Heather J. Chial

Gastric Accommodation and Emptying in Evaluation of Patients With Upper Gastrointestinal Symptoms

BACKGROUND & AIMS Endoscopy-negative dyspepsia is a common symptom that often is difficult to define in pathophysiologic terms. The aim of this study was to assess the frequency of disordered gastric accommodation and emptying in patients referred with unexplained upper gastrointestinal symptoms. METHODS A computerized diagnostic index was used to identify all patients, 18-70 years old, who underwent single-photon emission computed tomography (SPECT) to assess gastric accommodation at Mayo Clinic Rochester over a 3-year period. Demographics, clinical features, and results of diagnostic testing, including scintigraphic gastric emptying, were extracted from the electronic record. RESULTS A total of 214 patients were identified; the primary clinical diagnoses were functional dyspepsia, postfundoplication syndromes, rumination syndrome, and diabetic dyspepsia. Gastric accommodation was impaired in 43% of the whole group: 47% of functional dyspepsia, 44% of postfundoplication syndromes, and 33% of diabetic dyspepsia. Delayed gastric emptying was most prevalent in diabetic dyspepsia, and was accelerated in postfundoplication syndromes groups. Thirty-seven percent of patients had abnormal gastric emptying. The highest prevalence of delayed gastric emptying was in the diabetic dyspepsia and accelerated gastric emptying in postfundoplication syndromes groups. Twenty-five percent of patients with normal gastric emptying had impaired accommodation. Upper-gastrointestinal symptoms were not different in groups based on gastric accommodation or emptying results. CONCLUSIONS Impaired gastric accommodation is common in patients with unexplained dyspepsia. Symptoms alone cannot predict physiologic disturbances. These noninvasive tests identify single or combined pathophysiologic disturbances and may help to identify subgroups of patients as candidates for more selective pharmacotherapy in the future.

SPECT imaging of the stomach: comparison with barostat, and effects of sex, age, body mass index, and fundoplication

Background: Impaired gastric accommodation may lead to dyspeptic symptoms. A non-invasive method using single photon emission computed tomography (SPECT) has been developed to measure gastric volumes. Aims and methods: Our aims were: to assess the accuracy of SPECT with three dimensional image analysis to measure balloon volumes in vitro; to compare gastric barostat balloon volumes measured post-meal and post-distension with total gastric volumes measured simultaneously with SPECT; to present normal gastric volume data for healthy adults; and to compare SPECT data in health with symptomatic post-fundoplication patients. Results: In vitro balloon volumes measured by SPECT were highly accurate (R2=0.99). When measured simultaneously by gastric barostat and SPECT, postprandial/fasting volume ratios (2.2 (0.12) (mean (SEM)) v 2.3 (0.15), respectively; p=0.6) and post-distension volume ratios (1.4 (0.1) v1.3 (0.1); p=0.2) were highly comparable. In females, postprandial gastric volumes (675 (14) v 744 (20) ml for males; p=0.004) and changes in gastric volumes (464 (14) ml v 521 (20) ml for males; p=0.01) measured by SPECT were significantly lower than in males. No effects of age or body mass index were noted. The postprandial/fasting gastric volume ratio by SPECT was lower in post-fundoplication patients (2.7 (0.2)) than in healthy controls (3.4 (0.1); p=0.003). Conclusions: SPECT provides a non-invasive estimate of the effect of a meal on total gastric volume that is comparable to changes in balloon volume observed with the gastric barostat. The SPECT technique is promising for investigation of gastric volumes in health and disease and the effects of pharmacological agents.

SPECT imaging of the stomach

Background: Impaired gastric accommodation may lead to dyspeptic symptoms. A non-invasive method using single photon emission computed tomography (SPECT) has been developed to measure gastric volumes. Aims and methods: Our aims were: to assess the accuracy of SPECT with three dimensional image analysis to measure balloon volumes in vitro; to compare gastric barostat balloon volumes measured post-meal and post-distension with total gastric volumes measured simultaneously with SPECT; to present normal gastric volume data for healthy adults; and to compare SPECT data in health with symptomatic post-fundoplication patients. Results: In vitro balloon volumes measured by SPECT were highly accurate (R2=0.99). When measured simultaneously by gastric barostat and SPECT, postprandial/fasting volume ratios (2.2 (0.12) (mean (SEM)) v 2.3 (0.15), respectively; p=0.6) and post-distension volume ratios (1.4 (0.1) v1.3 (0.1); p=0.2) were highly comparable. In females, postprandial gastric volumes (675 (14) v 744 (20) ml for males; p=0.004) and changes in gastric volumes (464 (14) ml v 521 (20) ml for males; p=0.01) measured by SPECT were significantly lower than in males. No effects of age or body mass index were noted. The postprandial/fasting gastric volume ratio by SPECT was lower in post-fundoplication patients (2.7 (0.2)) than in healthy controls (3.4 (0.1); p=0.003). Conclusions: SPECT provides a non-invasive estimate of the effect of a meal on total gastric volume that is comparable to changes in balloon volume observed with the gastric barostat. The SPECT technique is promising for investigation of gastric volumes in health and disease and the effects of pharmacological agents.

A nutrient drink test to assess maximum tolerated volume and postprandial symptoms: effects of gender, body mass index and age in health

Abstract   To assess the effects of age, gender and body mass index on the maximum tolerated volume of a nutrient drink and postprandial symptoms in health. Healthy adolescents (15 M, 15 F, aged 13–17 years) and adults (15 M, 25 F, aged 19–51 years) ingested Ensure®(1 kcal mL−1) at a rate of 30 mL min−1. The maximum tolerated volume was recorded. Thirty minutes later, bloating, fullness, nausea and pain were rated using visual analogue scales. The Mann–Whitney test was used for comparisons between groups using body mass index and maximum tolerated volume as covariates. Age‐related differences in maximum tolerated volume were noted between adolescents and adults, and were observed in both genders. Adults had higher scores for bloating and pain, and lower scores for fullness. Gender‐related differences in maximum tolerated volume were noted in the group as a whole, and separately for adolescents and adults. Females had higher scores for nausea and pain. Gender and age‐related differences in the maximum tolerated volume of a nutrient drink and postprandial symptoms should be considered in future studies of upper gastrointestinal symptoms in disease. Body mass index does not appear to influence maximum tolerated volume beyond its association with age and gender.

Effects of asimadoline, a κ-opioid agonist, on satiation and postprandial symptoms in health

Aim:  To evaluate the effect of single administrations of asimadoline, a κ‐opioid agonist, on satiation volume, postprandial symptoms and gastric volumes.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

Esophageal leiomyomatosis presenting as achalasia diagnosed by high- resolution manometry and endoscopic core biopsy

m Esophageal leiomyomatosis is a rare disorder characterized by hamartomatous proliferation of the esophageal muscularis propria and leiomyomata in the esophageal wall.1 This condition may be sporadic or familial, an isolated disease or associated with Alport’s syndrome, and include leiomyomata within and outside of the GI tract.1,2 It presents with hronic dysphagia and may present anatomically with focal tricture or diffuse esophageal involvement,1-4 often diagosed at surgery. Esophageal leiomyomatosis rarely has been eported to cause “pseudoachalasia” by barium studies and y descriptive manometric data only.1,5,6 This is the first case to confirm a manometric pattern of achalasia on highresolution manometry and establish the diagnosis preoperatively by endoscopic esophageal core biopsy.