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

Is Chronic Ice Water Ingestion a Risk Factor for Gastric Cancer Development? An Evidence-Based Hypothesis Focusing on East Asian Populations

This article introduces a novel risk factor for gastric cancer (GC) by analyzing available epidemiological data from East Asian populations. A significantly higher age-standardized GC rate was observed in Japanese and Korean populations than in Chinese populations, despite nearly identical ethnicity, food habits, obesity rates, and alcohol consumption. Given the pivotal role of environmental factors in GC development, particularly for the intestinal type, a thorough evaluation of the lifestyles of these three populations was conducted to identify commonalities and disparities. It was observed that Japanese and Korean individuals prefer consuming ice water, while Chinese individuals tend to drink warm water, potentially influenced by traditional Chinese medicine disciplines. Considering the key features of GC development, a literature review was conducted to investigate the mechanisms through which the consumption of ice water might contribute to GC initiation and progression. Mechanistically, exposing gastric cells to hypothermia can increase the risk of carcinogenesis through multiple pathways. This includes the promotion of Helicobacter pylori colonization, prolonged gastric inflammation, and mitochondrial dysfunction in gastric cells. Furthermore, drinking ice water can enhance the survival, proliferation, and invasion of GC cells by releasing cold shock proteins, increasing gastric acid secretion, and delaying gastric emptying. Additionally, hypothermia can boost the immune evasion of cancer cells by weakening the antitumor immune system and activating different components of the tumor microenvironment. This paper also explores the association between exposure of GC cells to hypothermia and current insights into cancer hallmarks. These findings may partially elucidate the higher incidence of GC in Japanese and Korean populations and provide a clue for future experimental studies.Graphical abstract available for this article.

Symptoms from the Gastroparesis Cardinal Symptom Index and clinical factors associated with delayed gastric emptying in patients with suspected gastroparesis

BACKGROUND

The association between upper gastrointestinal symptoms and delayed gastric emptying (GE) shows conflicting results. This study aimed to assess whether the symptoms of the Gastroparesis Cardinal Symptom Index (GCSI) and/or the scores were associated with the result of GE tests and whether they could predict delayed GE.

METHODS

Patients referred for suspected gastroparesis (GP) were included in a prospective database. Demographical data, medical history, and symptoms of the GCSI score were collected for each patient. A GE scintigraphy was then performed with a 4-hour recording. Delayed GE was defined as a retention rate ≥ 10% at 4 h.

RESULTS

Among 243 patients included in this study, 110 patients (45%) had delayed GE. The mean age (49.9 vs. 41.3 years; p < 0.001) and weight loss (9.4 kg vs. 5.6 kg; p = 0.025) were significantly higher in patients with delayed GE. Patients with diabetes or a history of surgery had a higher prevalence of delayed GE (60% and 78%, respectively) than patients without comorbidity (17%; p < 0.001). The GCSI score was higher in patients with delayed GE (3.06 vs. 2.80; p = 0.045), but no threshold was clinically relevant to discriminate between patients with normal and delayed GE. Only vomiting severity was significantly higher in patients with delayed GE (2.19 vs. 1.57; p = 0.01).

CONCLUSION

GE testing should be considered when there are symptoms such as a higher weight loss, comorbidities (diabetes, and history of surgery associated with GP), and the presence of vomiting. Other symptoms and the GCSI score are not useful in predicting delayed GE.

Forecasting the effect of water gastric emptying patterns on model drug release in an in vitro glass-bead flow-through system

Oral solid dosage forms are most frequently administered with a glass of water which empties from the stomach relatively fast, but with a certain variability in its emptying kinetics. The purpose of this study was thus to simulate different individual water gastric emptying (GE) patterns in an in vitro glass-bead flow-through dissolution system. Further, the effect of GE on the dissolution of model drugs from immediate-release tablets was assessed by determining the amount of dissolved drug in the samples pumped out of the stomach compartment. Additionally, different HCl solutions were used as dissolution media to assess the effect of the variability of pH of the gastric fluid on the dissolution of three model drugs: paracetamol, diclofenac sodium, and dipyridamole. The difference in fast and slow GE kinetics resulted in different dissolution profiles of paracetamol in all studied media. For diclofenac sodium and dipyridamole tablets, the effect of GE kinetics was well observed only in media, where the solubility was not a limiting factor. Therefore, GE kinetics of co-ingested water influences the drug release from immediate-release tablets, however, in certain cases, other parameters influencing drug dissolution can partly or fully hinder the expression of this effect.

Scintigraphy of Gastrointestinal Motility: Best Practices in Assessment of Gastric and Bowel Transit in Adults

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.

Gastric Emptying Studies in Pediatrics: A Cincinnati Children's Hospital Experience

Gastric emptying studies are routinely performed in many nuclear medicine departments; however, there are many different techniques used to perform the procedure across the country. Creating consistency in clinical practice will aid gastroenterologists in diagnosing and treating illnesses associated with abnormalities related to gastric emptying. In 2017, Cincinnati Children's Hospital adopted adult standards for pediatric gastric emptying studies that included a standard meal along with imaging over the course of 4 h. Gastric emptying studies are the second-highest-volume examination performed in the nuclear medicine section at Cincinnati Children's Hospital. Accommodating this volume required changes in the scheduling template, scheduling questionnaire, and epic order sets, as well as identification of specific days and locations for gastric emptying studies. Both protocol standardization and workflow optimization are critically important in creating consistency in patient care. Gastric emptying can be evaluated with solid food, liquid food, or solid and liquid food simultaneously. The methodology of the study is initially determined by the ordering provider but may require special accommodations based on what the patient will tolerate. In coordination with the ordering and interpreting physicians, the nuclear medicine technologists at Cincinnati Children's Hospital have the decision-making ability to deviate from the provider's request as necessary, which helps expedite workflow and eliminates wasted time. Any deviation from the standardized protocol is documented by the nuclear medicine technologist and incorporated into the final report by the interpreting physician, as dietary information is meaningful to the ordering provider. Reference values associated with the standardized or modified protocol are also included in the final report.

Normative Data of Liquid Gastric Emptying and Small-bowel Transit: A Prospective Cross-sectional Study

Purpose of the Study

The primary objective was to establish the reference values for liquid gastric emptying and small bowel. The secondary objectives encompassed comparing the anterior view and geometric mean methods, assessing gender differences, and exploring potential correlations with age.

Materials and Methods

Thirty-five consecutive healthy participants (28 females and 7 males) with a mean age of 42 ± 11 years (median, 42; range, 23-65) underwent liquid gastric emptying scintigraphy at five intervals (0, 0.5, 1, 2, and 4 h), with optional additional imaging at 24 h. Liquid gastric emptying was evaluated using percent retention and half-time (T1/2). Small-bowel transit was assessed using the index of small-bowel transit (ISBT), calculated as the ratio of terminal ileal reservoir counts to total abdominal counts at 4 h. Reference values were established based on percentiles or mean and standard deviation (SD). Rapid small-bowel transit was determined through visual inspection. Statistical analysis involved paired Samples t-test or Wilcoxon signed-rank test for comparing imaging methods, independent Samples t-test or Mann-Whitney U-test for gender comparison, and Spearman's rank correlation for assessing age-related associations. A 2-tailed P < 0.05 indicated significance.

Results

Rapid liquid gastric emptying based on the geometric mean method was defined as percent retention <8% at 30 min, while delayed emptying as percent retention >33%, >20%, and >4% at 1, 2, and 4 h, respectively. The reference range of T1/2 of gastric emptying was 10-60 min. The reference value for small-bowel transit using the geometric mean method was established as ISBT >30% at 4 h, while rapid small-bowel transit was defined as the first visualization of activity in the cecum-ascending colon within 1 h. Parameters for liquid gastric emptying and small-bowel transit were notably higher in the anterior view method compared to the geometric mean method (P ≤ 0.019), except for percent retention at 2 h (P = 0.510). Nevertheless, the obtained reference values, whether based on percentiles or mean and SD, showed no notable variance between the two methods to warrant clinical significance. Gender did not display an impact on liquid gastric emptying or small-bowel transit in either method (P ≥ 0.173), and age demonstrated no significant moderate or strong correlations (Spearman's ρ ≤ 0.397).

Conclusion

The study determined reference values for liquid gastric emptying and small-bowel transit through a standard gastric emptying scintigraphy protocol, avoiding additional complex procedures or extended imaging sessions. The established normative data can apply to individuals of both genders aged ≥18 years. While advocating the geometric mean method as the primary choice, the study acknowledges that in busy centers handling multiple studies with limited resources and a single-head gamma camera catering to multiple studies, the anterior view method remains a feasible alternative.

A global bibliometric and visualized analysis of the status and trends of gastroparesis research

BACKGROUND

Gastroparesis has a substantial impact on the quality of life but has limited treatment options, which makes it a public health concern. No bibliometric studies on gastroparesis have been published thus far. Thus, this article aims to summarize and analyze research hotspots to provide a reference for clinical researchers.

MATERIALS AND METHODS

Gastroparesis-related research articles were searched in the Web of Science Core Collection (WOSCC), and relevant information was extracted after screening. A total of 1033 documents were analyzed with the bibliometric method using Microsoft Excel, Citespace, and VOSviewer.

RESULTS

Overall, our search retrieved 1033 papers contributed by 966 research institutions from 53 countries. Since 1980, publications in this field have increased rapidly. United States (n = 645) and Temple University (n = 122) were the most productive country and institution, respectively. Parkman, with 96 publications, was the most prominent author.

CONCLUSIONS

Research hotspots in gastroparesis can be summarized into four domains: innovation in diagnostic modalities, change of oral therapeutic agents, choice of surgical interventions, and pathological mechanisms. Future research on gastroparesis should focus on the quality of life of patients, diagnostic techniques, pyloromyotomy, and transpyloric stent placement.

Ten controversies in gastroparesis and a look to the future

BACKGROUND

Gastroparesis is a complex, challenging gastrointestinal disorder presenting with upper gastrointestinal symptoms, especially nausea and vomiting, with significant impact on patients' quality of life. After ruling out mechanical obstruction, it is essential to identify delay in gastric emptying for definitive diagnosis. The most common causes are idiopathic (no identified etiology), diabetes mellitus, and postsurgical status. Management of gastroparesis focuses on dietary modifications and treatment directed to symptom relief. Unfortunately, approximately one-third of patients are refractory to pharmacological therapy, and the effectiveness of the few nonpharmacological options has been questioned.

PURPOSE

Extensive review of the literature identifies several uncertainties or controversies regarding the differential diagnosis based on the spectrum of symptoms, the lack of availability of reliable diagnostic test, and questions regarding effective therapeutic options. In this review, we discuss ten controversies regarding gastroparesis: clinical presentation, diagnosis, overlap syndromes, pathophysiology, etiology, as well as pharmacological and nonpharmacological therapeutic options. In addition, we briefly review studies exploring pathological, inflammatory, and molecular disturbances affecting the intrinsic neuromuscular elements that may be involved in the pathophysiology of gastroparesis and may constitute possible therapeutic targets in the future. Finally, we tabulate future research opportunities to resolve these controversies in the management of patients with gastroparesis.

Tagging Efficiency of 99m Tc-SC Radiolabeled Alternative Gastric Emptying Meals: A Quantitative Study

Objective  The aim of this study was to know the tagging efficiencies of technetium-99m labeled sulfur colloid (99mTc-SC) with different meals. Materials and Methods  Egg white sandwiches are the gold standard for gastric-emptying scan (GES); thus, an egg white omelet labeled with ^99m Tc-SC is taken as a standard meal. For evaluation, we included four meals, bread and butter, instant oatmeal, idli, and chapatti, and all meals were prepared by labeling them with ^99m Tc-SC. After preparation, food articles were chopped with the help of a metal fork and mixed in simulated gastric fluid. Four samples were taken simultaneously from each food article and analyzed for 1 to 4hours after agitation within the centrifuge. The samples were filtered and separated from the sediments and supernatants. We analyzed the activity in each sample before and after filtration. Results  The mean values of labeling efficiency in per cent of various meals were obtained. There was no significant difference in labeling stability for egg whites, chapatti, and idli meals labeled with ^99m Tc-SC from 1 to 4hours as their p -value (p>0.05) was insignificant. Conclusion  Radiolabeled chapatti and idli with ^99m Tc-SC show higher labeling stability, while oatmeal and bread and butter samples show relatively low stability. Thus, for GES, chapatti and idli labeled with ^99m Tc-SC can be used as alternatives to eggs for vegetarian people or for those allergic to eggs.

Gastroparesis in systemic sclerosis: a detailed analysis using whole-gut scintigraphy

OBJECTIVES

Gastroparesis is a common complication of SSc. We sought to determine the degree of overlap between gastroparesis and dysmotility in other areas of the gut, correlate our findings with gastrointestinal (GI) symptoms, and examine associations between gastroparesis and SSc features.

METHODS

Whole-gut scintigraphy was performed on SSc patients who were enrolled in the Johns Hopkins Scleroderma Cohort, for whom detailed longitudinal clinical and serologic data are collected. A subset of patients completed the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) to quantify their GI symptoms. We examined associations between the presence and severity of gastroparesis, GI symptoms, and SSc clinical features.

RESULTS

Ninety-seven SSc patients with and without GI symptoms underwent whole-gut scintigraphy and completed the gastric emptying study. Of the 97, 34 (35%) met criteria for gastroparesis. Of the measures assessed, delayed liquid emptying captured more patients with delayed gastric transit than delayed solid emptying (74% vs 55%), and percentage liquid emptying correlated best with GIT Reflux (ρ = -0.33, P = 0.01) and Distension (ρ = -0.30, P = 0.03) scores. Of 33 patients with gastroparesis, 30 (91%) had abnormal transit in other areas of the GI tract. Higher anti-centromere protein B (CENP-B) titres correlated with slower gastric emptying (ρ = -0.26, P = 0.03), but no specific clinical features of SSc were associated with gastroparesis.

CONCLUSIONS

Gastric emptying of liquids when given alongside solids may be more sensitive and provide a more clinically relevant measure of gastroparesis in SSc than solid gastric emptying or liquid gastric emptying alone. SSc patients with gastroparesis frequently have dysmotility in other areas of the GI tract, underscoring the need for whole-gut scintigraphy to evaluate the entire gut.

Dynamics Changes of Solids Gastric Emptying Post -Pancreaticoduodenectomy

BACKGROUND: Gastric emptying (GE) is one of the common post-operative complications after pancreaticoduodenectomy (PD). Multiple factors have been involved in this complication. Dynamic studies such as GE scintigraphy (GES) have informed us about changes in the behavior of the stomach before and after the operation. AIM: The objective of this study is a short-term scintigraphic evaluation of GE in post-PD patients for solid food before (baseline) and after the operation for 30 days. METHODS: Between April 2016 and September 2019, 30 patients who underwent PD were investigated for the effect on GE of solids. GE scan GES was performed for the evaluation of solids in GE on pre-operative and post-operative day 30. The operative time, blood loss, the specimens’ pathology and resection margins, the interpretation of the GES study, and finally the hospital course data were all gathered and subjected to statistical analysis. RESULTS: Nineteen patients developed delayed GE (DGE) while four developed rapid GE or dumping. The type of pancreatic reconstruction affected the GE dynamics. DGE was evident in all cases with pancreaticogastrostomy (PG), while it was observed only in 4 patients of 15 with pancreaticojejunostomy (PJ). Seven cases developed a post-operative pancreatic fistula (POPF), 3 after PG versus 4 after PJ, and were all successfully managed conservatively. CONCLUSION: The reconstruction method of the remnant pancreas could affect the dynamics of GE. The DGE to solids was witnessed more in cases reconstructed by PG and less in cases with PJ. Post-operative complications associated, such as POPF, are factors associated with DGE.

Gastric Mobility and Gastrointestinal Hormones in Older Patients with Sarcopenia

Sarcopenia has serious clinical consequences and poses a major threat to older people. Gastrointestinal environmental factors are believed to be the main cause. The aim of this study was to describe the relationship between sarcopenia and gastric mobility and to investigate the relationship between sarcopenia and the concentration of gastrointestinal hormones in older patients. Patients aged ≥ 75 years were recruited for this prospective study from August 2018 to February 2019 at the emergency department. The enrolled patients were tested for sarcopenia. Gastric emptying scintigraphy was conducted, and laboratory tests for cholecystokinin(CCK), glucagon-like peptide-1 (GLP-1), peptide YY (PYY), nesfatin, and ghrelin were performed during the fasting period. We enrolled 52 patients with mean age of 86.9 years, including 17 (32.7%) patients in the non-sarcopenia group, 17 (32.7%) patients in the pre-sarcopenia group, and 18 (34.6%) in the sarcopenia group. The mean gastric emptying half-time had no significant difference among three groups. The sarcopenia group had significantly higher fasting plasma concentrations of CCK, GLP-1, and PYY. We concluded that the older people with sarcopenia had significantly higher plasma concentrations of CCK, GLP-1, and PYY. In the elderly population, anorexigenic gastrointestinal hormones might have more important relationships with sarcopenia than orexigenic gastrointestinal hormones.

Relationship Between Gastrointestinal Transit, Medsger Gastrointestinal Severity, and University of California-Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 Symptoms in Patients With Systemic Sclerosis

OBJECTIVE

Systemic sclerosis (SSc)-associated gastrointestinal (GI) complications are attributed to a variety of factors, including diet, microbiota dysbiosis, or GI transit abnormalities. Our objective was to examine the contribution of abnormal GI transit to SSc Medsger GI severity scores and/or University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA GIT) 2.0 symptoms.

METHODS

Patients with SSc and GI symptoms (n = 71) and healthy controls (n = 18) underwent whole gut transit (WGT) scintigraphy to assess transit from the esophagus to the colon. The presence of delayed transit and percent emptying in each GI region were measured. We compared the WGT measurements between categories of the Medsger GI severity score (0-4) and across UCLA GIT 2.0 domains and total score (0-3).

RESULTS

A total of 88% of patients had >1 abnormal region of the gut on WGT scintigraphy. All patients requiring total parenteral nutrition had delayed small bowel transit, compared to only approximately 11% of patients in other Medsger GI severity groups (P ≤ 0.01). Severe colonic transit delays were more likely in patients with Medsger GI scores of 3 (pseudo-obstruction and/or malabsorption) compared to other Medsger GI groups (P = 0.02). Seventy-percent of these patients had ≤30% colonic emptying at 72 hours. Modest associations were noted between gastroesophageal reflux disease symptoms and delayed esophageal (r = -0.31, P = 0.05) and gastric emptying (r = -0.32, P = 0.05).

CONCLUSION

These data are important in providing evidence that SSc bowel disease affects transit of GI content and that delay in transit accounts in part for both bowel symptoms and Medsger GI severity. Prospective studies examining the benefit of early therapeutic intervention targeting GI transit abnormalities in patients at high risk for severe GI complications are needed.

Early steps of an alternative test meal for gastric emptying scintigraphy

Background/Aim. Gastric emptying (GE) scintigraphy provides a physiologic and noninvasive measurement of GE. Although GE scintigraphy has been standardized, preparing a meal is still complex and not practical in daily routine. The aim of the study was to prepare a simple, practical, and easily standardizable semisolid meal and investigate its role in estimating the GE function in of rabbits. Methods. In the first part of the study (basal condition), the mixture of the macroaggregated albumin (MAA) labeled with 37 MBq (1 mCi) of technetium-99m (99mTc) and 40 g of barium sulfate (1g/mL) was applied to animals via a nasogastric catheter. A series of images (frame/min, 60 min) in the anterior and posterior projections were dynamically acquired, and the motion was corrected after the radiopharmaceutical application. A few days later, the same rabbits were scanned under the same protocol after a 1 mg atropine injection to simulate gastroparesis condition. Eleven rabbits were included according to inclusion and exclusion criteria, and a total of twenty-two imaging data sets were analyzed for quantification. Results. In the basal study, total counts of the mixture decreased from 87,800.83 ? 12,622.76 to 42,733.14 ? 6,591.53 at 30 min and to 13,684.19 ? 1,774.90 at 60 min, and these decreases were statistically significant (p = 0.003). Emptying percentages were 51.39 ? 0.78% at 30 min and 84.32 ? 1.56 at 60 min and were statistically significant (p = 0.003). After intravascular atropine sulfate injection, total counts of the mixture decreased from 84,508.78 ? 11,871.48 to 64,995.18 ? 9,298 at 30 min and to 53,507.17 ? 7,258.98 at 60 min, and these decreases were statistically significant (p = 0.003). Emptying percentages were 23.10 ? 1.11% at 30 min and 36.63 ? 1.42 at 60 min and were statistically significant (p = 0.003). The difference between basal and post-atropine sulfate gastric emptying percentage at 30th (p = 0.003) and 60th (p = 0.003) min was statistically significant. Conclusion. The meal, used in this study, is non-nutrient, fatty-free, and semisolid and is easy to prepare and administer. Due to its semisolid nature, it offers a chance to evaluate the quantification of regional and total GE as well as the separate roles of the fundus and antrum.

European guideline on indications, performance and clinical impact of 13 C-breath tests in adult and pediatric patients: An EAGEN, ESNM, and ESPGHAN consensus, supported by EPC

Introduction

¹³C‐breath tests are valuable, noninvasive diagnostic tests that can be widely applied for the assessment of gastroenterological symptoms and diseases. Currently, the potential of these tests is compromised by a lack of standardization regarding performance and interpretation among expert centers.

Methods

This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of ¹³C‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 43 experts from 18 European countries. Consensus on individual statements and recommendations was established if ≥ 80% of reviewers agreed and <10% disagreed.

Results

The guideline gives an overview over general methodology of ¹³C‐breath testing and provides recommendations for the use of ¹³C‐breath tests to diagnose Helicobacter pylori infection, measure gastric emptying time, and monitor pancreatic exocrine and liver function in adult and pediatric patients. Other potential applications of ¹³C‐breath testing are summarized briefly. The recommendations specifically detail when and how individual ¹³C‐breath tests should be performed including examples for well‐established test protocols, patient preparation, and reporting of test results.

Conclusion

This clinical practice guideline should improve pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, this guideline identifies areas of future clinical research involving the use of ¹³C‐breath tests.

13 C-gastric emptying breath tests: Clinical use in adults and children

¹³ C-gastric emptying breath tests (¹³ C-GEBT) are validated, reliable, and non-invasive tools for measurement of gastric emptying (GE) velocity of solids and liquids without radiation exposure or risk of toxicity. They are recommended and routinely used for clinical purposes in adult as well as pediatric patients and can be readily performed onsite or even at the patient's home. However, the underlying methodology is rather complex and test results can be influenced by dietary factors, physical activity, concurrent diseases, and medication. Moreover, epidemiological factors can influence gastric emptying as well as production and exhalation of ¹³ CO₂ , which is the ultimate metabolic product measured for all ¹³ C-breath tests. Accordingly, in this issue of Neurogastroenterology & Motility, Kovacic et al. report performance of the ¹³ C-Spirulina breath test in a large group of healthy children and show significant effects of gender, pubertal status, and body size on test results. The purpose of this mini-review is to evaluate the clinical use of ¹³ C-GEBT in adults and children, exploring available protocols, analytical methods, and essential prerequisites for test performance, as well as the role of GE measurements in the light of the current discussion on relevance of delayed GE for symptom generation.

The Satiation Framework: Exploring processes that contribute to satiation

Satiation has been described as a process that leads to the termination of eating and controls meal size. However, studies have shown that the termination of eating can be influenced by multiple behavioral and biological processes over the course of a meal as well as those related to the context in which the meal is consumed. To expand understanding of how individuals experience satiation during a meal, we recently developed the Reasons Individuals Stop Eating Questionnaire (RISE-Q). The development of the RISE-Q revealed five distinct factors reported to contribute to meal termination: Planned Amount, Self-Consciousness, Decreased Food Appeal, Physical Satisfaction, and Decreased Priority of Eating. Thus, we define satiation as a series of dynamic processes that emerge over the course of a meal to promote meal termination. We suggest that each of the factors identified by the RISE-Q represents a distinct process, and illustrate the contribution of each process to meal termination in the Satiation Framework. Within this framework the prominence of each process as a reason to stop eating likely depends on meal context in addition to individual variability. Therefore, we discuss contexts in which different processes may be salient as determinants of meal termination. Expanding the definition of satiation to include several dynamic processes as illustrated in the Satiation Framework will help to stimulate investigation and understanding of the complex nature of meal termination.

Reference values for the water load test in healthy school children and adolescents

BACKGROUND AND STUDY AIM

The water load test (WLT) is an easy and cheap tool, useful in evaluating gastric accommodation and visceral hypersensitivity. This test can be used in diagnosing functional gastrointestinal disorders, like functional dyspepsia. Our main aim was to propose reference values for the WLT. Our secondary aim was to correlate the water volume drunk with the students' gender, age, and anthropometric measures.

PATIENTS AND METHODS

We performed the WLT in students aged 8 to 17 years. Students drank water ad libitum for 3 minutes or until pain, satiety or vomiting occurred. We correlated anthropometric variables with water volumes drunk. Upper and lower limit for the maximum tolerated volume were calculated as the 5th and 95th percentile. Pain and nausea were recorded before and after the test.

RESULTS

We evaluated 99 students, with a median age (inter quartile range) of 11 years 10-13 years) and 55.6 % were girls. Median water volume drank was 380 ml (190-540 ml). Boys (523 ml, interquartile range : 275-760 ml) drank more water than girls (380 ml, interquartile range : 190-570 ml) (p = 0.016). There was a significant correlation between water volume drank and students´ age, weight, height, and body mass index. Of the students that completed the WLT, 22.2 % had nausea and 30.3 % had mild abdominal pain after the test.

CONCLUSIONS

We proposed reference values for the WLT in children aged 8 to 17 years. Adverse effects are minimal, it is safe to perform, and well tolerated.

Reflux Aspiration Associated with Oesophageal Dysmotility but Not Delayed Liquid Gastric Emptying

INTRODUCTION

Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility.

METHODS

Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed.

RESULTS

Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03).

CONCLUSION

Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

A transformational change in scintigraphic gastroesophageal reflux studies: A comparison with historic techniques

BACKGROUND

The inclusion of scintigraphy in the diagnostic algorithm for gastroesophageal reflux is controversial due to variability in methodology and reporting. A novel scintigraphic reflux study has been developed and validated against the current standards for the diagnosis of gastroesophageal reflux disease (GORD).

OBJECTIVE

To compare a new scintigraphic reflux test against historic techniques and standardised diagnostic reference tests for gastroesophageal reflux disease.

METHODS

Paired scintigraphic studies were conducted in seventeen patients. All patients underwent at least one other standardised diagnostic reflux test such as 24- hour oesophageal impedance/ pH, and oesophageal manometry, barium swallow, gastroscopy or the Peptest. Patients inadvertently presented at sites B for scintigraphic reflux testing rather than at Site A which was part of an approved study. The findings from sites B did not correlate with clinical symptoms and other diagnostic reference tests from GORD. These studies were then repeated at Site A with approval from the patients. A second reflux study was performed at site A, utilising a novel technique with the capability of assessing oesophageal and extra-oesophageal disease.

RESULTS

The Site A technique shows good concordance with the reference diagnostic tests with an accuracy of 82.4% and kappa of 0.64 (SE: 0.16, p = 0.00). Site B had an overall accuracy of 47.1% and kappa of 0.066 (SE: 0.068, p = 0.45).

CONCLUSION

The Site A technique shows higher accuracy than either site B or the historic reflux techniques. It has characteristics that make it an effective screening tool for assessment of local oesophageal disease and its extraoesophageal manifestations.

Medical and surgical management of gastroparesis: a systematic review

BACKGROUND

Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized.

OBJECTIVES

We present a review of the literature and provide an update of current therapies for patients with GPS.

SETTING

Department of General Surgery, Academic Hospital, United States.

METHODS

We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference.

RESULTS

A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review.

CONCLUSION

GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.

Enhancing Scintigraphy for Evaluation of Gastric, Small Bowel, and Colonic Motility

This article reviews the latest enhancements in standards and technology for performing gastric emptying and associated small bowel and colon transit scintigraphic studies. It discusses how developments in appropriate use criteria, American Medical Association Current Procedural Terminology coding, and advanced commercial software permit clinicians to obtain more comprehensive physiologic studies of gastric, small bowel, and colon gastrointestinal motility disorders. It shows how gastrointestinal scintigraphy has expanded to permit assessments of global and regional (fundic and antral) gastric motility and how it permits a single study (whole-gut transit scintigraphy), including measurement of solid and liquid gastric emptying and small bowel and colon transit.

Experience with Esophagogastrointestinal Transit Scintigraphy in the Initial 229 Patients: Multiple Regions of Dysmotility Are Common

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.

Pathophysiology, Aetiology and Treatment of Gastroparesis

Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.

Codeine delays gastric emptying through inhibition of gastric motility as assessed with a novel diagnostic intragastric balloon catheter

BACKGROUND

The use of opioids as analgesic is on the rise, despite their inhibitory effect on gastric emptying. A novel feeding catheter with integrated intragastric balloon was developed to continuously assess gastric motility, enabling to investigate the effect of opioids on motility and emptying simultaneously. We aimed to discriminate normal and pharmacologically impaired gastric motility and its impact on gastric emptying in healthy adults.

METHODS

The VIPUN Gastric Monitoring System comprises a nasogastric balloon catheter and a monitoring unit. In a four-way randomized, single-blinded, cross-over study, subjects received either placebo or 58.8 mg codeine phosphate in combination with either an uninflated or an inflated (180 mL) balloon catheter. Motility-induced pressure changes were recorded for 6 hours. During the first 2 hours, nutrients were infused (225 kcal, 75 mL/h). Gastric emptying was assessed with a ¹³ C-octanoate breath test and expressed as gastric half-emptying time (GET½). An algorithm, designed to detect phasic contractility, converted pressure changes to a gastric balloon motility index (GBMI). Results are presented as mean(SD).

KEY RESULTS

Eighteen subjects completed the investigation (32(13) years, 22(2) kg/m² ). After codeine, GBMI was lower (0.31(0.16)) and GET½ was longer (233(57) minutes) compared with placebo (GBMI: 0.48(0.15), P < .01 and GET½: 172(12) minutes, P < .001). Within-subject ΔGET½ correlated significantly with ΔGBMI (r = -0.77 and P < .001).

CONCLUSIONS AND INFERENCES

The VIPUN Gastric Monitoring System allowed to assess gastric motility safely and continuously. The correlation between pharmacologically decreased gastric emptying and motility indicates a strong link between both. Gastric motility, measured with this innovative device, can be an indicator for gastrointestinal intolerance.

In-vitro–in-silico investigation of the negative food effect of zolpidem when administered as immediate-release tablets

Objectives

The main objective of the present work was to combine in-vitro and in-silico tools to better understand the in-vivo behavior of the immediate release (IR) formulation of zolpidem in the fasted and fed states.

Methods

The dissolution of zolpidem was evaluated using biorelevant media simulating the gastric and intestinal environment in the fasted and fed states. Additionally, the influence of high viscosity and high fat content on the release of zolpidem under fed state conditions was investigated. The in-vitro results were combined with a physiologically based pharmacokinetic (PBPK) model constructed with Simcyp® to simulate the zolpidem pharmacokinetic profile in both prandial states.

Key findings

In vitro biorelevant dissolution experiments representing the fasted and fed states, combinedwith PBPKmodelling, were able to simulate the plasma profiles from the clinical food effect studies well. Experiments reflecting the pH and fat content of themeal led to a good prediction of the zolpidem plasma profile in the fed state, whereas increasing the viscosity of the gastricmedia led to an under-prediction.

Conclusions

This work demonstrates that the combination of biorelevant dissolution testing and PBPK modelling is very useful for understanding the in-vivo behavior of zolpidem in the fasted and fed states. This approach could be implemented in the development of other drugs exhibiting negative food effects, saving resources and bringing new drug products to the market faster.

GI Motility Testing: Stomach, Small Bowel, and Colon

Symptoms of abdominal pain, nausea, vomiting, bloating, abdominal distention, diarrhea, and constipation are common and may relate to abnormalities in gastrointestinal motility. There are a number of different options to study gastrointestinal motility. This article reviews novel and standard motility tests available in the stomach, small bowel, and colon. The indications for testing, technical details, advantages, and disadvantages of each test will be summarized.

Pathophysiology of idiopathic gastroparesis and implications for therapy

OBJECTIVES

Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis.

MATERIALS AND METHODS

Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases.

RESULTS

Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment.

CONCLUSIONS

Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.

Helping Patients with Gastroparesis

Gastroparesis is an increasing concern and options remain limited. Diagnosis hinges on recognition of delayed gastric emptying in the absence of mechanical obstruction. Nontransit studies evaluating gastric motility serve a complementary role and may help guide therapy. Treatment consists of a combination of lifestyle and dietary medication, medications (antiemetics, prokinetics, neuromodulators, and accommodation-enhancers), alternative and complementary therapy, endoscopic therapy (pyloric-directed therapy, temporary stimulation, jejunostomy, or venting gastrostomy) and surgical therapy (pyloroplasty, gastric electrical stimulation, gastrectomy). Treatment can be tailored to the individual needs and symptoms of the affected patient.

Nuclear Scintigraphy in Practice: Gastrointestinal Motility

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.

The Investigation and Treatment of Diabetic Gastroparesis

PURPOSE

This review provides an update on the investigations and treatment options for gastroparesis.

METHODS

A comprehensive literature search of Medline, PubMed, Embase and OVID was conducted which included all systematic reviews and research articles that focused on the diagnosis, investigations and management diabetic gastroparesis.

FINDINGS

Dietary modifications and pharmacologic treatment with prokinetics to increase gastric motility form the mainstay of treatment. However, the use of prokinetics is limited by adverse effects and serious adverse effects, leaving metoclopramide as the only drug approved by the US Food and Drug Administration for the treatment of gastroparesis. Newer therapies, including motilin receptor agonists, ghrelin receptor agonists, and neurokinin receptor antagonists, are currently being investigated. Transpyloric stenting, gastric electrical stimulation, and gastric per-oral endoscopic myotomy provide mechanical options for intervention, and surgical interventions in severe intractable gastroparesis include laparoscopic pyloroplasty or gastrectomy.

IMPLICATIONS

Advances to better understand the pathophysiology and management of diabetic gastroparesis have been limited, especially with discordance between symptoms and severity of delay in gastric emptying. Established treatment options are limited; however, recent pharmacologic and surgical interventions show promise.

Zinc Absorption from Milk Is Affected by Dilution but Not by Thermal Processing, and Milk Enhances Absorption of Zinc from High-Phytate Rice in Young Dutch Women

Background: Milk has been suggested to increase zinc absorption. The effect of processing and the ability of milk to enhance zinc absorption from other foods has not been measured directly in humans.Objective: We aimed to assess zinc absorption from 1) milk undergoing various processing and preparatory steps and 2) from intrinsically labeled high-phytate rice consumed with milk or water.Methods: Two randomized crossover studies were conducted in healthy young women [age:18-25 y; body mass index (in kg/m²): 20-25]: 1) a milk study (n = 19) comparing the consumption of 800 mL full-fat ultra-high temperature (UHT) milk [heat-treated milk (HTM)], full-fat UHT milk diluted 1:1 with water [heat-treated milk and water (MW)], water, or unprocessed (raw) milk (UM), each extrinsically labeled with ⁶⁷Zn, and 2) a rice study (n = 18) comparing the consumption of 90 g intrinsically ⁶⁷Zn-labeled rice with 600 mL of water [rice and water (RW)] or full-fat UHT milk [rice and milk (RM)]. The fractional absorption of zinc (FAZ) was measured with the double-isotope tracer ratio method. In vitro, we assessed zinc extraction from rice blended into water, UM, or HTM with or without phytate.Results: FAZ from HTM was 25.5% (95% CI: 21.6%, 29.4%) and was not different from UM (27.8%; 95% CI: 24.2%, 31.4%). FAZ from water was higher (72.3%; 95% CI: 68.7%, 75.9%), whereas FAZ from MW was lower (19.7%; 95% CI: 17.5%, 21.9%) than HTM and UM (both P < 0.01). FAZ from RM (20.7%; 95% CI: 18.8%, 22.7%) was significantly higher than from RW (12.8%; 95% CI: 10.8%, 14.6%; P < 0.01). In vitro, HTM and UM showed several orders of magnitude higher extraction of zinc from rice with HTM than from rice with water at various phytate concentrations.Conclusions: Milk enhanced human FAZ from high-phytate rice by 62% compared with water. Diluting milk with water decreases its absorption-enhancing proprieties, whereas UHT processing does not. This trial was registered at the Dutch trial registry as NTR4267 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4267).

Assessment of gastric emptying in children: Establishment of control values utilizing a standardized vegetarian meal

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.

Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation

Background. The optimal time interval between the last ingestion of bowel prep and sedation for colonoscopy remains controversial, despite guidelines that sedation can be administered 2 hours after consumption of clear liquids. Objective. To determine current practice patterns among anesthesiologists and gastroenterologists regarding the optimal time interval for sedation after last ingestion of bowel prep and to understand the rationale underlying their beliefs. Design. Questionnaire survey of anesthesiologists and gastroenterologists in the USA. The questions were focused on the preferred time interval of endoscopy after a polyethylene glycol based preparation in routine cases and select conditions. Results. Responses were received from 109 anesthesiologists and 112 gastroenterologists. 96% of anesthesiologists recommended waiting longer than 2 hours until sedation, in contrast to only 26% of gastroenterologists. The main reason for waiting >2 hours was that PEG was not considered a clear liquid. Most anesthesiologists, but not gastroenterologists, waited longer in patients with history of diabetes or reflux. Conclusions. Anesthesiologists and gastroenterologists do not agree on the optimal interval for sedation after last drink of bowel prep. Most anesthesiologists prefer to wait longer than the recommended 2 hours for clear liquids. The data suggest a need for clearer guidelines on this issue.

Normal values and symptom correlation of a simplified oatmeal-based gastric emptying study in the Chinese population

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.