Experience with a Simplified, Standardized 4-Hour Gastric-Emptying Protocol

Ziessman, Harvey A.; Bonta, Dacian; Goetze, Sibyll; Ravich, William J.

doi:10.2967/jnumed.106.036616

Cited by 71 publications

(40 citation statements)

References 16 publications

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“…One criticism of this method is that infrequent imaging does not allow for the analysis of the pattern of gastric contractility. The present investigation is the second time that we have integrated a research study and the 4-h Tougas protocol (24). In the prior study, we investigated whether the lag phase could predict delayed emptying.…”

Section: Discussionmentioning

confidence: 99%

The Added Diagnostic Value of Liquid Gastric Emptying Compared with Solid Emptying Alone

Ziessman

Chander

Clarke³

et al. 2009

J Nucl Med

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The medical literature states that solid gastric-emptying studies are more sensitive for the detection of gastroparesis than are liquid studies; thus, liquid studies are rarely required. However, we have seen patients with normal solid but delayed liquid emptying. The purpose of this investigation was to determine whether a study of clear liquid gastric empting has added value for the diagnosis of gastroparesis over a study of solid emptying alone. Methods: A total of 101 patients underwent both solid and liquid gastric-emptying studies, acquired sequentially on the same day. A 30-min (1-min frames) liquid study (300 mL of water with 7.4 MBq [0.2 mCi] of 111 In-diethylenetriaminepentaacetic acid) was followed by a standardized 4-h solid-meal study (a 99m Tcsulfur colloid-labeled egg-substitute sandwich meal). Emptying was quantified as a best-fit exponential emptying rate (T1/2) for liquids and percentage emptying at 4 h for solid empting. Thirty healthy volunteers underwent a study of clear liquid emptying to establish normal values. The results of the liquid and solid studies were compared. 111 In liquid downscatter into the subsequent 99m Tc solid meal results was analyzed. Results: The upper range of normal for clear liquid emptying (T1/2) for healthy volunteers was 22 min (mean 6 3 SDs) and 19 min (mean 6 2 SDs). Of 101 patients, delayed emptying was found in 36% of liquid and 16% of solid studies. Of all patients with normal solid emptying, 32% had delayed liquid emptying. 111 In downscatter into the 99m Tc window was not generally significant. Conclusion: For the detection of gastroparesis, a 30-min study of clear liquid gastric-emptying has considerable added diagnostic value over a study of solid emptying alone. The radionuclide gastric-emptying study has long been the standard clinical diagnostic test for the detection of gastroparesis. Both solid and liquid studies have been used over the years, either as individual or as dual-phase studies, for investigative and clinical purposes. Standard teaching has been that only a solid study is needed for clinical purposes because the liquid study is less sensitive for the detection of gastroparesis, and liquid studies should be reserved for patients who cannot tolerate solids (1-6).However, we have observed patients who have had delayed liquid but normal solid emptying (7). The primary purpose of this investigation was to determine, in a large patient population, whether liquid gastric emptying provided added diagnostic value over solid emptying alone for the diagnosis of gastroparesis.We chose to perform the studies on the same day to avoid potential problems (e.g., different fasting conditions, different medications, and possible intercurrent clinical conditions that might affect emptying) that might arise from separate-day studies. Thus, the clear liquid and solid gastricemptying studies were performed sequentially; that is, a 30-min water study was performed, followed by the 4-h simplified and standardized solid protocol recommended by recently published...

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Section: Discussionmentioning

confidence: 99%

The Added Diagnostic Value of Liquid Gastric Emptying Compared with Solid Emptying Alone

Ziessman

Chander

Clarke³

et al. 2009

J Nucl Med

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“…Currently, studies vary in length from as short as 60 min up to 4 h. Studies have shown that extending measurements out to 4 h increases the detection rate of delayed emptying (43,44). As more has been learned about the optimal methodology, some imaging centers have changed their protocols, but many centers have been reluctant to perform a 4-h procedure because reimbursement is not commensurate with the time and effort needed.…”

Section: Technical Factors In Ge Testsmentioning

confidence: 99%

“…Another study suggests that 30% is the optimal threshold for 3-h emptying data (44). A recent study using the Tougas et al meal has shown that the 3-h time point is nearly comparable to the 4-h value in detecting patients with delayed GE (51).…”

Section: Optimal Timing Of Imagingmentioning

confidence: 99%

Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine

Abell

Camilleri

Donohoe

et al. 2008

Journal of Nuclear Medicine Technology

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476

527

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This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, eggwhite meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.

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“…With the latter radiolabeled solid meal, the COV inter for GE at 4 h was 9.6 %, confirming the recommendation by Tougas et al [1] that the percent retention at 4 h is an endpoint useful for gastroparesis screening. Similarly, others have shown greater sensitivity of detection of abnormal GE with use of [5]. Conversely, the COV inter and COV intra for GE T 1/2 with the 296 kcal, 32 % fat meal were both *25 % [4], suggesting that a single observation of GE T 1/2 could only be useful as a screen for gastroparesis if the GE T 1/2 is[150 min (since the median and mean values in 319 patients were 120 and 121.7 min, respectively).…”

mentioning

confidence: 99%

Novel and Validated Approaches for Gastric Emptying Scintigraphy in Patients with Suspected Gastroparesis

Camilleri

Shin

2013

Dig Dis Sci

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Controversy exists regarding the relation of upper gastrointestinal symptoms to gastroparesis, which centers on the reportedly weak correlation between symptoms and gastric emptying (GE) measurements. Appropriate management of patients with suspected gastroparesis thus requires the use of validated assessments of GE.GE scintigraphy (GES) using a low-fat EggBeaters (chicken egg white) meal (ConAgra Foods Inc., Omaha, NE, USA) [1] is regarded as the gold standard due to standardized procedures, methods, and well-established normal values. Although this meal has the advantage of good tolerability by the majority of symptomatic patients, there are potential drawbacks: a few patients may not tolerate any solid meal, or the low fat and caloric content may not be able to adequately stress the system, failing to identify impaired gastric motor function in a subset of individuals. Therefore, identification of an alternative, appropriate test meal may be important for clinical and research applications.In this issue, Sachdeva et al.[2] compared GE of the low-fat EggBeaters solid meal (255 kcal containing 2 % fat, 24 % protein, 72 % carbohydrate, and 2 % fiber) to an Ensure Plus (Abbott Laboratories, North Chicago, IL, USA) liquid meal (350 kcal containing 28 % fat, 15 % protein, 57 % carbohydrate, and no fiber) to identify a valid alternative for patients unable to consume the standard low-fat egg-white meal. On separate days, 20 healthy volunteers participated in a well-designed prospective study comparing GES with these two meals; simultaneously, the authors evaluated gastric contractility using a wireless motility capsule (WMC) during both assessments.The objectives were to demonstrate feasibility and to provide hypothesis-generating data (e.g., definition of coefficient of variation [COV; standard deviation/mean] to facilitate the design of future studies).The conclusion that GE of a liquid nutrient meal is similar to that of low-fat egg-white meal (of similar calorie content) is valid, at least in healthy subjects. Nevertheless, as acknowledged by the authors, their results will require replication in a larger cohort, and in subjects with suspected gastroparesis who might differ from a healthy population in terms of having differential GE of solid versus liquid meals. Jones et al. [3] previously reported a significant but weak (r = 0.42, p \ 0.01) correlation between GE of solids and nutrient-containing liquids among 86 patients with diabetes mellitus. In the study by Sachdeva et al. [2], the correlation between the GE T 1/2 of the two meals was similarly weak (r = 0.53) among healthy subjects, suggesting that there are significant intraindividual differences in the emptying of the two meals, and that less than 30 % of the variance is attributable to the same mechanisms for emptying of the two types of meals.It is also necessary to clarify the inter-individual COV with the EggBeaters and the liquid nutrient meal. Diagnostic interpretation of GE T 1/2 by GES in an individual patient requires robust definition of the i...

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Experience with a Simplified, Standardized 4-Hour Gastric-Emptying Protocol

Cited by 71 publications

References 16 publications

The Added Diagnostic Value of Liquid Gastric Emptying Compared with Solid Emptying Alone

The Added Diagnostic Value of Liquid Gastric Emptying Compared with Solid Emptying Alone

Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine

Novel and Validated Approaches for Gastric Emptying Scintigraphy in Patients with Suspected Gastroparesis

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