The vagus, the duodenal brake, and gastric emptying

The bioelectrical conduction system around the ileocecal junction defined through in vivo high-resolution mapping in rabbits

Coordinated contractions across the small and large intestines via the ileocecal junction (ICJ) are critical to healthy gastrointestinal function and are in part governed by myoelectrical activity. In this study, the spatiotemporal characteristics of the bioelectrical conduction across the ICJ and its adjacent regions were quantified in anesthetized rabbits. High-resolution mapping was applied from the terminal ileum (TI) to the sacculus rotundus (SR), across the ICJ and into the beginning of the large intestine at the cecum ampulla coli (AC). Orally propagating slow wave patterns in the SR did not entrain the TI. However, aborally propagating patterns from the TI were able to entrain the SR. Bioelectrical activity was recorded within the ICJ and AC, revealing complex interactions of slow waves, spike bursts, and bioelectrical quiescence. This suggests the involvement of myogenic coordination when regulating motility between the small and large intestines. Mean slow wave frequency between regions did not vary significantly (13.74-17.16 cycles/min). Slow waves in the SR propagated with significantly faster speeds (18.51 ± 1.57 mm/s) compared with the TI (14.05 ± 2.53 mm/s, P = 0.0113) and AC (9.56 ± 1.56 mm/s, P = 0.0001). Significantly higher amplitudes were observed in both the TI (0.28 ± 0.13 mV, P = 0.0167) and SR (0.24 ± 0.08 mV, P = 0.0159) within the small intestine compared with the large intestine AC (0.03 ± 0.01 mV). We hypothesize that orally propagating slow waves facilitate a motor-brake pattern in the SR to limit outflow into the ICJ, similar to those previously observed in other gastrointestinal regions.NEW & NOTEWORTHY Competing slow wave pacemakers were observed in the terminal ileum and sacculus rotundus. Prevalent oral propagation in the sacculus rotundus toward the terminal ileum potentially acts as a brake mechanism limiting outflow. Slow waves and periods of quiescence at the ileocecal junction suggest that activation may depend on the coregulatory flow and distention pathways. Slow waves and spike bursts in the cecum impart a role in the coordination of motility.

Luminal Chemoreceptors and Intrinsic Nerves: Key Modulators of Digestive Motor Function

This chapter reviews data on the pathways by which luminal, mainly duodenal, chemoreceptors modulate gastro-pyloro-duodenal motor function to control emptying of nutrients into the small intestine. The vagus mediates proximal gastric relaxation caused by nutrient stimulation of duodenal/jejunal mucosal chemoreceptors. Modulation of the spatial patterning and inhibition of antral contractions during duodenal chemoreceptor activation are somewhat conflicting: both vagal control and ascending intramural nerves appear to play a role. Intraduodenal nutrients stimulate the localized pyloric contractions that prevent transpyloric flow via ascending duodenal intramural nerve pathways. Though not yet formally investigated, patterns of activation of the duodenal brake motor mechanism suggest that duodenal loop mucosal chemoreceptors signal to a brake mechanism at the most aborad region of the duodenum via descending intramural duodenal nerves.Intrinsic intramural pathways are important in the control of the first stages of digestion.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy

Purpose

The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy.

Materials and Methods

Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10–30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively.

Results

Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed.

Conclusions

Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients.

Trial Registration

Clinical Research Information Service Identifier: KCT0000823

Effect of chyme viscosity and nutrient feedback mechanism on gastric emptying

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Gastric emptying rate linked to intestinal bioaccessability by feedback mechanism.

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Gastric secretion model links the secretion rate to the gastric viscosity.

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Model fits emptying of low and high viscosity liquid meals.

A comprehensive mathematical model of the digestive processes in humans could allow for better design of functional foods which may play a role in stemming the prevalence of food related diseases around the world. This work presents a mathematical model for a nutrient based feedback mechanism controlling gastric emptying, which has been identified in vivo by numerous researchers. The model also takes into account the viscosity of nutrient meals upon gastric secretions and emptying. The results show that modelling the nutrient feedback mechanism as an on/off system, with an initial emptying rate dependent upon the secretion rate (which is a function of the gastric chyme viscosity) provides a good fit to the trends of emptying rate for liquid meals of low and high nutrient content with varying viscosity.

The Pancreatic Duct Ligated (Mini)pig as a Model for Pancreatic Exocrine Insufficiency in Man

Modern therapy of pancreatic exocrine insufficiency (PEI) using pancreatic enzyme replacement therapy (PERT) has largely been very effective and has greatly helped in improving the nutritional status of patients with PEI and in increasing the life expectancy in cystic fibrosis. It is believed that the use of predictable large animal models could play an important role in assessing and developing new therapies. This article reviews the pancreatic duct ligated (adult) minipig as a chronic model of total PEI, with a detailed look at the influence of PEI and response to PERT on prececal compared to fecal digestibility, to directly investigate effects on protein and starch digestion and absorption. In addition, the piglet with PEI is reviewed as a model for PEI in young patients with the aim of further improving the therapy and nutritional status of young patients with cystic fibrosis.

Gut hormones in the treatment of short-bowel syndrome and intestinal failure

PURPOSE OF REVIEW

The approval of teduglutide, a recombinant analog of human glucagon-like peptide (GLP) 2, by the US Food and Drug Administration (Gattex) and the European Medicines Agency (Revestive) has illustrated the potential of selected gut hormones as treatments in patients with short-bowel syndrome and intestinal failure. Gut hormones may improve the structural and functional intestinal adaptation following intestinal resection by decreasing a rapid gastric emptying and hypersecretion, by increasing the intestinal blood flow, and by promoting intestinal growth. This review summarizes the findings from phase 2 and 3 teduglutide studies, and pilot studies employing GLP-1 and agonists for this orphan condition.

RECENT FINDINGS

In a 3-week, phase 2, metabolic balance study, teduglutide increased the intestinal wet weight absorption by approximately 700 g/day and reduced fecal energy losses by approximately 0.8 MJ/day (∼200 Kcal/day). In two subsequent 24-week, phase 3 studies, teduglutide reduced the need for parenteral support in the same magnitude. Adverse events were mainly of gastrointestinal origin and consistent with the known mechanism of action of teduglutide. Pilot studies suggest that GLP-1 may be less potent. Synergistic effects may be seen by co-treatment with GLP-2.

SUMMARY

Gut hormones promote intestinal adaptation and absorption, decreasing fecal losses, thereby decreasing or even eliminating the need for parenteral support. This will aid the intestinal rehabilitation in these severely disabled short-bowel syndrome patients.

New approaches to the treatments of short bowel syndrome-associated intestinal failure

PURPOSE OF REVIEW

Teduglutide, a recombinant analog of human glucagon-like peptide 2, has recently been approved in the US and Europe (Gattex and Revestive, respectively) as the first targeted treatment of short bowel syndrome-associated intestinal failure (SBS-IF). Glucagon-like peptide 2 improves structural and functional intestinal adaptation following intestinal resection by decelerating a rapid gastric emptying, by decreasing gastric hypersecretion, by increasing intestinal blood flow and by promoting intestinal growth. This review summarizes the findings from phase 2 and 3 studies preceding the US Food and Drug Administration and the European Medicines Agency approval of subcutaneous teduglutide for this orphan condition.

RECENT FINDINGS

In a 3-week, phase 2, metabolic balance study, teduglutide increased intestinal wet weight absorption by approximately 700 g/day and reduced fecal energy losses by approximately 0.8 MJ/day (∼200 kcal/day). In two subsequent 24-week, phase 3 studies, teduglutide reduced the need for parenteral support in the same magnitude. Teduglutide had an acceptable tolerability profile, where adverse events generally were of gastrointestinal origin consistent with the known mechanism of action.

SUMMARY

Teduglutide will add incremental benefit to the limited medical treatment armamentarium in SBS patients by maximizing intestinal absorption, decreasing fecal losses, thereby decreasing or even eliminating the need for parenteral support. Future research should target and implement other key hormones with similar and possible additive or synergistic effects, thereby further promoting structural and functional adaptation and intestinal rehabilitation in these severely disabled SBS patients.

Gastrointestinal transit, post-prandial lipaemia and satiety following 3 days high-fat diet in men

BACKGROUND/OBJECTIVES

High-fat (HF) diets of 2 weeks have been shown to accelerate gastric emptying (GE). To date, no studies have shown any alteration in GE following shorter HF diets. The aim of this study was to assess if an HF, high-energy diet of 3 days can adapt gastrointestinal (GI) transit, blood lipids and satiety.

SUBJECTS/METHODS

Eleven male volunteers participated in a study consisting of three, 3-day interventions each separated by a test day. During the first intervention, volunteers recorded their diet. In the second and third interventions, volunteers repeated their food diary plus either a low-fat yogurt or HF yogurt supplement in randomized order. Test days involved measurement of GE using the (13)C octanoic-acid breath-test, mouth-to-caecum transit time (MCTT) using the inulin H(2) breath test and satiety using visual analogue scales. Blood samples for measurement of lipaemia were taken using a venous cannula.

RESULTS

MCTT was different between the three test days (P=0.038), with the shortest MCTT following the HF intervention. GE was shortest following the HF intervention. There were no differences in satiety between the interventions. The HF intervention reduced triglycerides, total cholesterol and low-density lipoprotein cholesterol, and increased high-density lipoprotein cholesterol.

CONCLUSION

This study shows that changes in GI transit owing to an HF diet can occur in a time period as short as 3 days.

The vagus is inhibitory of the late postprandial insulin secretion in conscious pigs

The vagus is involved in the cephalic phase of insulin secretion but its role in the meal absorption phase of insulin release remains to be defined. The aim of this study was therefore to evaluate the role of the vagus in the early and the late meal absorption phases of insulin secretion. In six pigs, venous insulin profiles were compared in intact animals, after ventral or dorsal vagal trunk section, and after section of both vagal trunks (truncal vagotomy). Since gastric emptying could be modified by vagotomy, it was recorded concomitantly by gamma scintigraphy. Semi-solid (porridge) and liquid (glucose 10%) meals were tested. Truncal vagotomy significantly increased insulin release compare to intact animals after glucose (63.8%) and porridge (174.4%) meals in the early and the late absorption phases of insulin secretion, respectively. For the glucose meal, this effect could be explained by a vagally mediated change in gastric emptying rate, since insulin concentrations for a similar amount of nutrient propelled to the duodenum were not different in intact and truncal vagotomized animals. In contrast, after the porridge meal, truncal vagotomy was associated with a second, later occurring increase in circulating insulin, which could not be explained by changes in gastric emptying rate. These results demonstrate for the first time an inhibitory role of the vagus in the late meal absorption phase of insulin release.

Role of vagal innervation on intragastric distribution and emptying of liquid and semisolid meals in conscious pigs

The role of vagal innervation on emptying patterns and intragastric distributions of liquid and semisolid meals is still controversial. We aimed to record these features after dorsal, ventral and truncal vagotomies, using external gamma scintigraphy in conscious pigs in which the dorsal vagus specifically innervates the proximal stomach. Imaging of the stomach was performed for all experimental situations and before surgery using 99mTc-labelled glucose and porridge meals. Emptying of liquids was faster after dorsal vagotomy, whereas it was unchanged after ventral and truncal vagotomies (T1/2 = 57 +/- 8.5, 31 +/- 14.4, 54 +/- 9.1 and 42 +/- 14.9 min for intact, dorsal, ventral and truncal vagotomies, respectively). On the other hand, truncal vagotomy significantly reduced the emptying rate of semisolids whereas dorsal and ventral vagotomies had no significant effect (T1/2 = 96 +/- 7.2, 113 +/- 8.1, 75 +/- 9.9 and 260 +/- 56.6 min for intact, dorsal, ventral and truncal vagotomies). Morphological analysis of the gastric shape confirmed an overdistended proximal stomach after truncal vagotomy only. For semisolids, proximal stomach emptying followed the same emptying pattern as the entire stomach, irrespective of the surgical procedure. We concluded that the proximal stomach is the main control for the emptying of liquids and semisolids. The vagal control of overall gastric emptying for semisolids is probably identical to that modulating the intragastric distribution of the meal.

A rare case of multiple carcinoids and endocrine cell micronests in a patient with chronic duodenitis

BACKGROUND

To the authors' knowledge, multiple carcinoid tumors of the duodenum have not been reported previously. However, multiple carcinoids in the stomach, ileum, and rectum, which were accompanied by the proliferation of endocrine cells, have been reported in the published literature.

METHODS

A patient with multiple carcinoids including argyrophilic cell hyperplasia of the duodenum and hypergastrinemia underwent surgery. The resected stomach and duodenum were analyzed histopathologically.

RESULTS

There were 11 carcinoid lesions, each of which was accompanied by peripheral endocrine cell micronests (ECMs). Increasing gastrin positive cells in the antral region and chronic duodenitis in the duodenal bulb also were observed. The peripheral ECMs usually were adjacent to proliferating argyrophilic cells in the Brunner gland ducts or the crypts of Lieberkühn, which showed focal pyloric gland metaplasia.

CONCLUSIONS

In the case presented in the current study, the development of the multiple carcinoid lesions may be strongly related to the presence of multifocal pyloric gland metaplasia, as well as to the trophic action of gastrin, which is present at high levels in the setting of chronic duodenitis.

The ileal brake: a fifteen-year progress report

The "ileal brake" is the primary inhibitory feedback mechanism to control transit of a meal through the gastrointestinal tract in order to optimize nutrient digestion and absorption. Neurohormonal factors mediating this response continue to be identified. Recently, additional brakes that fine-tune transit have been described. When gut traffic control is disrupted, pathologic states characterized by malabsorption and impaired drug bioavailability manifest as diarrhea and malnutrition. An understanding of the importance of these nutrient-triggered brakes provides essential clues to future treatments of chronic diarrhea, malnutrition, and drug malabsorption.

Lipids infused into the jejunum accelerate small intestinal transit but delay ileocolonic transit of solids and liquids

BACKGROUND

Various nutrients are known to alter small intestinal motility patterns although their effect on transit of fluids and solids in man is not clear.

AIMS

To determine small intestinal transit of solids and liquids during perfusion with lipids, protein, and non-energy solutions.

METHODS

Twenty eight healthy volunteers received a jejunal infusion (1 ml/minute for 30 minutes) of one of four solutions: a lipid or a protein solution (4.18 J/ml), a non-absorbable electrolyte solution containing polyethylene glycol, or 0.9% sodium chloride. As solid phase marker 1 g of amberlite resin pellets labelled with 111InCl3 was added; 99mTc DTPA was used as a fluid phase marker. Images were obtained on a gamma camera at 10 minute intervals for four hours or until all radiolabel was detected in the colon.

RESULTS

Intestinal transit of solids and liquids from the duodenojejunal junction to the caecum was simultaneous, and independent of the energy content of the solution infused. Lipid infusion accelerated transit through the small intestine but delayed transport of chyme along the ileocolonic junction. After protein small intestinal transit was slowest; ileocolonic transit on the other hand was fastest with protein. Transit of the non-energy solutions was in between that of the nutrient solutions.

CONCLUSIONS

Transit times through the small intestine and the ileocolonic junction were influenced by the luminal contents. In the small intestine fat induced significantly faster transit compared with proteins, but delayed ileocolonic transit. Once in the small intestine, solids and liquids transit the small bowel together, independent of the luminal content.

Effect of glucose and lipids on intestinal absorption of sorbitol: role of gastric emptying

The aim of our study was to test the hypothesis that the better absorption of sorbitol when ingested with glucose could be related to a delayed gastric emptying. We tested the effect of the ingestion of glucose and lipids on the gastric emptying and intestinal absorption of sorbitol in six healthy volunteers, using gastric scintigraphy and hydrogen breath test. After an overnight fast, subjects ingested in random order, on 48-h test periods separated by at least one week, the following solutions: (a) 20 g sorbitol alone; (b) 20 g sorbitol and 20 g glucose; (c) 20 g sorbitol and 9 g lipids. Isotopic acquisitions were taken for 3 h following the ingestion of sorbitol labelled with 111Indium. Hydrogen concentration was measured in end-expiratory samples during 5 h, and the areas under the breath hydrogen curve, reflecting the amounts of sorbitol unabsorbed in the small bowel, were compared between periods. Mean area under the curve was 397 +/- 159 when sorbitol was ingested alone, and this was significantly lower when ingested with glucose or lipids (313 +/- 181 and 337 +/- 135, respectively; P < 0.05). The three curves of sorbitol gastric emptying differed significantly from each other, the gastric emptying being the slowest for sorbitol plus lipids, and the fastest for sorbitol taken alone. We found a positive correlation between the half-emptying time and the hydrogen areas under the curve (r = 0.46, P = 0.05). In conclusion, our study demonstrates that adding glucose or lipids to a solution of sorbitol slows the gastric emptying of sorbitol, resulting in a better intestinal absorption of sorbitol.

Proximal colonic response and gastrointestinal transit after high and low fat meals

The fat component of meals has been thought to make a major contribution to the colonic response to feeding. We have combined gamma scintigraphy and radiotelemetry to noninvasively study the response of the normally inaccessible proximal colon after ingestion of either a high or low fat meal. Separate studies were performed to measure the rate of passage of the same meals through the whole gut. Gastric emptying and small bowel transit of the two meals to the colon was similar, 50% of meal marker reaching the ascending colon 4.8 +/- 0.2 and 4.5 +/- 0.3 hr after the high and low fat meals respectively (N = 8, difference not significant). The low fat meal caused a consistent increase in motility index, which rose from a basal value of 1.0 +/- 0.3 to 2.6 +/- 0.7 mm Hg in the 2 hr after the meal (N = 8, P < 0.01). Response to the high fat meal was less consistent, motility index increasing from 1.6 +/- 0.6 basally to 2.3 +/- 0.7 mm Hg postprandially (N = 8, P = 0.21). Despite these increases in motor activity there was no net caudal propulsion of colonic contents after either meal. The geometric center was comparable, being 3.2 +/- 0.4 and 3.7 +/- 0.4 before the high and low fat meals. This did not change significantly after either meal, being then 3.5 +/- 0.4 and 3.6 +/- 0.4 2 hr after the high and low fat meals, respectively. We conclude that in normal subjects equicaloric high and low fat meals transit the whole gut at a similar rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal effects of the products of lipid digestion on gastric electrical activity in the cat. Possible involvement of vagal intestinal receptors sensitive to lipids

The relationship between the lipid content of the intestinal lumen and gastric motor activity was studied in anesthetized cats. For this purpose the electromyographic activity was recorded in the antrum whereas the small intestine (duodenum and first part of jejunum or ileum) was perfused with various solutions including calcium propionate, tributyrin, sodium caprylate, potassium oleate, mixtures containing linoleic acid, monolein, triolein, mixture of triglycerides, and glycerol. Long-chain lipids and glycerol both induced a decrease in the rate of basal antral activity. This effect was found to depend on the state of lipid hydrolysis (triglycerides, monoglycerides, and fatty acids) and was most marked with monolein, linoleic acid, and glycerol. With the middle-chain lipids used, these effects were only slight; short-chain lipids did not induce any visible changes in gastric activity. All these effects were prevented by cervical bivagotomy. It was concluded that the two types of lipid-sensitive vagal receptors, which we recently showed to exist in the small intestine, trigger an inhibitory enterogastric reflex that contributes to the regulation of gastric emptying.

Mechanisms governing the biphasic pattern of gastric emptying after truncal vagotomy and pyloroplasty

The pattern of gastric emptying after truncal vagotomy and drainage is usually biphasic. An early rapid phase is followed by a characteristically abrupt transition to slow emptying. The mechanisms responsible for this pattern were studied in six dogs with truncal vagotomy and pyloroplasty, fitted with a proximal duodenal cannula. Gastric emptying was measured using gamma camera imaging of a radiolabelled 15% dextrose test meal. Sixty one hour studies were done using five designs. (1) With the cannula closed gastric emptying was initially rapid, followed by stasis (emptying at 15 min - 32% (5.3), 60 min - 34% (4.8); mean (SE)). (2) With the cannula open emptying was very rapid (15 min - 76% (4.2) p less than 0.001, 60 min - 88% (2.6) p less than 0.001 ANOVA). (3) Distal duodenal instillation of isotonic saline, at a rate equivalent to gastric emptying with the cannula closed, did not retard this rapid emptying (15 min - 78% (10.6), 60 min - 90% (5.4)). (4) With duodenal instillation of 15% dextrose, gastric emptying remained faster than in studies without diversion (15 min - 50% (7.0) NS, 60 min - 65% (6.8) p less than 0.01), but was slower than during diversion alone (p less than 0.05). (5) Finally, duodenal instillation of 15% dextrose before administration of the test meal produced slower initial emptying without subsequent stasis (15 min - 24% (4.5), 60 min - 47% (10.6)), although the amounts emptied were not significantly different from those with the cannula closed. These results indicate that after truncal vagotomy and pyloroplasty small bowel resistances play a significant role in controlling gastric emptying. Osmoreceptor responses persist after truncal vagotomy, but sympathetic inhibitory responses to small bowel distension are not involved in the regulatory process.

Gastric drainage procedures: effects in normal dogs. II. Clinical observations and gastric emptying

Complete gastric emptying time using barium sulfate mixed with commercial canned dog food was measured radiographically in 29 mature mixed breed dogs before and 3 to 4 weeks after Fredet-Ramstedt pyloromyotomy (FRP) (6 dogs), Heineke-Mikulicz pyloroplasty (HMP) (6 dogs), Finney pyloroplasty (FP) (6 dogs), Jaboulay's gastroduodenostomy (JG) (6 dogs), and antral gastrojejunostomy (AG) (5 dogs). The dogs were observed for clinical evidence of side effects. Postoperative endoscopic examination and double contrast gastrography were performed to subjectively evaluate the diameter of the gastrointestinal communication and the amount of enterogastric reflux. Although none of the procedures significantly (p less than 0.05) altered gastric emptying time, the overall tendency was toward slowing down gastric emptying time. The severity of gastrointestinal side effects and enterogastric reflux appeared to be related to the size and/or location of the gastrointestinal opening.

Gastric emptying, glucose tolerance, and insulin response after duodenojejunostomy

We investigated the impact of direct jejunal delivery of various meals on gastric emptying, glucose tolerance, and insulin response in a chronic dog model following duodenojejunostomy. Ten beagle dogs underwent duodenal transection 2 cm distal to the pylorus and end-to-side duodenojejunostomy 20 cm distal to the ligament of Treitz. Three months after operation each dog underwent gastric emptying studies using radiolabeled normal saline, 20% glucose solution, and standardized mixed solid meal. Glucose tolerance tests with plasma insulin determinations were obtained using the glucose meal. After duodenojejunostomy both the rapid exponential pattern of emptying of normal saline and the slower linear pattern of glucose emptying seen in intact dogs were preserved. The linear gastric emptying of the solid meal which was slower than gastric emptying of either of the liquid meals was also preserved. Although integrated plasma glucose levels over 2 hr were 484.8 +/- 40.4 and 456.6 +/- 30.4 mg X hr/dl in intact and duodenojejunostomy dogs, respectively (P greater than 0.05), the initial rate of rise of plasma glucose was significantly delayed in the duodenojejunostomy dogs. But integrated plasma insulin levels over 2 hr differed significantly (P less than 0.05) between the intact (71.6 +/- 9.2 microU X hr/nl) and duodenojejunostomy (48.3 +/- 6.2 microU X hr/nl) dogs. We conclude that duodenojejunostomy (jejunal delivery) preserved the patterns of gastric emptying of saline, glucose, and mixed solid meals; retarded initial plasma glucose response to the glucose meal; and blunted plasma insulin response to the glucose load.

Vagal receptors sensitive to lipids in the small intestine of the cat

In anesthetized cats, the unitary activity of 53 sensory vagal neurons was recorded in nodose ganglia by means of extracellular glass microelectrodes. All the neurons had non-medullated fibres, with conduction velocities ranging from 0.8 to 1.2 m/s. Forty of these cells were stimulated by perfusion of the small intestine with lipids. Two types of receptors were identified: 21 endings were activated by glycerol and short chain lipids, and 19 endings were activated by long chain lipids. These receptors did not respond to either mechanical or osmotic stimulation. The discharge frequency generally increased with the concentration. The short latency suggested that they were located close to the enterocyte. The role of vagal intestinal receptors sensitive to lipids is discussed. Their functional characteristics along with previous experimental data suggest that they may be involved in the regulation of gastric emptying and alimentary behaviour, particularly satiety mechanisms.

Further data on the inhibitory enterogastric reflex triggered by intestinal osmotic changes in cats

The relationship between osmotic pressure in the intestinal lumen and gastric motor activity was studied in anesthetized cats. For this purpose the EMG was recorded in the antrum while the small intestine (duodenum and the first part of jejunum) was perfused with various solutions: tap water (5 mOsm), NaCl, mannitol and glucose having an osmotic pressure of 70, 138, 275, 550 or 1100 mOsm. Hypotonic and hypertonic solutions both induced a decrease in the gastric activity, i.e. an increase in period of electrical control activity. This effect was found to depend both on the osmolarity value (the osmotic pressures furthest removed from the isotonic value produced the greatest effect) and on the substance used (glucose, mannitol and NaCl, in decreasing order of efficiency). The isotonic solution of glucose and, to a lesser extent, of mannitol was also active, unlike the isotonic solution of NaCl. All these gastric changes were prevented by cervical bivagotomy. It was concluded that the vagal osmosensitive receptors located in the small intestine trigger this inhibitory enterogastric reflex which probably constitutes an important part in the regulation of gastric emptying.

Osmosensitive vagal receptors in the small intestine of the cat

In anesthetized cats, the unitary activity of 66 sensory vagal neurones was recorded with extracellular glass microelectrodes implanted in the nodose ganglia. These neurones had non-medullated afferent fibres with conduction velocities between 0.8 and 1.2 m/s, as do most of the intestinal vagal fibres, and were silent or fired at low frequencies before any simulation. They were activated by perfusion of the small intestine (duodenum and first part of jejunum) with tap water and various solutions (glucose, NaCl and mannitol, in particular) having osmotic pressures ranged between 4 and 1100 mOsm. In general, hypotonic solutions and tap water induced the more marked responses, but differences were observed according to the solution used. Most of these neurones were also excited by other forms of stimulation including stroking of the mucosa and perfusion with warm (39-55 degrees C) and acid (HCl at pH 1) solutions. Therefore they must be considered to be polymodal receptors sensitive to osmotic pressure. The short latency of responses elicited by osmotic stimulations, the marked sensitivity to mucosal stroking and the disappearance of nervous activity after local anesthesia indicate that these receptors are located close to the epithelium. The role of these osmosensitive endings is discussed. Analysis of their general characteristics suggests that they may be involved in the inhibitory entero-gastric reflex modulating gastric emptying.

Functional diarrhoea

Functional diarrhoea remains an elusive and a difficult condition to diagnose and treat; however, with careful history-taking a logical approach to management can be made. Each patient must be considered individually and sub-classification should be attempted. It is very important to rule out organic disease. Unfortunately treatment remains empirical in the majority of cases, but more is now known about functional disorders and there is hope for the future.

Effect of truncal vagotomy and pylorotomy on gastric emptying

The effect of transthoracic vagotomy and a conventional pylorotomy on gastric emptying of a hyperosmolar glucose meal was evaluated in four dogs by means of an isotope technique. The measurements were made preoperatively and 1 month and 3-6 months after each operation. Vagotomy significantly increased the initial rate of gastric emptying, whereas the total fraction of the meal emptied in 60 min was the same as before operation. The pylorotomy did not alter the emptying. Approximately 50% of the meal was still retained in the stomach at the end of the tests. The abnormal gastric emptying of the glucose meal after vagotomy was normalized by drinking an 'aperitif' of 20% soya bean oil 15 min before the ingestion of the glucose meal. It is concluded that a vagotomy alters the pattern but not the 60-min fraction of gastric emptying of a liquid meal, whereas a pylorotomy alters neither the pattern nor the 60-min fraction of gastric emptying. The vagally denervated gastrointestinal tract has maintained mechanisms for control of the gastric emptying.

Patterns of small intestinal motility in duodenal ulcer patients before and after vagotomy

Prolonged (18-24 hours) recordings of the pattern of small intestinal motor activity have been made, using radiotelemetry, in seven patients before surgery for chronic duodenal ulcer, seven after truncal vagotomy, and four with persistent post-vagotomy diarrhoea. There was no difference in the pattern of fasting cyclical activity between the three groups but the duration of feeding activity after a standard meal was reduced in asymptomatic truncal vagotomy patients compared with duodenal ulcer controls (p less than 0 . 05). In patients with post-vagotomy diarrhoea, the duration of the feeding pattern was further reduced compared with the asymptomatic post-vagotomy patients (p less than 0 . 001). It is suggested that altered emptying of food from the stomach in these patients together with duodenal receptor insensitivity is the probable explanation of these changes.

Does osmotic control of gastric emptying persist after truncal vagotomy?

Gastric emptying of 5 per cent and 10 per cent glucose test meals has been measured in 43 patients with a duodenal ulcer prior to surgery and in 52 patients with an unsatisfactory result following truncal vagotomy and a drainage procedure. Seventeen patients had a recurrent ulcer and incomplete vagotomy while 35 patients were symptomatic with complete vagotomy. In both the preoperative and postoperative patients the 10 per cent glucose test meal emptied significantly more slowly than the 5 per cent glucose test meal regardless of the completeness of vagotomy. Thus, osmotic control of gastric emptying persists after vagotomy.

Evaluation of gastric emptying by a simple isotope technique. A methodological study in the dog

The gastric emptying of a fluid standard meal labelled with 99mTc-DTPA has been studied in dogs, using a scintillation detector. The method was assessed in a series of in vivo and in vitro experiments. The gastric emptying patterns were visualized as time-activity curves. In the initial phase, the typical curves showed a rapid emptying within 2-5 min after start of the meal, followed by a more varied emptying and a subsequent steady emptying in the basic phase. Duplicate tests showed acceptable reproducibility. The initial emptying varied among individuals, whereas the basic emptying did not vary significantly. Combined evacuation/isotope gastric emptying studies showed that the external counting technique produced results comparable to those obtained by evacuation. Short-lasting spikes and plateau-like dislocations were observed in the curves, indicating peristalsis and duodenogastric reflux, respectively. The observed data are comparable with those obtained in man when using a gamma camera. Gastric emptying tests, carried out during continuous infusion of distilled water, 20% soya bean oil, or 25% glucose into various parts of the proximal gastrointestinal tract, showed that in dogs inhibitory 'receptors' for fat and glucose were located in the small intestine distal to the ligament of Treitz.

Postvagotomy diarrhoea and dumping treated with reconstruction of the pylorus

The results of reconstruction of the pylorus in 12 patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty are reported. Eight patients, primarily operated on with a truncal vagotomy and pyloroplasty, all indicated frequent diarrhoea as their principal symptom. After the reconstruction operation the stools were normalized in five, and the frequency of diarrhoea was reduced considerably in two patients. Three of four patients who had had a selective vagotomy and pyloroplasty complained of severe dumping after all kinds of food; after the reconstruction these symptoms were milder and provoked by sweets and milk only. The fourth patient with heavy diarrhoea as the principal symptom had postoperatively a slight reduction of the frequency. The operation is easy to perform, and no complication was encountered. The pathogenesis of the symptoms is discussed, and it is recommended that patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty undergo a reconstruction of the pylorus.

Measurement of flow and sampling of digesta in the preruminant calf

1. Methods of measuring and sampling the flow of digesta passing through intestinal cannulas in preruminant calves were studied and compared. 2. The effect of collecting digesta from a duodenal cannula on abomasal emptying in a calf given whole milk was determined. When digesta were collected and returned to the duodenum manually in large amounts (about 200 g) the outflow of abomasal contents was intermittent. When digesta were returned to the animal either manually or automatically in amounts of less than about 50 g abomasal emptying was smooth. 3. An automatic apparatus for measuring and sampling the flow of digesta continuously was developed. The device allowed effluent to be returned smoothly to an ingoing cannula at the same rate that digesta left the outgoing cannula. After a feed of whole milk abomasal contents were observed to enter the duodenum in an orderly series of gushes. Each gush consisted of about 5--30 g of digesta. 4. The apparatus was rearranged to measure the effects of composition of duodenal digesta on abomasal emptying. Replacement of duodenal digesta with a suspension containing heated soyabean flour slowed the abomasal outflow of a feed containing casein. 5. Automatic apparatus was used to collect digesta arriving at the distal ileum. Withholding effluent from the large intestine did not affect the movement of digesta from the ileum.