faster after laparoscopic surgery and the fast-track program; laparoscopy and fast-track care lead to faster recovery of GI motility and improve clinical recovery.

Gastroesophageal reflux scintigraphy: interpretation methods and inter-reader agreement

BACKGROUND

Scintigraphic imaging is a useful screening tool for patients with suspected gastroesophageal reflux. New scintigraphic interpretation methods have recently been introduced. This study was undertaken to evaluate the efficiency of various scintigraphic interpretation methods in the detection of gastroesophageal reflux and to measure their influence on inter-reader agreement.

METHODS

Scintigraphic images of 49 children with suspected gastroesophageal reflux were interpreted by three different methods: visual interpretation, time activity curves, and condensed images. The readings were performed by three specialists and a resident. The discordant results were resolved by a consensus reading done together by all interpreters based on the three different methods. The gastroesophageal refluxes were grouped according to their number, location and intensity.

RESULTS

Gastroesophageal reflux scintigraphy revealed 22 patients with negative results and 27 with positive results. The sensitivity, positive predictive value and specificity for each of the three specialists vs. the resident were 96%, 96% and 81% vs. 96%; 93%, 90% and 96% vs. 81%; and 90%, 86%, and 95% vs. 73%, respectively. The mean inter-observer reproducibility (κ value) was 0.910 for visual interpretation, 0.652 for time activity curves and 0.789 for condensed images. Twenty-seven percent of the results were discordant and most of these refluxes were of low grade (92%), low intensity (77%) and localization in the distal esophagus (54%).

CONCLUSION

Gastroesophageal scintigraphy is a useful tool for detecting patients with suspected reflux, and visual interpretation is better than the other two methods in terms of accuracy and inter-observer reproducibility.

Optimizing the diagnostic power with gastric emptying scintigraphy at multiple time points

Background

Gastric Emptying Scintigraphy (GES) at intervals over 4 hours after a standardized radio-labeled meal is commonly regarded as the gold standard for diagnosing gastroparesis. The objectives of this study were: 1) to investigate the best time point and the best combination of multiple time points for diagnosing gastroparesis with repeated GES measures, and 2) to contrast and cross-validate Fisher's Linear Discriminant Analysis (LDA), a rank based Distribution Free (DF) approach, and the Classification And Regression Tree (CART) model.

Methods

A total of 320 patients with GES measures at 1, 2, 3, and 4 hour (h) after a standard meal using a standardized method were retrospectively collected. Area under the Receiver Operating Characteristic (ROC) curve and the rate of false classification through jackknife cross-validation were used for model comparison.

Results

Due to strong correlation and an abnormality in data distribution, no substantial improvement in diagnostic power was found with the best linear combination by LDA approach even with data transformation. With DF method, the linear combination of 4-h and 3-h increased the Area Under the Curve (AUC) and decreased the number of false classifications (0.87; 15.0%) over individual time points (0.83, 0.82; 15.6%, 25.3%, for 4-h and 3-h, respectively) at a higher sensitivity level (sensitivity = 0.9). The CART model using 4 hourly GES measurements along with patient's age was the most accurate diagnostic tool (AUC = 0.88, false classification = 13.8%). Patients having a 4-h gastric retention value >10% were 5 times more likely to have gastroparesis (179/207 = 86.5%) than those with ≤10% (18/113 = 15.9%).

Conclusions

With a mixed group of patients either referred with suspected gastroparesis or investigated for other reasons, the CART model is more robust than the LDA and DF approaches, capable of accommodating covariate effects and can be generalized for cross institutional applications, but could be unstable if sample size is limited.

Postgastrectomy nutrition

Gastric resection, whether partial or total gastrectomy, often results in nutrition-related complications including weight loss, diet intolerances, and micronutrient deficiencies. The physiology of normal and postgastrectomy digestion is the basis for most of the current diet recommendations after gastric surgery. A careful review reveals that there is not sufficient literature to support a standard postgastrectomy diet. Rather, individualized diet manipulation for symptom relief is recommended. This review highlights the physiology behind common postgastrectomy complications, provides guidelines for the medical and nutrition management of these complications, and presents a basic approach to postgastrectomy gastrointestinal symptoms.

Colonic dysmotility in constipation

Constipation is a common and distressing condition with major morbidity, health care burden, and impact on quality of life. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in the most severe cases of chronic constipation and physiological testing plays a role in identifying the colonic dysmotility and the subsequent patient management. Measurement of colonic motor patterns and transit has enhanced our knowledge of normal and abnormal colonic motor physiology. The scope of this review encompasses the latest findings that improve our understanding of the motility disorders associated with colonic dysfunction in both the paediatric and adult population suffering from constipation.

What is necessary to diagnose constipation?

Constipation is a common ailment with multiple symptoms and diverse etiology. Understanding the pathophysiology is important to guide optimal management. During the past few years, there have been remarkable developments in the diagnosis of constipation and defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular mechanisms of chronic constipation. These include use of digital rectal examination, Bristol stool scale, colonic scintigraphy, wireless motility capsule for assessment of colonic and whole gut transit, high resolution anorectal manometry, and colonic manometry. These tests provide a better definition of the underlying mechanism(s), which in turn can lead to improved management of this condition. In this review, we summarize the recent advances in diagnostic testing with a particular emphasis on when and why to test, and discuss the utility of diagnostic tests for chronic constipation.

Effects of meal size and proximal-distal segmentation on gastric activity

AIM: To evaluate the effects of meal size and three segmentations on intragastric distribution of the meal and gastric motility, by scintigraphy.

METHODS: Twelve healthy volunteers were randomly assessed, twice, by scintigraphy. The test meal consisted of 60 or 180 mL of yogurt labeled with 64 MBq ^99mTc-tin colloid. Anterior and posterior dynamic frames were simultaneously acquired for 18 min and all data were analyzed in MatLab. Three proximal-distal segmentations using regions of interest were adopted for both meals.

RESULTS: Intragastric distribution of the meal between the proximal and distal compartments was strongly influenced by the way in which the stomach was divided, showing greater proximal retention after the 180 mL. An important finding was that both dominant frequencies (1 and 3 cpm) were simultaneously recorded in the proximal and distal stomach; however, the power ratio of those dominant frequencies varied in agreement with the segmentation adopted and was independent of the meal size.

CONCLUSION: It was possible to simultaneously evaluate the static intragastric distribution and phasic contractility from the same recording using our scintigraphic approach.

What is new in radiology and pathology of motility disorders in children?

Disorders affecting colorectal motility lead to significant morbidity in children with surgical conditions. Etiology is frequently unknown, which in turn makes treatment empiric and compromises outcome. A thorough understanding of the normal mechanisms of control and the ability to recognize and manage defects is an important goal for clinicians. This article reviews recent advances made in the investigation of children with colorectal motility disorders, including the role of transit studies (marker studies and scintigraphy), options for assessing anatomy (ultrasound, contrast enema, and sectional imaging) and the use of manometry, both anorectal and colonic. Current concepts in microscopic evaluation are outlined.