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Camilleri M. Abnormal gastrointestinal motility is a major factor in explaining symptoms and a potential therapeutic target in patients with disorders of gut-brain interaction. Gut 2023; 72:2372-2380. [PMID: 37666657 PMCID: PMC10841318 DOI: 10.1136/gutjnl-2023-330542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023]
Abstract
The objective of this article is to review the evidence of abnormal gastrointestinal (GI) tract motor functions in the context of disorders of gut-brain interaction (DGBI). These include abnormalities of oesophageal motility, gastric emptying, gastric accommodation, colonic transit, colonic motility, colonic volume and rectal evacuation. For each section regarding GI motor dysfunction, the article describes the preferred methods and the documented motor dysfunctions in DGBI based on those methods. The predominantly non-invasive measurements of gut motility as well as therapeutic interventions directed to abnormalities of motility suggest that such measurements are to be considered in patients with DGBI not responding to first-line approaches to behavioural or empirical dietary or pharmacological treatment.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Wang Y, Chen JDZ, Nojkov B. Diagnostic Methods for Evaluation of Gastric Motility-A Mini Review. Diagnostics (Basel) 2023; 13:803. [PMID: 36832289 PMCID: PMC9955554 DOI: 10.3390/diagnostics13040803] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/11/2023] [Accepted: 02/18/2023] [Indexed: 02/23/2023] Open
Abstract
Gastric motility abnormalities are common in patients with disorders of gut-brain interaction, such as functional dyspepsia and gastroparesis. Accurate assessment of the gastric motility in these common disorders can help understand the underlying pathophysiology and guide effective treatment. A variety of clinically applicable diagnostic methods have been developed to objectively evaluate the presence of gastric dysmotility, including tests of gastric accommodation, antroduodenal motility, gastric emptying, and gastric myoelectrical activity. The aim of this mini review is to summarize the advances in clinically available diagnostic methods for evaluation of gastric motility and describe the advantages and disadvantages of each test.
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Affiliation(s)
| | | | - Borko Nojkov
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, USA
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Baker JR, Curtin BF, Moshiree B, Rao SSC. Organizing and Developing a GI Motility Lab in Community Practice: Challenges and Rewards. Curr Gastroenterol Rep 2022; 24:73-87. [PMID: 35674875 DOI: 10.1007/s11894-022-00838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Neurogastroenterology and motility is a rapidly evolving subspecialty that encompasses over 33% of gastroenterological disorders, and up to 50% of referrals to gastroenterology practice. It includes common problems such as dysphagia, gastroesophageal reflux disease, irritable bowel syndrome, chronic constipation, gastroparesis, functional dyspepsia, gas/bloating, small intestinal bacterial overgrowth, food intolerance and fecal incontinence Standard diagnostic tests such as endoscopy or imaging are normal in these conditions. To define the underlying mechanism(s)/etiology of these disorders, diagnostic motility tests are often required. These are best performed by well-trained personnel in a dedicated motility laboratory. Our purpose is to provide an up-to-date overview on how to organize and develop a motility laboratory based on our collective experiences in setting up such facilities in academia and community practice. RECENT FINDINGS A lack of knowledge, training and facilities for providing diagnostic motility tests has led to suboptimal patient care. A motility laboratory is the hub for diagnostic and therapeutic motility procedures. Common procedures include esophageal function tests such as esophageal manometry and pH monitoring, anorectal function tests suchlike anorectal manometry, neurophysiology and balloon expulsion, dysbiosis and food intolerance tests such as hydrogen/methane breath tests, and gastrointestinal transit assessment. These tests provide an accurate diagnosis and guide clinical management including use of medications, biofeedback therapy, neuromodulation, behavioral therapies, evidence-based dietary interventions and endoscopic or surgical procedures. Further, there have been recent developments in billing and coding of motility procedures and training requirements that are not well known. This review provides a stepwise approach on how to set-up a motility laboratory in the community or academic practice and includes the rationale, infrastructure, staffing needs, commonly performed motility tests and their clinical utility, billing and coding strategies, training needs and economic considerations for setting up this service.
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Affiliation(s)
- Jason R Baker
- Atrium Health, Charlotte, NC, USA.,Neurogastroenterology and Motility Laboratory, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28209, USA
| | - Bryan F Curtin
- Division of Neurogastroenterology, The Institute for Digestive and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | | | - Satish S C Rao
- Division of Neurogastroenterology/Motility, Augusta University Medical Center, Augusta, GA, USA.
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Strunz PP, Vuille-Dit-Bille RN, R Fox M, Geier A, Maggiorini M, Gassmann M, Fruehauf H, Lutz TA, Goetze O. Effect of high altitude on human postprandial 13 C-octanoate metabolism, intermediary metabolites, gastrointestinal peptides, and visceral perception. Neurogastroenterol Motil 2022; 34:e14225. [PMID: 34342373 DOI: 10.1111/nmo.14225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE At high altitude (HA), acute mountain sickness (AMS) is accompanied by neurologic and upper gastrointestinal symptoms (UGS). The primary aim of this study was to test the hypothesis that delayed gastric emptying (GE), assessed by 13 C-octanoate breath testing (OBT), causes UGS in AMS. The secondary aim was to assess post-gastric mechanisms of OBT, which could confound results under these conditions, by determination of intermediary metabolites, gastrointestinal peptides, and basal metabolic rate. METHODS A prospective trial was performed in 25 healthy participants (15 male) at 4559 m (HA) and at 490 m (Zurich). GE was assessed by OBT (428 kcal solid meal) and UGS by visual analogue scales (VAS). Blood sampling of metabolites (glucose, free fatty acids (FFA), triglycerides (TG), beta-hydroxyl butyrate (BHB), L-lactate) and gastrointestinal peptides (insulin, amylin, PYY, etc.) was performed as well as blood gas analysis and spirometry. STATISTICAL ANALYSIS variance analyses, bivariate correlation, and multilinear regression analysis. RESULTS After 24 h under hypoxic conditions at HA, participants developed AMS (p < 0.001). 13 CO2 exhalation kinetics increased (p < 0.05) resulting in reduced estimates of gastric half-emptying times (p < 0.01). However, median resting respiratory quotients and plasma profiles of TG indicated that augmented beta-oxidation was the main predictor of accelerated 13 CO2 -generation under these conditions. CONCLUSION Quantification of 13 C-octanoate oxidation by a breath test is sensitive to variation in metabolic (liver) function under hypoxic conditions. 13 C-breath testing using short-chain fatty acids is not reliable for measurement of gastric function at HA and should be considered critically in other severe hypoxic conditions, like sepsis or chronic lung disease.
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Affiliation(s)
- Patrick-Pascal Strunz
- Division of Rheumatology and Immunology, Department of Medicine II, University Hospital Wurzburg, Germany
| | | | - Mark R Fox
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Digestive Diseases, Klinik Arlesheim, Arlesheim, Switzerland
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University Hospital Wurzburg, Germany
| | - Marco Maggiorini
- Institute of Intensive Care, University Hospital Zurich, Zurich, Switzerland
| | - Max Gassmann
- Institute of Veterinary Physiology, Vetsuisse Faculty and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Heiko Fruehauf
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zentrum für Gastroenterologie und Hepatologie, Zurich, Switzerland
| | - Thomas A Lutz
- Institute of Veterinary Physiology, Vetsuisse Faculty and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Oliver Goetze
- Division of Hepatology, Department of Medicine II, University Hospital Wurzburg, Germany
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Keller J, Hammer HF, Afolabi PR, Benninga M, Borrelli O, Dominguez-Munoz E, Dumitrascu D, Goetze O, Haas SL, Hauser B, Pohl D, Salvatore S, Sonyi M, Thapar N, Verbeke K, Fox MR. European guideline on indications, performance and clinical impact of 13 C-breath tests in adult and pediatric patients: An EAGEN, ESNM, and ESPGHAN consensus, supported by EPC. United European Gastroenterol J 2021; 9:598-625. [PMID: 34128346 PMCID: PMC8259225 DOI: 10.1002/ueg2.12099] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction 13C‐breath tests are valuable, noninvasive diagnostic tests that can be widely applied for the assessment of gastroenterological symptoms and diseases. Currently, the potential of these tests is compromised by a lack of standardization regarding performance and interpretation among expert centers. Methods This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of 13C‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 43 experts from 18 European countries. Consensus on individual statements and recommendations was established if ≥ 80% of reviewers agreed and <10% disagreed. Results The guideline gives an overview over general methodology of 13C‐breath testing and provides recommendations for the use of 13C‐breath tests to diagnose Helicobacter pylori infection, measure gastric emptying time, and monitor pancreatic exocrine and liver function in adult and pediatric patients. Other potential applications of 13C‐breath testing are summarized briefly. The recommendations specifically detail when and how individual 13C‐breath tests should be performed including examples for well‐established test protocols, patient preparation, and reporting of test results. Conclusion This clinical practice guideline should improve pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, this guideline identifies areas of future clinical research involving the use of 13C‐breath tests.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital University of Hamburg, Hamburg, Germany
| | - Heinz F Hammer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Paul R Afolabi
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK
| | - Enrique Dominguez-Munoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago, Spain
| | | | - Oliver Goetze
- Department of Medicine II, Division of Hepatology, University Hospital Würzburg, Würzburg, Germany
| | - Stephan L Haas
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussels, Brussels, Belgium
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Marc Sonyi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria.,Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK.,Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Australia
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Mark R Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
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Keller J, Hammer HF, Hauser B. 13 C-gastric emptying breath tests: Clinical use in adults and children. Neurogastroenterol Motil 2021; 33:e14172. [PMID: 33998745 DOI: 10.1111/nmo.14172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/28/2022]
Abstract
13 C-gastric emptying breath tests (13 C-GEBT) are validated, reliable, and non-invasive tools for measurement of gastric emptying (GE) velocity of solids and liquids without radiation exposure or risk of toxicity. They are recommended and routinely used for clinical purposes in adult as well as pediatric patients and can be readily performed onsite or even at the patient's home. However, the underlying methodology is rather complex and test results can be influenced by dietary factors, physical activity, concurrent diseases, and medication. Moreover, epidemiological factors can influence gastric emptying as well as production and exhalation of 13 CO2 , which is the ultimate metabolic product measured for all 13 C-breath tests. Accordingly, in this issue of Neurogastroenterology & Motility, Kovacic et al. report performance of the 13 C-Spirulina breath test in a large group of healthy children and show significant effects of gender, pubertal status, and body size on test results. The purpose of this mini-review is to evaluate the clinical use of 13 C-GEBT in adults and children, exploring available protocols, analytical methods, and essential prerequisites for test performance, as well as the role of GE measurements in the light of the current discussion on relevance of delayed GE for symptom generation.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital University of Hamburg, Hamburg, Germany
| | - Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussel, Brussels, Belgium
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Chen X, Liu Y, Pan D, Cao M, Wang X, Wang L, Xu Y, Wang Y, Yan J, Liu J, Yang M. 68Ga-NOTA PET imaging for gastric emptying assessment in mice. BMC Gastroenterol 2021; 21:69. [PMID: 33581729 PMCID: PMC7881688 DOI: 10.1186/s12876-021-01642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Positron emission tomography (PET) has the potential for visualization and quantification of gastric emptying (GE). The traditional Chinese medicine (TCM) has been recognized promising for constipation. This study aimed to establish a PET imaging method for noninvasive GE measurement and to evaluate the efficacy of a TCM on delayed GE caused by constipation using PET imaging. METHODS [68Ga]Ga-NOTA was synthesized as the tracer and sesame paste with different viscosity were selected as test meals. The dynamic PET scans were performed after [68Ga]Ga-NOTA mixed with test meals were administered to normal mice. Two methods were utilized for the quantification of PET imaging. A constipation mouse model was treated with maren chengqi decoction (MCD), and the established PET imaging scans were performed after the treatment. RESULTS [68Ga]Ga-NOTA was synthesized within 20 min, and its radiochemical purity was > 95%. PET images showed the dynamic process of GE. %ID/g, volume, and total activity correlated well with each other. Among which, the half of GE time derived from %ID/g for 4 test meals were 3.92 ± 0.87 min, 13.1 ± 1.25 min, 17.8 ± 1.31 min, and 59.7 ± 3.11 min, respectively. Constipation mice treated with MCD showed improved body weight and fecal conditions as well as ameliorated GE measured by [68Ga]Ga-NOTA PET. CONCLUSIONS A PET imaging method for noninvasive GE measurement was established with stable radiotracer, high image quality, and reliable quantification methods. The efficacy of MCD on delayed GE was demonstrated using PET.
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Affiliation(s)
- Xueyan Chen
- Department of Veterinary Medicine, Southwest University, Rongchang, Chongqing, 402460, China
| | - Yu Liu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Donghui Pan
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Maoyu Cao
- Department of Veterinary Medicine, Southwest University, Rongchang, Chongqing, 402460, China
| | - Xinyu Wang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Lizhen Wang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Yuping Xu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Yan Wang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Junjie Yan
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China
| | - Juan Liu
- Department of Veterinary Medicine, Southwest University, Rongchang, Chongqing, 402460, China. .,Immunology Center, Medical Research Institute of Southwest University, Rongchang, Chongqing, 402460, China.
| | - Min Yang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, 214063, Jiangsu, China.
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Induction of Meal-related Symptoms as a Novel Mechanism of Action of the Duodenal-Jejunal Bypass Sleeve. J Clin Gastroenterol 2020; 54:528-535. [PMID: 32301829 DOI: 10.1097/mcg.0000000000001353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment with a duodenal-jejunal bypass sleeve (DJBS) induces clinically significant weight loss, but little is known about the mechanisms of action of this device. AIM The aim of this study was to characterize the mechanisms of action of the DJBS and determine the durability of weight loss and metabolic improvements. MATERIALS AND METHODS We studied a cohort of 19 subjects with severe obesity and type 2 diabetes (baseline body mass index: 43.7±5.3 kg/m). Anthropometry, body composition, blood pressure, biochemical measures, and dietary intake were monitored for 48 weeks after DJBS implantation, and then for 1 year after device removal. Gastric emptying and triglyceride absorption were measured at baseline, 8 weeks after implant, and within 3 weeks of device explant. Visceral sensory function was assessed at baseline, 4 weeks after implant, and within 3 weeks after explant. RESULTS Significant weight loss (P<0.01) occurred following DJBS placement, with a mean weight reduction of 17.0±6.5% at 48 weeks. The symptom burden following a standardized nutrient challenge was increased after DJBS implantation (P<0.05), returning to baseline after DJBS removal. Neither gastric emptying nor triglyceride absorption changed with the device in situ. A significant reduction in energy intake was observed [baseline: 7703±2978 kJ (1841±712 kcal), 24 weeks: 4824±2259 kJ (1153±540 kcal), and 48 weeks: 4474±1468 kJ (1069±351 kcal)]. After 1 year, anthropometry remained significantly improved, but there was no durable impact on metabolic outcomes. CONCLUSIONS DJBS treatment resulted in substantial weight loss. Weight loss is related to reduced caloric intake, which seems linked to an augmented upper gastrointestinal symptom response, but not altered fat absorption.
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Keller J, Bassotti G, Clarke J, Dinning P, Fox M, Grover M, Hellström PM, Ke M, Layer P, Malagelada C, Parkman HP, Scott SM, Tack J, Simren M, Törnblom H, Camilleri M. Expert consensus document: Advances in the diagnosis and classification of gastric and intestinal motility disorders. Nat Rev Gastroenterol Hepatol 2018; 15:291-308. [PMID: 29622808 PMCID: PMC6646879 DOI: 10.1038/nrgastro.2018.7] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Disturbances of gastric, intestinal and colonic motor and sensory functions affect a large proportion of the population worldwide, impair quality of life and cause considerable health-care costs. Assessment of gastrointestinal motility in these patients can serve to establish diagnosis and to guide therapy. Major advances in diagnostic techniques during the past 5-10 years have led to this update about indications for and selection and performance of currently available tests. As symptoms have poor concordance with gastrointestinal motor dysfunction, clinical motility testing is indicated in patients in whom there is no evidence of causative mucosal or structural diseases such as inflammatory or malignant disease. Transit tests using radiopaque markers, scintigraphy, breath tests and wireless motility capsules are noninvasive. Other tests of gastrointestinal contractility or sensation usually require intubation, typically represent second-line investigations limited to patients with severe symptoms and are performed at only specialized centres. This Consensus Statement details recommended tests as well as useful clinical alternatives for investigation of gastric, small bowel and colonic motility. The article provides recommendations on how to classify gastrointestinal motor disorders on the basis of test results and describes how test results guide treatment decisions.
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Affiliation(s)
- Jutta Keller
- Israelitic Hospital, Academic Hospital University of Hamburg, Orchideenstieg 14, 22297 Hamburg, Germany.,
| | - Gabrio Bassotti
- University of Perugia, Piazza dell’Università, 1, 06121 Perugia, Italy
| | - John Clarke
- Stanford University, 900 Blake Wilbur Dr, Palo Alto, CA 94304, USA
| | - Phil Dinning
- Flinders Medical Centre, GPO Box 2100, Adelaide 5001, Australia
| | - Mark Fox
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland, and St. Claraspital, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | | | - Per M. Hellström
- Uppsala University Hospital, Building 40, SE‑75185, Uppsala, Sweden
| | - Meiyun Ke
- Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Peter Layer
- Israelitic Hospital, Academic Hospital University of Hamburg, Orchideenstieg 14, 22297 Hamburg, Germany
| | - Carolina Malagelada
- University of Barcelona, Passeig de la Vall d’Hebron, 119–129, 08035 Barcelona, Spain
| | - Henry P. Parkman
- Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140, USA
| | - S. Mark Scott
- Queen Mary University of London, The Wingate Institute, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK
| | - Jan Tack
- University Hospital Gasthuisberg, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Magnus Simren
- Sahlgrenska Academy, University of Gothenburg, Blå stråket 5, 41345 Gothenburg, Sweden
| | - Hans Törnblom
- Sahlgrenska Academy, University of Gothenburg, Blå stråket 5, 41345 Gothenburg, Sweden
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Wilbaux M, Wölnerhanssen BK, Meyer-Gerspach AC, Beglinger C, Pfister M. Characterizing the dynamic interaction among gastric emptying, glucose absorption, and glycemic control in nondiabetic obese adults. Am J Physiol Regul Integr Comp Physiol 2016; 312:R314-R323. [PMID: 27974316 DOI: 10.1152/ajpregu.00369.2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 01/21/2023]
Abstract
The effects of altered gastric emptying on glucose absorption and kinetics are not well understood in nondiabetic obese adults. The aim of this work was to develop a physiology-based model that can characterize and compare interactions among gastric emptying, glucose absorption, and glycemic control in nondiabetic obese and lean healthy adults. Dynamic glucose, insulin, and gastric emptying (measured with breath test) data from 12 nondiabetic obese and 12 lean healthy adults were available until 180 min after an oral glucose tolerance test (OGTT) with 10, 25, and 75 g of glucose. A physiology-based model was developed to characterize glucose kinetics applying nonlinear mixed-effects modeling with NONMEM7.3. Glucose kinetics after OGTT was described by a one-compartment model with an effect compartment to describe delayed insulin effects on glucose clearance. After the interactions between individual gastric emptying and glucose absorption profiles were accounted for, the glucose absorption rate was found to be similar in nondiabetic obese and lean controls. Baseline glucose concentration was estimated to be only marginally higher in nondiabetic obese subjects (4.9 vs. 5.2 mmol/l), whereas insulin-dependent glucose clearance in nondiabetic obese subjects was found to be cut in half compared with lean controls (0.052 vs. 0.029 l/min) and the insulin concentration associated with 50% of insulin-dependent glucose elimination rate was approximately twofold higher in nondiabetic obese subjects compared with lean controls (7.1 vs. 15.3 μU/ml). Physiology-based models can characterize and compare the dynamic interaction among gastric emptying, glucose absorption and glycemic control in populations of interest such as lean healthy and nondiabetic obese adults.
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Affiliation(s)
- Mélanie Wilbaux
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland;
| | - Bettina K Wölnerhanssen
- Department of Biomedicine, Division of Gastroenterology and Hepatology, University Hospital of Basel, Basel, Switzerland; and
| | - Anne Christin Meyer-Gerspach
- Department of Biomedicine, Division of Gastroenterology and Hepatology, University Hospital of Basel, Basel, Switzerland; and
| | - Christoph Beglinger
- Department of Biomedicine, Division of Gastroenterology and Hepatology, University Hospital of Basel, Basel, Switzerland; and
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, Calfornia
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12
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Mechanisms Regulating Insulin Response to Intragastric Glucose in Lean and Non-Diabetic Obese Subjects: A Randomized, Double-Blind, Parallel-Group Trial. PLoS One 2016; 11:e0150803. [PMID: 26942445 PMCID: PMC4778796 DOI: 10.1371/journal.pone.0150803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 02/17/2016] [Indexed: 12/21/2022] Open
Abstract
Background/Objectives The changes in blood glucose concentrations that result from an oral glucose challenge are dependent on the rate of gastric emptying, the rate of glucose absorption and the rate of insulin-driven metabolism that include the incretins, glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1). The rate of insulin-driven metabolism is clearly altered in obese subjects, but it is controversial which of these factors is predominant. We aimed to quantify gastric emptying, plasma insulin, C-peptide, glucagon and glucose responses, as well as incretin hormone secretions in obese subjects and healthy controls during increasing glucose loads. Subjects/Methods The study was conducted as a randomized, double-blind, parallel-group trial in a hospital research unit. A total of 12 normal weight (6 men and 6 women) and 12 non-diabetic obese (BMI > 30, 6 men and 6 women) participants took part in the study. Subjects received intragastric loads of 10 g, 25 g and 75 g glucose dissolved in 300 ml tap water. Results Main outcome measures were plasma GLP-1 and GIP, plasma glucagon, glucose, insulin, C-peptide and gastric emptying. The primary findings are: i) insulin resistance (P < 0.001) and hyperinsulinemia (P < 0.001); ii) decreased insulin disposal (P < 0.001); iii) trend for reduced GLP-1 responses at 75 g glucose; and iv) increased fasting glucagon levels (P < 0.001) in obese subjects. Conclusions It seems that, rather than changes in incretin secretion, fasting hyperglucagonemia and consequent hyperglycemia play a role in reduced disposal of insulin, contributing to hyperinsulinemia and insulin resistance. Trial Registration ClinicalTrials.gov NCT01875575
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Keller J, Binnewies U, Rösch M, Juul Holst J, Beglinger C, Andresen V, Layer P. Gastric emptying and disease activity in inflammatory bowel disease. Eur J Clin Invest 2015; 45:1234-42. [PMID: 26426315 DOI: 10.1111/eci.12542] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/25/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastric emptying (GE) is delayed in a subset of patients with inflammatory bowel disease (IBD). We have shown before that altered release of gastrointestinal hormones may contribute to GE disturbances, but overall effects of disease activity remain unclear. Thus, we aimed to evaluate GE in patients with IBD during active disease and following therapy. DESIGN A total of 20 healthy subjects (HC) and 26 patients with IBD hospitalized because of an acute episode of their disease (Crohn's disease (CD) n = 13, ulcerative colitis (UC) n = 13) underwent a standardized (13) C-octanoic acid GE breath test (baseline test). Plasma glucose, cholecystokinin (CCK), peptide YY (PYY) and glucagon-like peptide-1 (GLP-1) were measured periodically throughout the test. A total of 16 patients underwent a second GE test after 3-4 months of therapy. RESULTS At baseline, nine patients with IBD had pathologically delayed GE half-time (T½ > 150 min) (P = 0·028 vs. HC). Moreover, T½ was significantly longer in the total group of patients with IBD than in HC (129 ± 12 min vs. 96 ± 7, P = 0·030). Postprandial GLP-1 responses were elevated in IBD (P = 0·002 vs. HC) and correlated with T½ (P = 0·05). Following therapy clinical activity indices and T½ were decreased in IBD (P ≤ 0·01 vs. baseline), and T½ no longer differed from HC (P > 0·5). Moreover, GLP-1 plasma levels decreased significantly (P = 0·031). CONCLUSIONS Higher disease activity in IBD is associated with prolonged GE and increased release of GLP-1. Following effective therapy, GE is accelerated and GLP-1 release decreases significantly. Thus, increased release of GLP-1 from the inflamed mucosa might contribute to GE disturbances in IBD.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany
| | - Ulrich Binnewies
- Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany
| | - Marie Rösch
- Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany
| | - Jens Juul Holst
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christoph Beglinger
- Department of Gastroenterology and Hepatology, Universitätsspital Basel, Basel, Switzerland
| | - Viola Andresen
- Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany
| | - Peter Layer
- Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany
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Influence of habitual physical activity on gastric emptying in healthy males and relationships with body composition and energy expenditure. Br J Nutr 2015; 114:489-96. [PMID: 26168984 DOI: 10.1017/s0007114515002044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although a number of studies have examined the role of gastric emptying (GE) in obesity, the influences of habitual physical activity level, body composition and energy expenditure (EE) on GE have received very little consideration. In the present study, we compared GE in active and inactive males, and characterised relationships with body composition (fat mass and fat-free mass) and EE. A total of forty-four males (active n 22, inactive n 22; BMI 21-36 kg/m2; percentage of fat mass 9-42%) were studied, with GE of a standardised (1676 kJ) pancake meal being assessed by the [13C]octanoic acid breath test, body composition by air displacement plethysmography, RMR by indirect calorimetry, and activity EE (AEE) by accelerometry. The results showed that GE was faster in active compared with inactive males (mean half-time (t 1/2): active 157 (sd 18) and inactive 179 (sd 21) min, P< 0.001). When data from both groups were pooled, GE t 1/2 was associated with percentage of fat mass (r 0.39, P< 0.01) and AEE (r - 0.46, P< 0.01). After controlling for habitual physical activity status, the association between AEE and GE remained, but not that for percentage of fat mass and GE. BMI and RMR were not associated with GE. In summary, faster GE is considered to be a marker of a habitually active lifestyle in males, and is associated with a higher AEE level and a lower percentage of fat mass. The possibility that GE contributes to a gross physiological regulation (or dysregulation) of food intake with physical activity level deserves further investigation.
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Prokinetic drugs for gastric emptying in critically ill ventilated patients: Analysis through breath testing. J Crit Care 2015; 30:655.e7-13. [PMID: 25746849 DOI: 10.1016/j.jcrc.2014.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/28/2014] [Accepted: 12/30/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE The prupose was to identify, through the BreathID automatic breath-testing device, the best prokinetic therapy to enhance gastric-emptying rate (GER) in ventilated intensive care unit patients. MATERIALS AND METHODS This was a prospective, crossover, nonrandomized study. Consecutive ventilated patients who could be fed enterally and expected to require 5 days of ventilation were included. (13)C-labeled-acetate in 100 mL Osmolite (BreathID; Exalenz Bioscience Ltd, Jerusalem, Israel) was administered intragastrically and followed by a 4-hour continuous recording of expiratory (13)CO2 by the BreathID. Prokinetics were changed daily: (1) baseline (no prokinetic), (2) intravenous (IV) metoclopramide (10 mg every 6 hours), (3) IV metoclopramide (10 mg every 6 hours) and continuous low-dose erythromycin (10 mg/h), (4) IV continuous low-dose erythromycin alone (10 mg/h), and (5) IV bolus erythromycin (200 mg every 12 hours). Gastric-emptying rate was assessed by the percentage dose recovered (PDR)-change from time 0 of the recording in the ratio of (13)CO2/(12)CO2 in exhaled gases (%/h). We used PDR peak values and time to peak (minutes to reach PDR peak) to express GER. RESULTS In the first 17 patients (group A), baseline GER measurements preceded prokinetic therapy. In the subsequent 14 patients (group B), 2 prokinetic regimens preceded baseline. No order-time effect was observed, justifying pooled analysis of all 31 patients. Combined metoclopramide-continuous low-dose erythromycin yielded significantly higher PDR peak and shorter time to peak vs baseline (P = .0001, P = .005, respectively). The PDR peak was also significantly higher from baseline during continuous low-dose administration of erythromycin alone (P = .004). Metoclopramide alone did not improve GER significantly. CONCLUSIONS Combined metoclopramide-continuous low-dose erythromycin was found to be the best protocol in the current study to increase GER in ventilated patients. It should be tested as a first-line prokinetic therapy in ventilated patients with poor gastric emptying in further randomized controlled studies. The breath-test device presented in this study can be a user-friendly and practical method to monitor GER, enabling individual tailoring of prokinetic therapy. Further studies to explore its utility are warranted.
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Abstract
OPINION STATEMENT Gastroparesis is defined as the presence of delayed gastric emptying in the absence of mechanical obstruction, with a variety of upper gastrointestinal symptoms. Although measurement of gastric emptying is necessary for the diagnostic labeling, this finding has little impact in terms of explaining the symptom pattern and determining the prognosis and therapeutic approach. Clinical management is based on ruling out of mechanical causes and serum electrolyte imbalances, followed by initial medical treatment with a gastroprokinetic agent in most cases. However, the evidence that these drugs provide substantial symptomatic benefit is weak. Recent attempts to establish efficacy with newer prokinetics, including serotonin-4, motilin, and ghrelin receptor agonists, have seen few successes, but a new group of agents is under evaluation. More recently, also, no benefit was found with treatment with a tricyclic antidepressant in idiopathic gastroparesis. In refractory cases, especially when there is weight loss, invasive therapeutics such as insertion of feeding tubes, intrapyloric injection of botulinum toxin, implantable gastric electrical stimulation, or surgical (partial) gastrectomy are occasionally considered, but there is little evidence of efficacy, and these are not devoid of potentially major complications. Gastroparesis is likely to remain a challenging condition in the clinic in the foreseeable future.
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Abstract
OBJECTIVE The clinical relevance of pancreatic exocrine insufficiency (PEI) in diabetic patients is unclear mostly because established function tests are invasive and expensive or lack sensitivity and specificity. A modified version of the noninvasive 13C-mixed triglyceride breath test (13C-MTGT) has recently been shown to detect moderate PEI reliably in patients with chronic pancreatitis. Its sensitivity and specificity in other patient groups are unknown. We therefore aimed to clarify the significance of this test for patients with diabetes mellitus (DM). METHODS A secretin cerulein test and a modified 13C-MTGT were performed in 14 patients with DM (10 patients with type 1 DM) and 10 healthy volunteers. RESULTS Secretin cerulein test showed significantly lower outputs of amylase, trypsin, and lipase in DM compared with healthy volunteers (P < 0.05). Likewise, 13C-MTGT showed significantly lower maximal and cumulative 13C-exhalation in DM (P < 0.005). Stimulated lipase output correlated with cumulative 13C-exhalation (P < 0.05). However, when compared with normal values, only 2 patients with diabetes had abnormally low lipase output, whereas cumulative 13C-exhalation was pathologically decreased in 8 patients, including those with decreased lipase output. CONCLUSIONS The noninvasive 13C-MTGT can detect mild to moderate PEI in DM. However, the specificity of the 13C-MTGT is low in these patients probably because nonpancreatic mechanisms contribute to decreased intestinal lipolysis.
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Keller J, Meier V, Wolfram KU, Rosien U, Layer P. Sensitivity and specificity of an abbreviated (13)C-mixed triglyceride breath test for measurement of pancreatic exocrine function. United European Gastroenterol J 2014; 2:288-94. [PMID: 25083286 PMCID: PMC4114120 DOI: 10.1177/2050640614542496] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 05/22/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A modified (13)C-mixed triglyceride breath test ((13)C -MTGT) detects moderate pancreatic exocrine insufficiency noninvasively and reliably, but it requires prolonged breath sampling (6 hours (hr)). OBJECTIVE We aimed to investigate whether (13)C -MTGT can be abbreviated, to optimize clinical usability. METHODS We analyzed the (13)C-MTGT of 200 consecutive patients, retrospectively. Cumulative 1-5 hr (13)C-exhalation values were compared with the standard parameter (6-hr cumulative (13)C-exhalation). We determined the sensitivity and specificity of shortened breath sampling periods, by comparison with the normal values from 10 healthy volunteers, whom also underwent a secretin test to quantitate pancreatic secretion. Moreover, we evaluated the influence of gastric emptying (GE), using a (13)C-octanoic acid breath test in a subset (N = 117). RESULTS The 1-5 hr cumulative (13)C-exhalation tests correlated highly and significantly with the standard parameter (p < 0.0001). Sensitivity for detection of impaired lipolysis was high (≥77%), but the specificity was low (≥38%) for the early measurements. Both parameters were high after 4 hrs (88% and 94%, respectively) and 5 hrs (98% and 91%, respectively). Multivariate linear correlation analysis confirmed that GE strongly influenced early postprandial (13)C-exhalation during the (13)C-MTGT. CONCLUSION Shortening of the (13)C -MTGT from 6 to 4 hrs of duration was associated with similar diagnostic accuracy, yet increased clinical usability. The influence of GE on early postprandial results of the (13)C-MTGT precluded further abbreviation of the test.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
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Gastric and intestinal satiation in obese and normal weight healthy people. Physiol Behav 2014; 129:265-71. [PMID: 24582673 DOI: 10.1016/j.physbeh.2014.02.043] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 01/17/2014] [Accepted: 02/18/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The gastrointestinal tract plays a key role in feelings of satiation. It is known that there is a reciprocal interaction between the stomach and intestine, but it is not known which factors are of gastric origin and which are intestinal. This three-step study therefore sought to provide illumination on satiation parameters with respect to body mass. METHOD In the first part, the time needed to reach maximal satiation and total caloric intake was calculated after participants (20 normal weight, 20 obese) imbibed a standardized nutrient drink. In the second part gastric emptying of solids and liquids was evaluated using the (13)C-breath test (participants: 16 normal weight, 9 obese for gastric emptying of solids; 15 normal weight, 14 obese for gastric emptying of liquids). And in the third part, fasting and post-prandial plasma glucagon-like peptide-1 (GLP-1), peptide tyrosine tyrosine (PYY) and ghrelin levels were measured after a standardized nutrient drink (participants: 20 normal weight, 20 obese). RESULTS Our results show that, when compared to those of normal weight, obese participants reached maximal satiation sooner (P=0.006), their total intake of calories was higher (P=0.013), and their gastric emptying rates were delayed (P<0.001). Furthermore, their post-prandial increase in plasma GLP-1 and PYY was reduced, (P<0.001 for both), as was their ghrelin suppression (P=0.001). DISCUSSION We conclude that, in obese subjects gastric emptying can be impaired with delayed interaction of nutrients with the intestine resulting in decreased GLP-1 and PYY secretion. This could imply that obese participants would require more calories before their maximal satiation is reached and they stop eating.
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Kuyumcu S, Goetze O, Menne D, Treier R, Boesiger P, Fox M, Fried M, Schwizer W, Steingoetter A. Gastric secretion does not affect the reliability of the 13C-acetate breath test: A validation of the 13C-acetate breath test by magnetic resonance imaging. Neurogastroenterol Motil 2013; 25:176-e87. [PMID: 23066987 DOI: 10.1111/nmo.12025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND (13)C-Acetate labeled meals are widely used to determine meal emptying by means of analyzing resulting (13)CO(2) exhalation dynamics. In contrast to the underlying metabolic processes, only few (13)C breath test meal emptying studies have focused on intragastric processes that may alter (13)CO(2) exhalation. This work assessed the effect of enhanced gastric secretion on the reliability of half emptying time (t50) measurements by (13)C-acetate breath test. METHODS (13)CO(2) exhalation data were acquired in a double-blind, randomized, cross-over gastric emptying study in 12 healthy volunteers receiving either pentagastrin or placebo intravenously. The standard method proposed by Ghoos et al. was applied to calculate t50 (t50_Ghoos) from (13)CO(2) exhalation data, which were compared and tested for agreement to meal half emptying times (t50_MV) from concurrent recorded MRI (magnetic resonance imaging) volume data. In addition, the accumulated gastric secretion volumes during infusion as detected by MRI (AUC_SV(60)) were correlated with the corresponding cumulative percent (13)C doses recovered (cPDR(60)). KEY RESULTS t50_Ghoos and t50_MV showed a linear correlation with a slope of 1.1 ± 0.3 (r(2) = 0.67), however, a positive offset of 136 min for t50_Ghoos. No correlation was detected between AUC_SV(60) and cPDR(60) (r(2) = 0.11). Both, breath test and MRI, revealed a prolonged t50 under pentagastrin infusion with median differences in t50_Ghoos of 45[28-84] min (P = 0.002) and t50_MV of 39[28-52] min (P = 0.002). CONCLUSIONS & INFERENCES This study suggests that (13)CO(2) exhalation after ingestion of a (13) C-labeled liquid test meal is not affected by stimulated gastric secretion, but is rather reflecting the dynamics of meal or caloric emptying from the stomach.
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Affiliation(s)
- S Kuyumcu
- Division of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
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Sugimachi K, Shirabe K, Tokunaga N, Akiho H, Taketomi A, Soejima Y, Gion T, Nakamura K, Higashi H, Maehara Y. Assessment of delayed gastric emptying after major hepatectomy using a 13C-acetic acid breath test. Surg Today 2012; 42:1046-50. [PMID: 22941387 DOI: 10.1007/s00595-012-0321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/12/2011] [Indexed: 11/26/2022]
Abstract
PURPOSES Delayed gastric emptying (DGE) after hepatectomy affects the quality of life of patients, although the causes and related conditions have not been investigated. This study evaluated the relationship between hepatectomy and DGE by the objective assessment of gastric emptying (GE). METHODS Nineteen patients who underwent major hepatectomy were prospectively enrolled in the study. Their GE was studied using the (13)C-acetic acid breath test before and after hepatectomy. The results of the GE analysis were correlated with the postoperative course after hepatectomy. RESULTS Clinically evident DGE, which was defined as the inability to take in an appropriate amount of solid food orally by postoperative day 14, was not found in these patients, but the gastric half-emptying times before and after hepatectomy were 20.2 ± 9.7 and 28.6 ± 12.2 min, respectively (P = 0.01). The GE time was significantly delayed in patients aged ≥ 41 years, or who underwent right hemihepatectomy. CONCLUSIONS Gastric emptying was significantly inhibited in patients who underwent major hepatectomy, and aging and a right-sided hemihepatectomy may be related to the development of DGE.
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Affiliation(s)
- Keishi Sugimachi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan.
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Marie I, Gourcerol G, Leroi AM, Ménard JF, Levesque H, Ducrotté P. Delayed gastric emptying determined using the 13C-octanoic acid breath test in patients with systemic sclerosis. ACTA ACUST UNITED AC 2012; 64:2346-55. [DOI: 10.1002/art.34374] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Ogungbenro K, Aarons L. A semi-mechanistic gastric emptying pharmacokinetic model for (13)C-octanoic acid: an evaluation using simulation. Eur J Pharm Sci 2012; 45:302-10. [PMID: 22155547 DOI: 10.1016/j.ejps.2011.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 10/25/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
Abstract
The aim of this paper is to assess the performance of a new mechanistic model for analysing (13)C-octanoic acid breath test data using simulation studies. The (13)C-octanoic acid breath test is widely used for indirect assessment of the rate of gastric emptying and it is yet to achieve universal acceptance due to inconsistencies when the results are compared with simultaneous and direct measurements using scintigraphy. The new semi-mechanistic model has five separate compartments; stomach, intestine, central and peripheral body and breath compartments. Stomach and breath profiles were simulated for 50 individuals under four conditions: variability on all parameters; no variability on the rate constant of gastric emptying and the rate constant of absorption; variability on the rate constant of gastric emptying and the rate constant of absorption only; and no variability on all parameters. A mono-exponential model was fitted to the stomach profile and the new semi-mechanistic model and three other widely used methods were fitted to the breath profiles. The gastric emptying half times from stomach profiles correlate better (R(2)=1,1,1,1 for the four conditions) with the half emptying times from the semi-mechanistic model compared with half emptying times from the modified exponential model (R(2)=0.72,0.53,0.88,1), Ghoos method (R(2)=0.72,0.54,0.88,1) and Wagner-Nelson method (R(2)=0.79,0.68,0.89,1) for the four simulation studies. The semi-mechanistic model is very effective for the assessment of GE using the (13)C-octanoic acid breath test and could be applied in the development of drugs that influence GE.
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Affiliation(s)
- Kayode Ogungbenro
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom.
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Abstract
OBJECTIVES The noninvasive ¹³C-mixed triglyceride breath test (¹³C-MTG-T) has been shown to diagnose severe pancreatic exocrine insufficiency reliably. We hypothesized that sensitivity of the test could be increased by strict limitation of physical activity, correction for gastric emptying velocity, and/or increased lipid dose. METHODS In 10 healthy volunteers and 9 patients with suspected pancreatic disease, a secretin test, a modified ¹³C-MTG-T (250 mg ¹³C-MTG, 26 g fat, breath samples over 8 hours), and a ¹³C-octanoic acid gastric emptying test were performed. Subjects remained strictly seated during breath testing. RESULTS Intravenously administered secretin 1 U/kg·h stimulated outputs of all enzymes significantly. Mean basal and stimulated enzyme outputs were similar in patients and healthy controls; however, compared with normal values, 5 patients and 1 control had moderately decreased lipase output. Cumulative 4-, 6-, and 8-hour ¹³C exhalation was significantly lower in patients than in controls. Sensitivity of ¹³C-MTG-T (6-h cumulative ¹³C exhalation <27% of dose) for detection of decreased lipase output was 100%; specificity was 92%. Gastric emptying parameters were similar in patients and controls, and correction for these did not improve accuracy of ¹³C-MTG-T. CONCLUSIONS The modified ¹³C-MTG-T detects moderate pancreatic exocrine insufficiency.
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Ogungbenro K, Aarons L. Structural identifiability analysis of pharmacokinetic models using DAISY: semi-mechanistic gastric emptying models for 13C-octanoic acid. J Pharmacokinet Pharmacodyn 2011; 38:279-92. [PMID: 21347679 DOI: 10.1007/s10928-011-9193-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 02/11/2011] [Indexed: 11/27/2022]
Abstract
Structural identifiability analysis is necessary for efficient parameter estimation and it is concerned with determination of whether the parameters in a model can be identified from specified experiments with perfect input-output data. Structural identifiability analysis is very important in mathematical modelling of biological and biomedical experiments and should be considered at the design stage of these experiments. There are three possible outcomes from a structural identifiability analysis; globally/uniquely identifiable, locally/non-uniquely identifiable or non-identifiable/unidentifiable. An ideal outcome is a globally/uniquely identifiable model, however a locally/non-uniquely identifiable outcome can help to identify areas of the model or experiment that need improvement. Despite the importance of structural identifiability analysis, it is still not widely used due to the heavy computational burden involved and the lack of software. A new software package, DAISY, that implemented differential algebra for identifiability analysis was recently released. DAISY is freely available, easy to use and does not require any high-level programming skill. The (13)C-octanoic acid breath test is now widely used for assessing the rate of gastric emptying in patients. Unlike scintigraphy, which is the gold standard and is a direct measure of the rate of gastric emptying, the (13)C-octanoic acid breath test is an indirect method for assessing the rate of gastric emptying. However the (13)C-octanoic acid breath test is cheaper, safer and easy to perform. Because the rate of excretion of (13)CO(2) in breath does not only reflect the rate of gastric emptying but other processes involved between the ingestion of (13)C-octanoic acid and elimination of (13)CO(2) in breath, the parameters commonly derived from the excretion data are not direct measures of gastric emptying. The aim of this paper was to propose a new semi-mechanistic model for the analysis of (13)C-octanoic acid breath excretion data and demonstrate the use of DAISY to assess the identifiability of the model. One- and two-compartment disposition models were linked to a model which has separate compartments for the stomach, intestine and breath. To obtain a globally identifiable model, a repeated (13)C-octanoic breath test in the same individual experimental design was also investigated and this adds a separate stomach compartment to the model. Finally the gastric emptying rate constant from the first (13)C-octanoic breath test was constrained to be the same as the absorption rate constant from the intestine. From the structural identifiability analysis carried out in DAISY, the model based on two experiments (baseline and treatment) and a constraint is globally identifiable. In summary, the present work describes a new semi-mechanistic model that will allow efficient and reliable assessment of the rate of gastric emptying from the (13)C-octanoic breath test.
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Affiliation(s)
- Kayode Ogungbenro
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Rao SSC, Camilleri M, Hasler WL, Maurer AH, Parkman HP, Saad R, Scott MS, Simren M, Soffer E, Szarka L. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies. Neurogastroenterol Motil 2011; 23:8-23. [PMID: 21138500 DOI: 10.1111/j.1365-2982.2010.01612.x] [Citation(s) in RCA: 231] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Disorders of gastrointestinal (GI) transit and motility are common, and cause either delayed or accelerated transit through the stomach, small intestine or colon, and affect one or more regions. Assessment of regional and/or whole gut transit times can provide direct measurements and diagnostic information to explain the cause of symptoms, and plan therapy. PURPOSE Recently, several newer diagnostic tools have become available. The American and European Neurogastroenterology and Motility Societies undertook this review to provide guidelines on the indications and optimal methods for the use of transit measurements in clinical practice. This was based on evidence of validation including performance characteristics, clinical significance, and strengths of various techniques. The tests include measurements of: gastric emptying with scintigraphy, wireless motility capsule, and (13)C breath tests; small bowel transit with breath tests, scintigraphy, and wireless motility capsule; and colonic transit with radioopaque markers, wireless motility capsule, and scintigraphy. Based on the evidence, consensus recommendations are provided for each technique and for the evaluations of regional and whole gut transit. In summary, tests of gastrointestinal transit are available and useful in the evaluation of patients with symptoms suggestive of gastrointestinal dysmotility, since they can provide objective diagnosis and a rational approach to patient management.
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Affiliation(s)
- S S C Rao
- Division of Gastroenterology/Hepatology, University of Iowa Carver College of Medicine, Iowa City, IA 52242-1009, USA.
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A Semi-mechanistic Gastric Emptying Model for the Population Pharmacokinetic Analysis of Orally Administered Acetaminophen in Critically Ill Patients. Pharm Res 2010; 28:394-404. [DOI: 10.1007/s11095-010-0290-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 09/20/2010] [Indexed: 10/19/2022]
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Deane AM, Zaknic AV, Summers MJ, Chapman MJ, Lange K, Ritz MA, Davidson G, Horowitz M, Fraser RJL. Intrasubject variability of gastric emptying in the critically ill using a stable isotope breath test. Clin Nutr 2010; 29:682-6. [PMID: 20409622 DOI: 10.1016/j.clnu.2010.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 03/03/2010] [Accepted: 03/11/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Isotope breath tests are increasingly used to evaluate the effects of prokinetic drugs on gastric emptying. The aim was to assess intrasubject variability in gastric emptying, when using an isotope breath test in the critically ill. METHODS A retrospective analysis of data was undertaken in 12 patients who had gastric emptying measurements on consecutive days using a (13)C-octanoic acid breath test. The gastric emptying coefficient--GEC (a global index for the gastric emptying rate), and the t(50) (calculated time for 50% of meal to empty) were calculated, together with the coefficient of variability for these parameters. Data are mean (SD). RESULTS Neither GEC (day 1: 3.3 (0.8) vs. day 2: 3.1 (0.6); P = 0.31) nor t(50) (day 1: 127 (43) min vs. day 2: 141 (48) min; P = 0.46) were significantly different between the two days. Intrasubject variability was less for GEC (15.6%) than for t(50) (31.8%). CONCLUSION There is only modest intrasubject variability in GEC measurements using the (13)C-octanoic acid breath test in critically ill patients. As such, it may be an acceptable measurement tool to assess the effects of prokinetic drugs in this group.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.
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13CO2 breath tests, a tool to assess intestinal and liver function in the ICU? Curr Opin Crit Care 2010; 16:169-75. [DOI: 10.1097/mcc.0b013e3283376739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Verbeke K. Will the 13C-octanoic acid breath test ever replace scintigraphy as the gold standard to assess gastric emptying? Neurogastroenterol Motil 2009; 21:1013-6. [PMID: 19737258 DOI: 10.1111/j.1365-2982.2009.01388.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The applicability of the 13C-octanoic acid breath test for the assessment of gastric emptying is discussed. In the current issue of this journal, Keller and her colleagues described the application of different mathematical models for analysis of the 13C-octanoic acid test in a very large patient population.
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Affiliation(s)
- K Verbeke
- Department of Gastrointestinal Research, University of Leuven, Leuven, Belgium.
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