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Freiberg B. Can an Abnormal Gastric Emptying Study Be Normal? J Nucl Med Technol 2025:jnmt.124.269182. [PMID: 40037658 DOI: 10.2967/jnmt.124.269182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 02/04/2025] [Indexed: 03/06/2025] Open
Abstract
The American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine and Molecular Imaging collaboratively wrote consensus statements to standardize gastric emptying scintigraphy. Despite this, centers are using nonstandard protocols. This study examined how these protocols contrast with standards. Methods: Consecutive charts were analyzed for meal, radionuclide dose, half-emptying time (T½) and its normal range, and documented retention and emptying. Impressions were compared with how emptying mapped on a graph based on standard 4-h values. Results: Thirty-four studies were identified. Ten of 14 abnormal studies were normal when plotted on the standard 4-h graph. Eight of 10 abnormal studies had normal 2- or 4-h retention. Normal T½ ranges varied significantly. Most altered the meal, and over 25% received a radionucleotide dose outside the recommended range. Conclusion: The upper bound of normal T½ falls within standard 4-h bounds, with many individuals given an erroneous impression. Though further optimization may be needed, adhering to standards is critical.
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Affiliation(s)
- Ben Freiberg
- Pediatric Gastroenterology, Cleveland Clinic Children's, Cleveland, Ohio
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Wulfeck MK, Ramis P, Hillman A, Nielsen P, Rohren EM. Beyond the Standard Meal: An Observational Analysis of Meals Used in Nuclear Medicine Gastric Emptying Studies. Clin Nucl Med 2025; 50:214-218. [PMID: 39668481 DOI: 10.1097/rlu.0000000000005635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2024]
Abstract
RATIONALE Standardized guidelines for meals used in adult gastric emptying studies (GES) have been available since 2009; however, there is still great variability in the diets that are clinically used in these studies. The purpose of this retrospective study is to perform an observational analysis of GES meals that are used within a national radiology practice to assess for compliance. It is hypothesized that despite having well-validated standardized meal protocols, there remains great variability in its use and interpretation. METHODS This retrospective observational analysis included 11,458 GESs and their associated reports. GES meals were divided into 5 categories including solid, liquid, dual liquid and solid, alternative meals, and other. Further analysis was performed on the solid and liquid meal GESs. The total amount of studies performed with each meal was collected as well as the percentages of the results of each study categorized as normal, delayed, rapid, and limited. RESULTS A total of 10,602 studies were included in the analysis, which included 9974 solid meals and 628 liquid meals. Of the solid meal type, the standard recommended meal was used most often followed by the protein variant meal. The oatmeal protocol had the least number of delayed results; however, there was otherwise a similar distribution of results for the remaining solid meal variants. The most common liquid meal utilized the nutritional drink or protein shake, and compared with the solid meal types, there were less rapid or limited results. CONCLUSIONS Variability remains in clinical practice regarding the type of meal that is used in GESs as well as in the interpretation of the study. Continued reinforcement of the standardized solid meal diet and validated cutoff values for interpretation remains crucial until there is increased validation and standardization of other diets.
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Shargo R, Luongo M, Mhaskar R, Lu PL, Wilsey M. Assessing the Clinical Value of 2-h Versus 4-h Gastric Emptying Scintigraphy in Pediatrics: A Systematic Review and Meta-Analysis. Neurogastroenterol Motil 2025; 37:e14978. [PMID: 39638920 DOI: 10.1111/nmo.14978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 11/11/2024] [Accepted: 11/23/2024] [Indexed: 12/07/2024]
Abstract
INTRODUCTION The gold-standard diagnostic test for gastroparesis is gastric emptying scintigraphy (GES). Although a 4-h GES is recommended in adult guidelines, no similar guidelines exist in the pediatric population, with many hospitals utilizing a 2-h scan to reduce radiation exposure and save time. METHODS We performed a systematic review and meta-analysis to evaluate differences in the diagnosis of gastroparesis during 2-h versus 4-h GES. Four databases were systematically searched for articles reporting results of GES at both the 2- and 4-h time points in a pediatric population. Outcomes included the proportion of patients with gastroparesis at 2- and 4-h and the number of patients with differing transit status (normal or abnormal) from 2- to 4-h. Meta-analyses were conducted utilizing a random effects model. Heterogeneity among studies was assessed utilizing the I2 statistic. KEY RESULTS A total of 344 records were identified, of which 9 articles met inclusion criteria. Of these, six articles were included in the meta-analysis. The pooled proportion of patients with alterations in gastric transit between 2 and 4 h was 0.2 (95% CI: 0.11 to 0.30). Overall, the extended 4-h scan captured an additional 10% of patients with gastroparesis. There was significant heterogeneity among the studies (I2 = 91.8%, p < 0.001), likely due to differences in GES protocol and patient samples. CONCLUSIONS AND INFERENCES The 4-h GES offers a higher diagnostic yield in pediatric patients compared to a 2-h study, despite heterogeneity in existing research. Further prospective studies are necessary to further quantify this advantage.
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Affiliation(s)
- Ryan Shargo
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Michael Luongo
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Rahul Mhaskar
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Department of Internal Medicine and Medical Education, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Peter L Lu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michael Wilsey
- Department of Pediatric Gastroenterology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Georgiou MF, Sfakianaki E, Diaz-Kanelidis MN, Moshiree B. Gastric Emptying Scintigraphy Protocol Optimization Using Machine Learning for the Detection of Delayed Gastric Emptying. Diagnostics (Basel) 2024; 14:1240. [PMID: 38928655 PMCID: PMC11202747 DOI: 10.3390/diagnostics14121240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/01/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
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.
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Affiliation(s)
- Michalis F. Georgiou
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA;
| | - Efrosyni Sfakianaki
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA;
| | | | - Baha Moshiree
- Atrium Health, Wake Forest University, Charlotte, NC 28204, USA
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Banks KP, Revels JW, Tafti D, Moshiri M, Shah N, Moran SK, Wang SS, Solnes LB, Sheikhbahaei S, Elojeimy S. Scintigraphy of Gastrointestinal Motility: Best Practices in Assessment of Gastric and Bowel Transit in Adults. Radiographics 2024; 44:e230127. [PMID: 38814800 DOI: 10.1148/rg.230127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Various radiologic examinations and other diagnostic tools exist for evaluating gastrointestinal diseases. When symptoms of gastrointestinal disease persist and no underlying anatomic or structural abnormality is identified, the diagnosis of functional gastrointestinal disorder is frequently applied. Given its physiologic and quantitative nature, scintigraphy often plays a central role in the diagnosis and treatment of patients with suspected functional gastrointestinal disorder. Most frequently, after functional gallbladder disease is excluded, gastric emptying scintigraphy (GES) is considered the next step in evaluating patients with suspected gastric motility disorder who present with upper gastrointestinal symptoms such as dyspepsia or bloating. GES is the standard modality for detecting delayed gastric emptying (gastroparesis) and the less commonly encountered clinical entity, gastric dumping syndrome. Additionally, GES can be used to assess abnormalities of intragastric distribution, suggesting specific disorders such as impaired fundal accommodation or antral dysfunction, as well as to evaluate gastric emptying of liquid. More recently, scintigraphic examinations for evaluating small bowel and large bowel transit have been developed and validated for routine diagnostic use. These can be performed individually or as part of a comprehensive whole-gut transit evaluation. Such scintigraphic examinations are of particular importance because clinical assessment of suspected functional gastrointestinal disorder frequently fails to accurately localize the site of disease, and those patients may have motility disorders involving multiple portions of the gastrointestinal tract. The authors comprehensively review the current practice of gastrointestinal transit scintigraphy, with diseases and best imaging practices illustrated by means of case review. ©RSNA, 2024 See the invited commentary by Maurer and Parkman in this issue.
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Affiliation(s)
- Kevin P Banks
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Jonathan W Revels
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Dawood Tafti
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Mariam Moshiri
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Neal Shah
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Shamus K Moran
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Sherry S Wang
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Lilja B Solnes
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Sara Sheikhbahaei
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
| | - Saeed Elojeimy
- From the Department of Radiology, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, San Antonio, TX 78234 (K.P.B., D.T.); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Md (K.P.B., D.T.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (J.W.R., M.M., N.S.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (S.K.M.); Department of Radiology, University of Washington, Seattle, Wash (S.S.W.); Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (L.B.S., S.S.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (S.E.)
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Tafti D, Farrell MB, Dearborn MC, Banks KP. Reexamining Compliance with Gastric Emptying Scintigraphy Guidelines: An Updated Analysis of the Intersocietal Accreditation Commission Database. J Nucl Med Technol 2024; 52:26-31. [PMID: 37316303 PMCID: PMC10924152 DOI: 10.2967/jnmt.123.265496] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/10/2023] [Indexed: 06/16/2023] Open
Abstract
Many variables can influence the results of gastric emptying scintigraphy (GES). A lack of standardization causes variability, limits comparisons, and decreases the credibility of the study. To increase standardization, in 2009 the Society of Nuclear Medicine and Molecular Imaging (SNMMI) published a guideline for a standardized, validated GES protocol for adults based on a 2008 consensus document. Laboratories must closely follow the consensus guideline to provide valid and standardized results as an incentive to achieve consistency in patient care. As part of the accreditation process, the Intersocietal Accreditation Commission (IAC) evaluates compliance with such guidelines. The rate of compliance with the SNMMI guideline was assessed in 2016 and showed a substantial degree of noncompliance. The aim of this study was to reassess compliance with the standardized protocol across the same cohort of laboratories, looking for changes and trends. Methods: The IAC nuclear/PET database was used to extract GES protocols from all laboratories applying for accreditation from 2018 to 2021, 5 y after the initial assessment. The number of labs was 118 (vs. 127 in the initial assessment). Each protocol was again evaluated for compliance with the methods described in the SNMMI guideline. The same 14 variables were assessed in a binary fashion: patient preparation (4 variables-types of medications withheld, withholding of these medication for 48 h, blood glucose ≤ 200 mg/dL, blood glucose recorded), meal (5 variables-use of consensus meal, nothing by mouth for 4 h or more, meal consumed within 10 min, documentation of percentage of meal consumed, meal labeled with 18.5-37 MBq [0.5-1.0 mCi]), acquisition (2 variables-anterior and posterior projections obtained, imaging each hour out to 4 h), and processing (3 variables-use of the geometric mean, decay correction of data, and measurement of percentage retention). Results: Protocols from the 118 labs demonstrated that compliance is improving in some key areas but remains suboptimal in others. Overall, labs were compliant with an average of 8 of the 14 variables, with a low of 1-variable compliance at 1 site, and only 4 sites compliant with all 14 variables. Nineteen sites met an 80% threshold for compliance (11+ variables). The variable with the highest compliance was the patient's taking nothing by mouth for 4 h or more before the exam (97%). The variable with the lowest compliance was the recording of blood glucose values (3%). Notable areas of improvement include the use of the consensus meal, now 62% versus previously only 30% of labs. Greater compliance was also noted with measurement of retention percentages (instead of emptying percentages or half-times), with compliance by 65% of sites versus only 35% 5 y prior. Conclusion: Almost 13 y after the publication of the SNMMI GES guidelines, there is improving but still suboptimal protocol adherence among laboratories applying for IAC accreditation. Persistent variation in the performance of GES protocols may significantly affect patient management, as results may be unreliable. Using the standardized GES protocol permits interpretation of results in a consistent manner that allows interlaboratory comparisons and fosters acceptance of the test validity by referring clinicians.
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Affiliation(s)
- Dawood Tafti
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas; and
| | | | - M Cory Dearborn
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas; and
| | - Kevin P Banks
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas; and
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Ezaizi Y, Hasan B, Manini ML, Absah I. Intrapyloric Botulinum Toxin A Injection for Gastroparesis and Functional Upper Gastrointestinal Symptoms in Children: Mayo Clinic Experience, Review of the Literature, and Meta-analysis. Paediatr Drugs 2022; 24:539-545. [PMID: 35768647 DOI: 10.1007/s40272-022-00518-x] [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] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We aimed to assess the efficacy of intrapyloric botulinum toxin A injection (IPBTI) in children with and without gastroparesis and to perform a meta-analysis and review of the literature. METHODS We retrospectively searched our electronic health records to identify children (aged < 18 years) who underwent an esophagogastroduodenoscopy with IPBTI between 2007 and 2018 for persistent upper gastrointestinal tract symptoms. We included children with and without gastroparesis and excluded children with a history of gastrointestinal surgery, gastrointestinal obstruction, or mucosal disease that could explain their symptoms. A meta-analysis including our study findings was performed. RESULTS We identified 20 children (mean [standard deviation] age, 9.7 [5.8] years; 14 [70%] girls) with upper gastrointestinal symptoms who underwent IPBTI at our institution during the study period. Of the 20 children, 17 (85%) underwent gastric emptying scintigraphy, only nine (53%) of whom had gastroparesis. Response to IPBTI was reported in ten children (50%). Response to IPBTI did not differ by the presence of gastroparesis in included children (p = 0.64). Repeated IPBTI was performed in four children who had a response to the first injection; all four reported no benefit from the second IPBTI. There were no reported complications of IPBTI in our cohort. The meta-analysis indicated that 68% (95% confidence interval 59-78) of patients had a response to IPBTI, regardless of the presence of gastroparesis; 66% (95% confidence interval 53-78) of patients who had gastroparesis had a response to IPBTI. CONCLUSIONS Intrapyloric botulinum toxin A injection is safe in children and can offer transient relief for patients with refractory upper gastrointestinal symptoms with and without gastroparesis.
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Affiliation(s)
- Yamen Ezaizi
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. .,Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. .,Pediatric Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Bashar Hasan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Mhd Louai Manini
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Imad Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Diagnostic Evaluation of Gastric Motor and Sensory Disorders. Am J Gastroenterol 2021; 116:2345-2356. [PMID: 35134012 DOI: 10.14309/ajg.0000000000001562] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/18/2021] [Indexed: 12/11/2022]
Abstract
Disorders of gastric motor and sensory function affect 10%-20% of the world's population and adversely impact nutrition, quality of life, work productivity, and health care costs. Classifying these disorders can be challenging given the heterogeneity of symptom presentation, the presence of symptoms unexplained by endoscopic, radiographic and/or laboratory evaluation, and overlap with other luminal gastrointestinal disorders. Accurately diagnosing these highly prevalent disorders relies upon an understanding of epidemiology and risk factors, the ability to take a careful clinical history focused on symptoms, and the presence of predisposing medical, surgical, and psychological conditions. A variety of diagnostic studies are now available to assess gastric motor function and identify maladaptive relaxation, accommodation, and abnormal sensation. FDA-approved treatment options are limited and thus many patients undergo a series of empirical treatment trials that target individual symptoms, often without much benefit. This article provides updated recommendations for identifying and classifying the most common gastric motor and sensory disorders using currently accepted diagnostic tests, and provides a brief supplemental overview on treatment options. "Things sweet to taste prove in digestion sour." -Shakespeare, Richard II, 1595.
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Wise JL, Vazquez-Roque MI, McKinney CJ, Zickella MA, Crowell MD, Lacy BE. Gastric Emptying Scans: Poor Adherence to National Guidelines. Dig Dis Sci 2021; 66:2897-2906. [PMID: 32418002 DOI: 10.1007/s10620-020-06314-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/02/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Accurately diagnosing gastroparesis relies upon gastric emptying scintigraphy (GES) being performed correctly. Jointly published protocol guidelines have long been available; however, the extent to which practitioners adhere to these guidelines is unknown. AIMS This study aimed to assess national compliance with established GES protocol guidelines. METHODS We developed a questionnaire addressing the key protocol measures outlined in the Consensus Recommendations for Gastric Emptying Scintigraphy. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), reporting (7), and institutional demographic data (7). The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. RESULTS A total of 121 out of 872 potential medical institutions (MI) responded (13.9%); 49 (40.4%) were academic/teaching medical centers. The annual number (mean) of GES procedures was 199.9 (range 5-2000 GES/year). On average, MI performed 33.5/52 (64%) of protocol measures according to guidelines while academic medical centers performed 31.5/52 (61%) of protocol measures according to guidelines. Only 4 out of 88 MI (4.5%) performed GES while adhering to three critical measures: validated study duration; controlled blood glucose levels; and proper restriction of medications. CONCLUSIONS Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines for gastric scintigraphy.
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Affiliation(s)
- Journey L Wise
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Maria I Vazquez-Roque
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Caleb J McKinney
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael A Zickella
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Gastroparesis and Severity of Delayed Gastric Emptying: Comparison of Patient Characteristics, Treatments and Medication Adverse Events. Dig Dis Sci 2021; 66:526-534. [PMID: 32306190 DOI: 10.1007/s10620-020-06258-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastroparesis is a heterogeneous disorder. Patient characteristics and treatment responsiveness may differ based on the extent of delay in gastric emptying. AIMS Characterize gastroparesis patients based on the degree of delay in gastric emptying, and assess the relationship of patient demographics, symptoms and response to therapy based on the extent of delay. METHODS 1333 solid-phase 4-h scintigraphic gastric emptying scans were reviewed. Delayed emptying was categorized on percent retention at 4 h: mild (10-19%), moderate (20-29%), and severe (≥ 30%). Analyses were performed with regard to demographics, symptoms, esophagogastroduodenoscopy findings, medication use, and emergency department (ED) visits/hospitalizations. RESULTS 284 patients had delayed gastric emptying: mild (42.6%), moderate (19.3%), and severe (37.3%). 79.5% were women, the mean age was 45 years (± 15), and mean symptom duration was 4.6 years (± 6.5). The main categories of gastroparesis were idiopathic and diabetes mellitus. The most commonly prescribed medications were metoclopramide, domperidone and erythromycin. Opiate use (n = 69) was associated with an increased degree of delayed gastric emptying (p = 0.03) with 50% of opiate users having very delayed gastric emptying. One-way analysis revealed that severely delayed gastric emptying correlated with both increased hospitalizations and ED visits. CONCLUSIONS Severe delay in gastric emptying is a risk factor for increased hospitalizations and ED visits. Opiate use correlates with increased severity of gastric emptying. Identifying at-risk patients, stopping opioids, and instituting a programmatic care plan for patients with severely delayed gastric emptying may reduce ED visits, hospitalizations, and healthcare costs.
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11
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Mat Nawi N, Tagiling N, Mohd Rohani MF, Wan Zainon WMN, Zanial MS, Wong MS, Lee YY. 99mTc-sodium phytate is a valid alternative to the gold-standard 99mTc-sulfur colloid in the measurement of gastric emptying among healthy multi-ethnic Asian population: results of a randomized cross-over trial. BMC Gastroenterol 2020; 20:293. [PMID: 32867699 PMCID: PMC7457507 DOI: 10.1186/s12876-020-01426-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is unclear if the 99mTc-sodium phytate (99mTc-SP) is as reliable as the gold-standard 99mTc-sulfur colloid (99mTc-SC) for gastric emptying scintigraphy (GES). This study is aimed to compare the emptying rates of both radiotracers in a prospective, randomized cross-over trial and to determine the normative data of a healthy multi-ethnic Asian population. METHODS Out of the 44 healthy individuals screened, 31 (14 females; mean age: 28.4 ± 7.0 years) were enrolled and underwent GES using the standardized egg-white meal. All participants were randomly assigned to either 99mTc-SP or 99mTc-SC on the first GES session before crossed over to the other formulation after 2 weeks. RESULTS Both kits achieved the radiochemical purities of > 95%. The median rate (95th upper normative limit) of gastric emptying, reported as total gastric meal retention between 99mTc-SP and 99mTc-SC, was found to be comparable at all measured time points: 0.5 h [85.0% (96.6%) vs. 82.0% (94.0%)], 1 h [70.0% (86.4%) vs. 65.0% (86.6%)], 2 h [31.0% (55.8%) vs. 25.0% (64.4%)], 3 h [7.0% (26.3%) vs. 5.0% (29.9%)], and 4 h [3.0% (10.3%) vs. 2.0% (9.9%)]; P > 0.05. In addition, both radiotracers correlated well (Kendall's Tau (τ) coefficient = 0.498, P < 0.001) and presented with a good agreement at the 4th-hour time frame based on the Bland-Altman plot analysis. CONCLUSIONS 99mTc-SP is a valid radiotracer alternative to 99mTc-SC for routine GES examination. The normative values for both radiotracers have also been determined for the healthy multi-ethnic Asian population. TRIAL REGISTRATION This trial was registered retrospectively in the Thai Clinical Trials Registry on May 23rd, 2020 (Identifier: TCTR20200526004; http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=6296 ).
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Affiliation(s)
- Norazlina Mat Nawi
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Nashrulhaq Tagiling
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | | | - Wan Mohd Nazlee Wan Zainon
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | | | - Mung Seong Wong
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Yeong Yeh Lee
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia.
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia.
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12
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Ziessman HA, Jeyasingam M, Khan AU, McMahan Z, Pasricha PJ. Experience with Esophagogastrointestinal Transit Scintigraphy in the Initial 229 Patients: Multiple Regions of Dysmotility Are Common. J Nucl Med 2020; 62:115-122. [PMID: 32482790 DOI: 10.2967/jnumed.120.243527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/05/2020] [Indexed: 11/16/2022] Open
Abstract
The purpose of this investigation was to review our experience with our comprehensive esophagogastrointestinal transit study in the first 229 patients. This scintigraphic study analyzes the motility of the entire gut, from the esophagus through the rectosigmoid colon. Methods: Data were reviewed for our first 2 y of experience with this examination (184 women and 45 men aged 20-79 y [mean ± SD, 44 ± 16 y]). Patients were referred with symptoms suggestive of a motility disorder. They first swallowed 111In-diethylenetriaminepentaacetic acid in water for the esophageal-swallow study and then 300 mL for a 30-min 111In water-only study, followed by 120 mL of 111In water simultaneously with the solid standardized 99mTc egg-substitute meal. Images and quantification were obtained for esophageal transit, water-only gastric emptying, water-with-solid gastric emptying, small-bowel transit, and colonic transit. Results: Of the 229 patient studies, 45 (20%) were normal. The remaining 184 (80%) had at least 1 region of dysmotility, for a total of 336 regions of abnormal motility. A single region of dysmotility was seen in 92 patients (50%), 2 regions in 50 (27%), 3 regions in 26 (14%), 4 regions in 12 (7%), and 5 regions in 4 (2%). There was a poor correlation between the results of the water-only study and water with the solid meal. Three different patterns of delayed colonic transit were seen. Patient symptoms were often not predictive of the scintigraphic findings. Conclusion: This study highlights the frequent occurrence of dysmotility in more than 1 region of the gastrointestinal tract in patients with a suspected motility disorder and the frequent concurrence of both upper- and lower-tract dysmotility in the same patients. It provides information to referring physicians regarding which motility disorders may be causing the patient symptoms, why the patient is or is not responding to the present therapy, and if and what additional workup and therapy may be needed.
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Affiliation(s)
- Harvey A Ziessman
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mathurika Jeyasingam
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahsan U Khan
- Department of Radiology, West Virginia University, Morgantown, West Virginia
| | - Zsuzsanna McMahan
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Pankaj J Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Febo‐Rodriguez L, Chumpitazi BP, Shulman RJ. Childhood gastroparesis is a unique entity in need of further investigation. Neurogastroenterol Motil 2020; 32:e13699. [PMID: 31407456 PMCID: PMC7015769 DOI: 10.1111/nmo.13699] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures. PURPOSE The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.
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Affiliation(s)
- Liz Febo‐Rodriguez
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
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14
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15
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Nuclear Medicine Imaging Techniques of the Gastrointestinal System. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Setya A, Nair P, Cheng SX. Gastric electrical stimulation: An emerging therapy for children with intractable gastroparesis. World J Gastroenterol 2019; 25:6880-6889. [PMID: 31908392 PMCID: PMC6938723 DOI: 10.3748/wjg.v25.i48.6880] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Management of gastroparesis remains challenging, particularly in pediatric patients. Supportive care and pharmacological therapies for symptoms remain the mainstay treatment. Although they are effective for mild and some moderately severe cases, often time they do not work for severe gastroparesis. There are a few prokinetics available, yet the use of these drugs is limited by a lack of persistent efficacy and/or safety concerns. Currently, the only modality for adult patients with severe intractable gastroparesis is surgery, e.g., pyloroplasty and partial gastrectomy, however, this option is generally considered too radical for a growing child. Novel therapeutic approaches, particularly those which are less invasive, are needed. This article explores gastric electrical stimulation (GES), a new therapy for gastroparesis. Unlike others, it neither needs medications nor gastrectomy; rather, it treats through the use of microelectrodes to deliver high-frequency low energy electric stimulation to the pacemaker area of the stomach. Thus, it is tolerated and safe in children. Like in adult patients, GES appears to work in releasing symptoms, improving nutrition, and enhancing the quality of life; it also helps wean off medications and eliminate many needs for hospitalization. Considering the transient nature of gastroparesis in children in many occasions, GES is considered a “bridging” therapy after failed medical interventions and before surgery.
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Affiliation(s)
- Aniruddh Setya
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Priyanka Nair
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Sam Xianjun Cheng
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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17
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Gomez Cifuentes J, Radetic M, Lopez R, Gabbard S. Clinical Predictors of Rapid Gastric Emptying in Patients Presenting with Dyspeptic Symptoms. Dig Dis Sci 2019; 64:2899-2909. [PMID: 30982211 DOI: 10.1007/s10620-019-05620-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rapid gastric emptying (RGE) is defined as less than 30% retention at 1 h of solid meal ingestion. It is unclear whether RGE represents a separated clinical entity or part of the functional dyspepsia spectrum. AIMS To determine clinical predictors of RGE in patients presenting with dyspeptic symptoms. METHODS Retrospective study of patients who underwent solid Gastric Emptying Scintigraphy to evaluate dyspeptic symptoms from January 2011 to September 2012. Patients with delayed gastric emptying (> 10% gastric retention at 4 h) or prior gastric surgery were excluded. Patients with RGE were compared to those with normal gastric emptying (NGE) in a patient ratio of 1:3. Demographic data, symptoms, comorbidities, surgeries, endoscopy findings, medications, HbA1c, and TSH were analyzed. Univariate and multivariate logistic regression analyses were performed. RESULTS A total of 808 patients were included, 202 patients with RGE and 606 patients with NGE. Mean gastric retention at 1 h was 18% [12.0, 24.0] and 65% [52.0, 76.0], respectively. Patient with RGE were more likely to present with nausea/vomiting (OR 2.4, p < 0.001), weight loss (OR 1.7, p = 0.008), and autonomic symptoms (OR 2.8, p = 0.022). Identified clinical predictors of RGE were older age (OR 1.08 [1.01, 1.1], p = 0.018), male gender (OR 2.0 [1.4, 2.9], p ≤ <0.001), higher BMI (OR 1.03 [1.00, 1.05], p = 0.018), diabetes (OR 1.8 [1.2, 2.7], p = 0.05), and fundoplication (OR 4.3 [2.4, 7.7], p ≤ 0.001). CONCLUSION RGE represents a distinct population among patients presenting with dyspepsia in whom fundoplication, diabetes, and male gender were the strongest clinical predictors. RGE was significantly associated with nausea/vomiting, weight loss, and autonomic symptoms.
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Affiliation(s)
| | - Mark Radetic
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Gabbard
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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18
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Abstract
OBJECTIVES The purpose of this study was to establish normal gastric-emptying values for EnsurePlus in healthy subjects and to determine whether it is an acceptable alternative to the recommended standardized Tc-sulfur colloid egg meal. METHODS Twenty-one healthy subjects underwent gastric-emptying scintigraphy with In-DTPA EnsurePlus. Normal gastric emptying values were established for 1, 2, 3, and 4 hours after meal ingestion. The gastric-emptying results were compared with another group of normal subjects (n = 18) who ingested the standardized egg meal. RESULTS The mean (95% upper reference limit) percentages for gastric retention for EnsurePlus were as follows: 69.9% (87.1%) at 1 hour, 35.1% (64.3%) at 2 hours, 13.5% (23.2%) at 3, and 8.9% (13.5%) at 4 hours. There were time-related differences in the gastric emptying of the EnsurePlus compared with the egg meal. In the first and second hours, there were no difference between EnsurePlus and the egg meal in terms of percentage retention (P = 0.92 at 1 hour, P = 0.05 at 2 hours). However, at 3 and 4 hours after meal ingestion, the mean percentage gastric retention of the EnsurePlus was significantly higher than the egg meal (P < 0.001). CONCLUSION EnsurePlus is a good and acceptable alternative to the standardized egg meal.
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19
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Edwards ST, Cocjin J, Theut SB, Rivard D, Sherman AK, Friesen CA. A comparison of the diagnosis of gastroparesis in 4 h pediatric gastric emptying studies versus 2 h studies. BMC Gastroenterol 2019; 19:26. [PMID: 30744574 PMCID: PMC6371451 DOI: 10.1186/s12876-019-0948-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 01/31/2019] [Indexed: 01/24/2023] Open
Abstract
Background In adults, there is a consensus for standards to diagnose gastroparesis utilizing a gastric emptying study as the key diagnostic modality but there is no consensus for a standard in pediatrics. Additionally, some cost savings might be achieved if symptoms could be utilized to predict patients with gastroparesis. The aims of the current study were to confirm the sensitivity of a 4 h study in the pediatric population and to assess whether the severity of symptoms were predictive of delayed gastric emptying. Study This was a single site, two part study. In the first part, results were reviewed for all patients who had completed a 4-h, solid gastric emptying study over the course of a 3 year period. In the second portion of the study, participants scheduled for a gastric emptying study, completed a modified GCSI questionnaire. Results Out of a total of 109 participants, at 2 h, 14 participants (12.8%) had abnormal studies as compared to 26 (23.85%) participants who had abnormal studies at 4 h (p = .0027). Of the 95 participants with normal studies at 2 h, 15% (14/95) were abnormal at 4 h. There were no differences in symptom severity scores between those with slow and those with normal emptying at either 2 h or 4 h. Conclusions Our study adds independent confirmation that extending studies from 2 to 4 h increases the diagnostic yield and should be the standard in children and adolescents as it is in adults. Electronic supplementary material The online version of this article (10.1186/s12876-019-0948-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Turnipseed Edwards
- Division of Gastroenterolgy, Children's Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO, 64108, USA. .,Department of Pediatric Gastroenterology, Children's Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO, 64108, USA.
| | - Jose Cocjin
- Division of Gastroenterolgy, Children's Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO, 64108, USA
| | | | - Douglas Rivard
- Department of Radiology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Ashley K Sherman
- Health Services and Outcomes Research Division, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Craig A Friesen
- Division of Gastroenterolgy, Children's Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO, 64108, USA
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Hirsch W, Nee J, Ballou S, Petersen T, Friedlander D, Lee HN, Cheng V, Lembo A. Emergency Department Burden of Gastroparesis in the United States, 2006 to 2013. J Clin Gastroenterol 2019; 53:109-113. [PMID: 29256990 PMCID: PMC6005709 DOI: 10.1097/mcg.0000000000000972] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis, a chronic gastrointestinal disorder defined by delayed stomach emptying in the absence of obstruction, is often associated with frequent and costly visits to the emergency department (ED). The aim of this study was to analyze trends in gastroparesis-related ED visits from 2006 to 2013. MATERIALS AND METHODS Patients with a primary diagnosis of gastroparesis were identified from the Nationwide Emergency Department Sample (NEDS), the largest publicly available ED all-payer representative database in the United States. ED visits, admission rates, duration of hospitalizations, and charges were compiled. Patients with a secondary diagnosis of diabetes mellitus were analyzed as a subgroup. RESULTS The number of ED visits for gastroparesis as a primary diagnosis in the United States increased from 15,459 in 2006 to 36,820 in 2013, an increase from 12.9 to 27.3 per 100,000 ED visits. The total charges associated with these ED visits and subsequent admissions increased from $286 million to $592 million. In contrast, admission rates through the ED decreased by 22%, procedure rates decreased by 6.2%, and the mean length of stay was shortened by 0.6 days. ED visits for patients with diabetic gastroparesis increased from 5696 to 14,114, an increase from 4.7 to 10.5 per 100,000 ED visits, with an increase in total associated charges for ED visits and subsequent admissions from $84 million to $182 million. CONCLUSIONS The number of ED visits and associated charges for a primary diagnosis of gastroparesis with or without a secondary diagnosis of diabetes mellitus rose significantly from 2006 to 2013.
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Affiliation(s)
- William Hirsch
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Ballou
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Travis Petersen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Friedlander
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ha-Neul Lee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Cheng
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Abstract
OBJECTIVE The purpose of this article is to describe the clinical utility of state-of-theart gastrointestinal transit scintigraphy, including the standardized esophageal transit, solid and liquid gastric emptying, small-bowel transit, colon transit, and whole-gut transit scintigraphy, with an emphasis on procedure performance. CONCLUSION Radionuclide gastrointestinal motility studies are noninvasive, quantitative, and physiologic diagnostic tools for evaluating patients with gastrointestinal complaints.
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Abstract
BACKGROUND AND AIMS Gastroparesis (GP) patients suffer from recurrent symptoms of nausea, vomiting, early satiety, and abdominal pain. The impact of GP on quality of life (QoL), health care utilization and daily activities is not well understood. MATERIALS AND METHODS Part 1: 398 adult patients (≥18 y) with documented GP (symptoms >6 mo) were surveyed to assess QoL and pain using the Short Form 36 and McGill pain questionnaires. Part 2: 491 adult GP patients were surveyed to evaluate employment status, work and daily activities, medication use, physician visits, diagnostic testing, emergency room visits, and hospitalizations related to their GP symptoms. Both protocols received Institutional Review Board approval. RESULTS Part 1: 250 fully evaluable surveys were returned (63%). The mean age was 46.8 years (range, 18 to 84 y); 78% were women. Mean Short Form 36 scores for mental health (56.9) and social functioning (68.1) were analogous to scores for patients with serious chronic medical disorders and depression. Pain scores were lower in patients with idiopathic GP compared with diabetic GP. Part 2: 228 evaluable surveys were analyzed (58.3% response rate). The mean age was 49.6 (19 to 86 y); 77.2% were women. GP symptoms reduced daily activities in 67.5% and lowered annual income in 28.5%. In total, 11% were disabled due to GP symptoms. CONCLUSIONS GP reduces patients' QoL and places a significant financial burden on the health care system. Treatment strategies for GP patients should be broad based and incorporate pain management, psychological evaluation and management, and strategies to improve overall well-being with a return to work and daily activities.
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Zheng WW, Zhang MM, Zhang Y, Li Z, Zuo XL, Lu XF, Li YQ. Gastric peroral endoscopic myotomy for pylorospasm: Case report and literature review. J Dig Dis 2017; 18:709-712. [PMID: 28727260 DOI: 10.1111/1751-2980.12509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/19/2017] [Accepted: 07/17/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Wen Wen Zheng
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Ming Ming Zhang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yan Zhang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Zhen Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Xiu Li Zuo
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Xue Feng Lu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yan Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
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Asano H, Tomita T, Nakamura K, Yamasaki T, Okugawa T, Kondo T, Kono T, Tozawa K, Ohda Y, Oshima T, Fukui H, Fukushima K, Hirota S, Watari J, Miwa H. Prevalence of Gastric Motility Disorders in Patients with Functional Dyspepsia. J Neurogastroenterol Motil 2017; 23:392-399. [PMID: 28423481 PMCID: PMC5503289 DOI: 10.5056/jnm16173] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/14/2017] [Accepted: 02/08/2017] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Gastric motility abnormalities have been considered to be pathophysiological features of functional dyspepsia (FD) that are closely related to dyspepsia symptoms, especially postprandial distress syndrome (PDS). The aims of this study are to (1) investigate the prevalence of gastric motility disorders and (2) evaluate the association between gastric motility abnormalities and dyspeptic symptoms using gastric scintigraphy in the PDS type of FD. Methods Forty healthy subjects and 94 PDS type FD patients were enrolled in the study. The volunteers and patients ingested a radiolabeled (technetium-99m) solid test meal, and scintigraphic images were recorded. Gastric accommodation and emptying were assessed by scintigraphic imaging. The patients’ dyspeptic symptoms were also explored using self-completed symptom questionnaires with 10 variables (4 scales, 0–3 points) at the same time. Results In 94 Japanese FD patients, the prevalence of impaired gastric accommodation and delayed emptying were 14.9% (14/94) and 10.6% (10/94), respectively. Gastric motility abnormalities were seen in 25.5% (24/94) of FD patients. There was no association between gastric motility abnormalities and dyspeptic symptoms. Conclusions Gastric motility abnormalities were seen in 25.5% of Japanese PDS type FD patients. However, there was no association between gastric motility abnormalities and dyspeptic symptoms on gastric scintigraphy.
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Affiliation(s)
- Haruki Asano
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Toshihiko Tomita
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kumiko Nakamura
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takahisa Yamasaki
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takuya Okugawa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takashi Kondo
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tomoaki Kono
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Katsuyuki Tozawa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshio Ohda
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tadayuki Oshima
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirokazu Fukui
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazuhito Fukushima
- Division of Nuclear Medicine and PET Center, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shozo Hirota
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Jiro Watari
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Wadhwa V, Mehta D, Jobanputra Y, Lopez R, Thota PN, Sanaka MR. Healthcare utilization and costs associated with gastroparesis. World J Gastroenterol 2017; 23:4428-4436. [PMID: 28706426 PMCID: PMC5487507 DOI: 10.3748/wjg.v23.i24.4428] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/23/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To use a national database of United States hospitals to evaluate the incidence and costs of hospital admissions associated with gastroparesis.
METHODS We analyzed the National Inpatient Sample Database (NIS) for all patients in whom gastroparesis (ICD-9 code: 536.3) was the principal discharge diagnosis during the period, 1997-2013. The NIS is the largest publicly available all-payer inpatient care database in the United States. It contains data from approximately eight million hospital stays each year. The statistical significance of the difference in the number of hospital discharges, length of stay and hospital costs over the study period was determined by regression analysis.
RESULTS In 1997, there were 3978 admissions with a principal discharge diagnosis of gastroparesis as compared to 16460 in 2013 (P < 0.01). The mean length of stay for gastroparesis decreased by 20 % between 1997 and 2013 from 6.4 d to 5.1 d (P < 0.001). However, during this period the mean hospital charges increased significantly by 159 % from $13350 (after inflation adjustment) per patient in 1997 to $34585 per patient in 2013 (P < 0.001). The aggregate charges (i.e., “national bill”) for gastroparesis increased exponentially by 1026 % from $50456642 ± 4662620 in 1997 to $568417666 ± 22374060 in 2013 (P < 0.001). The percentage of national bill for gastroparesis discharges (national bill for gastroparesis/total national bill) has also increased over the last 16 years (0.0013% in 1997 vs 0.004% in 2013). During the study period, women had a higher frequency of gastroparesis discharges when compared to men (1.39/10000 vs 0.9/10000 in 1997 and 5.8/10000 vs 3/10000 in 2013). There was a 6-fold increase in the discharge diagnosis of gastroparesis amongst type 1 DM and 3.7-fold increase amongst type 2 DM patients over the study period (P < 0.001).
CONCLUSION The number of inpatient admissions for gastroparesis and associated costs have increased significantly over the last 16 years. Inpatient costs associated with gastroparesis contribute significantly to the national healthcare bill. Further research on cost-effective evaluation and management of gastroparesis is required.
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Farrell MB, Costello M, McKee JLD, Gordon LL, Fig LM. Compliance with Gastric-Emptying Scintigraphy Guidelines: An Analysis of the Intersocietal Accreditation Commission Database. J Nucl Med Technol 2017; 45:6-13. [DOI: 10.2967/jnmt.116.184473] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/14/2016] [Indexed: 11/16/2022] Open
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Mekaroonkamol P, Li L, Cai Q. The role of pyloric manometry in gastric per-oral endoscopic pyloromyotomy (G-POEM): response to Jacques et al. Neurogastroenterol Motil 2017; 29. [PMID: 28028900 DOI: 10.1111/nmo.12949] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 12/15/2022]
Affiliation(s)
- P Mekaroonkamol
- Division of Digestive Diseases, Emory University, Atlanta, GA, USA
| | - L Li
- Division of Digestive Diseases, Emory University, Atlanta, GA, USA
| | - Q Cai
- Division of Digestive Diseases, Emory University, Atlanta, GA, USA
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Ziessman HA. Gastrointestinal Transit Assessment: Role of Scintigraphy: Where Are We Now? Where Are We Going? ACTA ACUST UNITED AC 2016; 14:452-460. [DOI: 10.1007/s11938-016-0108-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Comparative assessment of gastric emptying in obese patients before and after laparoscopic sleeve gastrectomy using radionuclide scintigraphy. Nucl Med Commun 2016; 36:854-62. [PMID: 25932537 DOI: 10.1097/mnm.0000000000000337] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radionuclide scintigraphy provides a standard physiologic evaluation of gastric emptying (GE) after laparoscopic sleeve gastrectomy (LSG). This operation can be associated with motor gastric dysfunction and abnormal GE. The aim of this study was to evaluate the short-term effect of LSG on GE quantitative indices for liquids and solids compared with preoperative results. Forty obese patients were divided into two equal groups, the liquid and solid groups. Tc-sulfur colloid GE scintigraphy was performed on all patients submitted to LSG before and after surgery (1-4 weeks for liquids and 4-6 weeks for solids). The quantitative indices included half emptying time (T1/2) and percentage gastric retention at 15, 30, and 60 min for liquids and at 30, 60, 90, and 120 min for solids. A modified technique was used to label a boiled egg in order to be tolerated by the patients. T1/2 was significantly enhanced after LSG compared with baseline (25.3±4.4 vs. 11.8±3.0 min for liquids and 74.9±7.1 vs. 28.4±8.3 min for solids, respectively, P<0.001). The percentage of gastric retention in operated patients was significantly less than that at baseline for liquids at 15, 30, and 60 min (33.9±5.6, 17.7±3.9, and 7.5±2.8% vs. 69.4±10.5, 55.6±14.95, and 26.1±4.7%, respectively, P<0.001), as well as for solids at 30, 60, 90, and 120 min (42.0±11.1, 20.8±6.1, 11.0±5.9, and 3.8±2.7% vs. 79.9±8.7, 67.4±12.2, 37.0±10.9%, and 13.8±4.4%, respectively, P<0.001). The significant acceleration of GE of liquids and solids after LSG may have contributed to weight loss in the immediate postoperative period (4-6 weeks). It remains to be determined whether the weight loss will continue beyond that period.
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Malik R, Srivastava A, Gambhir S, Yachha SK, Siddegowda M, Ponnusamy M, Poddar U. Assessment of gastric emptying in children: Establishment of control values utilizing a standardized vegetarian meal. J Gastroenterol Hepatol 2016; 31:319-25. [PMID: 26267844 DOI: 10.1111/jgh.13145] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM Disorders of gastric emptying constitute an important group of conditions in children. The diagnostic gold standard is scintigraphy, and recommendations for standardization have been published with adult normative data. Pediatric literature lacks standardized age specific normative values. Our aim was to establish normal values of solid phase gastric emptying utilizing scintigraphy in children (5-18 years) using the recommended imaging protocol and standardized meal. METHODS Gastric emptying was assessed by scintigraphy of a (99m) Tc-labeled vegetarian meal. Image acquisition was dynamic for first hour and static at 2, 3, and 4 h. Results were reported as percent intragastric retention; lag phase defined as time to 5% emptying. RESULTS Thirty (17 boys) healthy children, mean ages of 9.5 ± 3.1 (range 5 to 16) years, were enrolled. Median values (5th and 95th percentiles) for percent gastric retention at 30 min, 1, 2, 3 and 4 h were 90% (76 and 100%), 77% (56 and 96%), 33% (10 and 71%), 16% (3 and 44%), and 7% (0.5 and 22%). The median (5th and 95th percentiles) lag phase was 18 min (6 and 60 min). Lag phase had no correlation with gastric retention at 4 h. CONCLUSIONS This study provides valuable normative ranges for solid phase gastric emptying in children. Using adult normative data in children may be inappropriate.
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Affiliation(s)
- Rohan Malik
- Departments of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Departments of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Gambhir
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surender K Yachha
- Departments of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Murthy Siddegowda
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Madusudhanan Ponnusamy
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Departments of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Abstract
OPINION STATEMENT Gastroparesis (GP) is a syndrome characterized by delayed gastric emptying in association with symptoms of epigastric pain, nausea, and vomiting in the absence of mechanical obstruction. The prevalence of gastroparesis has been estimated at 24 per 100,000, with women more commonly affected than men. Diabetes appears to be the underlying cause in approximately 25 % of patients, while connective tissue disorders, autoimmune disorders, prior gastric surgery, ischemia, and medications make up a smaller percentage of the remaining identifiable causes. However, the largest group of GP patients falls into the idiopathic category (~50 %); many of these patients likely develop GP as a result of a prior viral infection. Symptoms of gastroparesis develop due to a number of different pathophysiologic processes, including disorders of fundic accommodation, antroduodenal dyscoordination, a weak antral pump, gastric dysrhythmias, abnormal duodenal feedback, and enhanced visceral sensation. Once the diagnosis of GP is made, the clinician has a number of different treatment options. For patients with mild to moderate symptoms, dietary modifications in conjunction with or without prokinetics and antiemetics are often all that is required. However, many patients with severe symptoms who fail to respond to standard therapy may benefit from neuroenteric stimulation (gastric electrical stimulation). This monograph will review the role of the neuroenteric stimulator therapy for gastroparesis, discuss possible mechanisms of action of neuroenteric stimulation, review data from recently published studies on its efficacy, and discuss patient selection and adverse events.
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Affiliation(s)
- Brian E Lacy
- Division of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Low CS, Ahmed H, Notghi A. Pitfalls and Limitations of Radionuclide Hepatobiliary and Gastrointestinal System Imaging. Semin Nucl Med 2015; 45:513-29. [DOI: 10.1053/j.semnuclmed.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
Gastroparesis (GP) is a chronic neuromuscular disorder of the upper gastrointestinal tract. The incidence of GP is not well described; however, the number of individuals affected by symptoms of GP in the United States is estimated to be over 4 million. The etiology of GP is diverse. Approximately 25% of cases are associated with diabetes, whereas nearly 50% are classified as idiopathic; many of these latter cases likely represent a postinfectious process. Connective tissue disorders, autoimmune disorders, prior gastric surgery, ischemia, and medications make up the vast majority of the remaining cases. The pathophysiology of GP is also diverse. Abnormalities in fundic tone, antroduodenal dyscoordination, a weak antral pump, gastric dysrhythmias, and abnormal duodenal feedback all contribute to delays in gastric emptying and symptom expression. Characteristic symptoms of GP include nausea, vomiting, epigastric pain, early satiety, and weight loss. The diagnosis of GP is made using a combination of characteristic symptoms in conjunction with objective evidence of delayed gastric emptying in the absence of mechanical obstruction. Once the diagnosis is made, treatment options include dietary modification, medications to accelerate gastric emptying, antiemetic agents, gastric electrical stimulation, and surgery. In the following sections we will provide an overview of the health care impact of GP, describe the underlying pathophysiology, and review treatment options using an evidence-based approach.
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Guidoccio F, Paglianiti I, Boni G, Mariani G. Will Comprehensive Assessment from Esophagus to Large Bowel Revive the Momentum for Radionuclide Gastrointestinal Transit Studies? J Nucl Med 2015; 56:657-8. [DOI: 10.2967/jnumed.115.154963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022] Open
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Antoniou AJ, Raja S, El-Khouli R, Mena E, Lodge MA, Wahl RL, Clarke JO, Pasricha P, Ziessman HA. Comprehensive Radionuclide Esophagogastrointestinal Transit Study: Methodology, Reference Values, and Initial Clinical Experience. J Nucl Med 2015; 56:721-7. [DOI: 10.2967/jnumed.114.152074] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/14/2015] [Indexed: 01/27/2023] Open
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Tseng PH, Wu YW, Lee YC, Cheng MF, Tzen KY, Wang HP, Lin JT, Hsieh ST, Yang WS, Wu MS. Normal values and symptom correlation of a simplified oatmeal-based gastric emptying study in the Chinese population. J Gastroenterol Hepatol 2014; 29:1873-1882. [PMID: 24909819 DOI: 10.1111/jgh.12640] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Instant oatmeal has been proposed as a good alternative to the standardized low-fat egg white test meal for gastric emptying studies. We aim to establish normal values of oatmeal-based gastric emptying scintigraphy and test its correlation with gastroparesis symptoms in the Chinese population. METHODS This study prospectively enrolled 60 healthy volunteers, 30 functional dyspepsia and 30 diabetes patients with gastroparesis symptoms. All participants were evaluated using the Gastroparesis Cardinal Symptom Index. Each participant ingested instant oatmeal mixed with 1 mCi of (99m) Tc diethylenetriaminepentacetic acid, and serial imaging was immediately acquired for 3 h in the supine position using a left anterior oblique projection. Time-activity curves were generated and quantitative parameters were determined. Normal values were established from healthy volunteers and further applied in the symptomatic patients. RESULTS All participants finished the test meal and tolerated the procedure well. All gastric emptying parameters were not significantly affected by age or gender. Values above the 95th percentile of T1/2 , gastric retention at 1, 2, and 3 h (85 min, 65%, 28%, and 8%, respectively) were indicative of delayed gastric emptying. Values below the 5th percentile of gastric retention at 0.5 and 1 h (40% and 15%, respectively) were indicative of rapid gastric emptying. The lower gastric retention limit at 0.5 and 1 h were 40% and 15%, respectively. Four (13.3%) diabetes and four (13.3%) functional dyspepsia patients had delayed emptying while three diabetes patients (10%) had rapid emptying. Gastric emptying parameters correlated best with vomiting (r = 0.621) and nausea (r = 0.566) in diabetes patients. CONCLUSIONS We established normal values of oatmeal-based gastric emptying scintigraphy and observed good correlation with cardinal gastroparesis symptoms in the Chinese population.
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Affiliation(s)
- Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Novel and validated approaches for gastric emptying scintigraphy in patients with suspected gastroparesis. Dig Dis Sci 2013; 58:1813-5. [PMID: 23695877 DOI: 10.1007/s10620-013-2715-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/02/2013] [Indexed: 12/09/2022]
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Severity of dyspeptic symptoms correlates with delayed and early variables of gastric emptying. Dig Dis Sci 2013; 58:478-87. [PMID: 22918685 DOI: 10.1007/s10620-012-2355-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 08/01/2012] [Indexed: 01/17/2023]
Abstract
BACKGROUND A simplified report of gastric retention values at select times is now recommended for scintigraphic gastric emptying test (GET). AIMS The purpose of this study was to assess correlation between severity of gastroparetic symptoms and all variables of GET, compared to select variables in clinical use. METHODS This was a prospective study of patients referred for scintigraphic GET. The Gastroparesis Cardinal Symptom Index questionnaire was obtained prior to the scintigraphy. Variables determined were lag time, half emptying time (T1/2), retention at 30 min, 1, 2 and 4 h. Statistical analysis was by Spearman rank correlation and Wilcoxon rank test with a significance set at p ≤ 0.05. RESULTS Seven hundred seventeen patients had GET from 03/09 to 03/11. Results are from 325 patients who did not take medications known to affect GET were analyzed (64.9 % females, mean age 47 ± 18.9 years, 21.8 % diabetics, 78.2 % non-diabetic, of which 7.6 % were post-surgical, primarily post-fundoplication). Combined gastric retention at 2 and 4 h detected delayed GET in 83.5 % non-diabetics and 76.6 % of diabetics. Rapid GET was present in 11 % of patients at 30 min and 4 % at 1 h. Significant positive correlation was observed between nausea, vomiting, loss of appetite and variables of GET, but not with the half-time of emptying (T1/2). Bloating negatively correlated with retention at 2 h. There was no association between duration of symptoms and GET variables. CONCLUSIONS Gastroparetic symptoms correlate with different retention times of GET, but not with T1/2. However, symptoms poorly distinguish between categories of gastroparesis or status of gastric emptying. Delayed GE is best detected by 2 and 4 h retention times, while 30 min and 1 h retention times detect rapid GE.
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Maurer AH. Advancing gastric emptying studies: standardization and new parameters to assess gastric motility and function. Semin Nucl Med 2012; 42:101-12. [PMID: 22293165 DOI: 10.1053/j.semnuclmed.2011.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
For many years, gastric emptying (GE) studies were performed using various local protocols and different radiolabeled meals. This lack of standardization and normal values made the test results unreliable and difficult to compare from one site to another. A recent consensus has been published that now provides guidance and standardization on how to perform a radiolabeled solid-meal GE study. It is widely recognized, however, that simple measurement of total GE of a solid meal often does not provide an answer to the etiology of symptoms for a large number of patients who present with functional dyspepsia. Advances in our understanding of the different roles of the fundus and antrum and their complex interaction with the proximal small bowel and central nervous system have led to the development of new methods to study gastric motility. This review describes how a more comprehensive approach to studying GE is needed and how this will lead to better diagnosis and treatment for patients referred for GE studies.
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Affiliation(s)
- Alan H Maurer
- Department of Radiology, Nuclear Medicine, Temple University Hospital and School of Medicine, Philadelphia, PA 19140, USA.
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Middleton ML, Strober MD. Planar scintigraphic imaging of the gastrointestinal tract in clinical practice. Semin Nucl Med 2012; 42:33-40. [PMID: 22117811 DOI: 10.1053/j.semnuclmed.2011.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Michael L Middleton
- Division of Nuclear Radiology & Advanced Molecular Imaging, Department of Radiology, Scott & White Healthcare System, Texas A&M Health Science Center, Temple, TX 76513, USA.
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Abstract
INTRODUCTION Recommendations for gastric emptying scintigraphy (GES) suggest imaging over 4 hours to better define gastroparesis. AIMS To determine the value of defining delayed gastric emptying at time points earlier than 4 hours. METHODS GES was performed with ingestion of a liquid egg white meal with imaging at 0, 0.5, 1, 2, 3, and 4 hours. Patients completed the Patient Assessment of Gastrointestinal Symptoms questionnaire immediately before GES. RESULTS Of 1499 patients undergoing GES from September 2007 to January 2010 (76.2% were female, mean age of 45.5±0.5 y, 21.3% had diabetes, 9.5% had earlier gastric surgery), 160 (10.7%) had increased gastric retention at 1 hour (>90%), 404 (27%) had increased retention at 2 hours (>60%), 576 (38.4%) had increased retention at 3 hours (>30%), and 629 (42%) had increased retention at 4 hours (>10%). Gastric retention at 4 hours correlated with retention at 3 hours (r=0.890; P<0.001), 2 hours (r=0.738; P<0.001), and 1 hour (r=0.510; P<0.001). Symptoms correlated better with the gastric retention at later time points. The symptoms correlating with gastric retention at 4 hours included early satiety (r=0.170; P<0.01), vomiting (r=0.143; P<0.01), feeling excessively full after meals (r=0.123; P<0.01), and loss of appetite (r=0.122; P<0.01). CONCLUSIONS Gastric retention at 4 hours correlates well with gastric retention at 3 hours, good at 2 hours, but only fair with gastric retention at 1 hour. Gastric retention at 1 hour may miss 36% of patients found to have delayed gastric emptying at 4 hours. Symptoms (early satiety, vomiting, feeling excessively full after meals, and loss of appetite) correlated better with the gastric retention at later time points.
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Horner KM, Byrne NM, Cleghorn GJ, Näslund E, King NA. The effects of weight loss strategies on gastric emptying and appetite control. Obes Rev 2011; 12:935-51. [PMID: 21729233 DOI: 10.1111/j.1467-789x.2011.00901.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The gastrointestinal tract plays an important role in the improved appetite control and weight loss in response to bariatric surgery. Other strategies which similarly alter gastrointestinal responses to food intake could contribute to successful weight management. The aim of this review is to discuss the effects of surgical, pharmacological and behavioural weight loss interventions on gastrointestinal targets of appetite control, including gastric emptying. Gastrointestinal peptides are also discussed because of their integrative relationship in appetite control. This review shows that different strategies exert diverse effects and there is no consensus on the optimal strategy for manipulating gastric emptying to improve appetite control. Emerging evidence from surgical procedures (e.g. sleeve gastrectomy and Roux-en-Y gastric bypass) suggests a faster emptying rate and earlier delivery of nutrients to the distal small intestine may improve appetite control. Energy restriction slows gastric emptying, while the effect of exercise-induced weight loss on gastric emptying remains to be established. The limited evidence suggests that chronic exercise is associated with faster gastric emptying, which we hypothesize will impact on appetite control and energy balance. Understanding how behavioural weight loss interventions (e.g. diet and exercise) alter gastrointestinal targets of appetite control may be important to improve their success in weight management.
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Affiliation(s)
- K M Horner
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
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44
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Winstead NS. The challenges of chronic nausea and vomiting and normal gastric emptying. Clin Gastroenterol Hepatol 2011; 9:534-5. [PMID: 21440667 DOI: 10.1016/j.cgh.2011.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 03/13/2011] [Indexed: 02/07/2023]
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Seok JW. How to interpret gastric emptying scintigraphy. J Neurogastroenterol Motil 2011; 17:189-91. [PMID: 21602998 PMCID: PMC3093013 DOI: 10.5056/jnm.2011.17.2.189] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 02/21/2011] [Accepted: 02/23/2011] [Indexed: 01/09/2023] Open
Abstract
Gastric emptying scintigraphy has long been the standard method for measuring gastric motility. Various methodologies for this study have been used including meal composition, patient positioning, instrumentation, frequency of data acquisition, study length and quantitative method. For accurate quantification, it is not important which method is in use, except that the methodology should always be the same and normal values need to be derived and validated for that methodology.
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Affiliation(s)
- Ju Won Seok
- Department of Nuclear Medicine, College of Medicine, Chung-Ang University, Seoul, Korea.
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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: 239] [Impact Index Per Article: 17.1] [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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Hou Q, Lin Z, Dusing RW, Gajewski BJ, McCallum RW. A Bayesian hierarchical assessment of gastric emptying with the linear, power exponential and modified power exponential models. Neurogastroenterol Motil 2010; 22:1308-17. [PMID: 20649756 DOI: 10.1111/j.1365-2982.2010.01572.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many studies assessed gastric retention over time utilizing different models, mostly with scintigraphic measures at varied endpoints from limited number of normal volunteers. With a standardized 4-h gastric emptying (GE) protocol, we compared model fit by the linear, power exponential (PE), and modified power exponential (MPE) models to contrast differences in GE among different groups based on clinical diagnosis and gender. METHODS We retrospectively collected 320 patient records with four consecutive hourly scintigraphic measures of percent intragastric residual at the Kansas University Medical Center. We obtained parameter estimates with the Bayesian hierarchical models using informative priors from previous research. KEY RESULTS The PE or MPE model captured the time dependent GE rate better than the linear model. The estimated GE rates more than doubled for those without gastroparesis compared to patients diagnosed with gastroparesis. Males tended to empty gastric content faster but were not significantly different from females at the 5% level. CONCLUSIONS & INFERENCES The point estimates and 95% credible interval for GE rates obtained with the PE and MPE models may provide an alternative diagnostic tool for clinicians since it utilizes gastric emptying scintigraphy measures at multiple endpoints which may be sensitive to different aspects of the disease. No agreement in lag phases was obtained by the three models based on respective definitions from previous researches, but similar results would be obtained with the PE and MPE models if both defined lag phase by back projecting the regression lines to the same gastric retention level.
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Affiliation(s)
- Q Hou
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
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Abstract
BACKGROUND The medical literature states that solid radionuclide gastric emptying studies are more sensitive than liquid studies for detection of gastroparesis and thus liquid studies are rarely indicated. At our institution, patients are often referred for both studies. Our initial purpose was to review the results in those patients. The surprising results led us to initiate a prospective investigation to more directly determine the relative value of solid versus liquid emptying studies. METHODS The retrospective review included 21 patients who had both studies performed on separate days. The subsequent prospective investigation was initiated so that the solid and liquid emptying studies were acquired sequentially on the same day. A total of 40 consecutive patients with symptoms suggestive of gastroparesis (mean age 44.8, 12 males, 28 females) were investigated. All ingested 300 mL water with radiotracer and were imaged each minute 30. They then ingested the radiolabeled solid meal and were imaged each hour 4. A liquid emptying rate (T1/2) and solid percent emptying each hour 4 was determined. RESULTS In the retrospective review, 17 of 21 patients had normal solid emptying; of those, 13 had delayed liquid emptying. In the subsequent prospective study, 30/40 (75%) had normal solid emptying; of those, 10 (33%) had delayed liquid emptying. Nine patients (23%) had delayed solid emptying; 13 (32%) had delayed liquid emptying. CONCLUSIONS Liquid gastric emptying is commonly abnormal in patients who have normal solid studies. Liquid studies should be routinely performed in addition to solid studies to fully evaluate gastric motility in patients with symptoms suggestive of gastroparesis.
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