Studio dello Svuotamento Gastrico

STRUTTURA COMPLESSA GASTROENTEROLOGIA, CagliariSTRUTTURA COMPLESSA GASTROENTEROLOGIA, Cagliari

Dott. Paolo Usai Satta

Venezia-Mesre, 18 Marzo 2011

Disorders of gastric function:

Impaired fundic relaxationImpaired fundic relaxation

Abnormal fundic emptyingAbnormal fundic emptying

Weak 3 cpm rhythmWeak 3 cpm rhythm

Dilated gastric antrumDilated gastric antrum

Antral hypomotilityAntral hypomotility

GastroparesisGastroparesis

Gastric dysrhythmiasGastric dysrhythmias

Small bowelSmall bowel

dysmotilitydysmotility

GASTRIC EMPTYING

PROBLEMS

ABSORPTION

AND

BIO-AVAILABILITY

OF DRUGS

FOOD ASSUMPTION

REGULATION

DIGESTION

AND ABSORPTION

OF NUTRIENTS

HORMONAL AND

METABOLIC ANSWER

Jackson, 2005

THERAPEUTIC

EFFECTS

Tests to Assess Gastric Tests to Assess Gastric EmptyingEmptying

Upper gastrointestinal radiographic study

Scintigraphy

13C-Breath tests

Paracetamol

US for serial changes in antral area

Magnetic Resonance Imaging

SPECT

Smart Pill

Tests to Assess Gastric Tests to Assess Gastric EmptyingEmptying

Upper gastrointestinal radiographic study

Scintigraphy

13C-Breath tests

Paracetamol

US for serial changes in antral area

Magnetic Resonance Imaging

SPECT

Smart Pill

Rao S, NeuroGastroenterol Mot, 2011

Recommended Tests in clinical Recommended Tests in clinical practicepractice

Gastric emptying scintigraphygold standard

• 99mTc-sulfur colloid in eggs (solid meal) -

• Half-empty time (solid meal,60 土 30min;

liquid meal, 30 土 15min)

• Gastric outlet obstruction or function obstruction, DM gastroparesis, s/p vagotomy, gastrinoma…

• Follow up and evaluation of the effectiveness of treatment.

Gastric emptying Breath test

1313C-octanoic acid BT C-octanoic acid BT (solid food)(solid food)13C-acetate BT (liquid food)

Gastric emptying 13C-octanoic acid in egg yolk Passage through pylorus

Intestinal absorption 13C-octanoic acid in duodenal lumen Passage through portal vein system

Liver oxidation 13CO2 production in mitochondria Plasmatic bicarbonate pool

Breath excretion 13CO2

Principle of 13C-OBTPrinciple of 13C-OBT

Ghoos et al Gastroenterology 1993 = excellent correlation

Choi et al Gastroenterology 1997 = poor correlation

OBT vs Scintigraphy

Delbende B, Eur J Gastroenterol Hepatol, 2000

From 2000…… = good correlation

t 1/2b Ghoos et al

Choi et al.

Delbende et al.

CV intra

(SDd/(mean*1.41) 20% 12% 15%

CV inter (SD/mean) 30% 20% 24%

Intra-individual variability

Perri*

et al

17%

(2010)

(2000)(1997)(1993)

*Perri F, Dig Liv Dis, 2010

In a large patient cohort (1279) cumulative 4h-13CO2-excretion is only marginally influenced by patient

characteristics and diseases with theoretical impact on absorption and/or postabsorptive metabolism of 13C-

octanoic acid

Criticisms concerning OBT metabolism

Keller J, NeuroGastroenterol Mot, 2009

Kloetzer L, Neuro-Gastroenterol Mot 2010

Wireless motility capsuleSmart Pill

-Measures pH, pressure and temperature

-Gastric emptying time

-Small bowel transit time

-Colonic transit time

- Whole gut transit time

Validated vs scintigraphy

Rao S, NeuroGastroenterol Mot, 2011

Contraindications:

•history of gastric bezoar•disorders of swallowing•suspected strictures, fistulas, or physiological GI obstruction•GI surgery within the past three months•severe dysphagia to food or pills•Crohns disease or diverticulitis•a subject who uses an implanted or portable electro-mechanical medical device such as a cardiac pacemaker or infusion pump

The SmartPill Capsule is not for use in pediatric populations.

Tests to Assess Gastric Tests to Assess Gastric EmptyingEmptying

What is their clinical significance?

Dyspepsia and gastric emptying

Usai Satta P, Eur Rev Med Pharmacol Sci, 2005

Stanghellini V., Gastroenterol, 1996

Dyspepsia and Scintigraphy

**p< 0.01

Sarnelli G,Gastroenterol 2003

393 pts

Dyspepsia and 13C-OBT

Usai Satta P, 2005

Other diseases and 13C-OBT

Influences on nutritional status and drug efficacy?

The association of delayed emptying with specific symptoms is relatively weak

Gastric emptying tests do not yield a high diagnostic specificity

With few exceptions, most studies have failed to demonstrate a correlation between the severity of delayed emptying and prokinetic therapy

An initial treatment approach should be required before performig gastric emptying test

In refractory patients or in those with symptoms that impair nutritional status or the ability to function normally, assessment of gastric emptying may play a pivotal role

Tack J, Best Pact Res Clin Gastroenterol, 2009

Clinical impact

Conclusions

- Several recommended tests to assess gastric emptying are available

- The clinical impact of these tests is yet uncertain

- A pivotal role may be played in refractary patients and in the impairment of nutritional status

Cagliari

Pisa

GenovaGenovaPadova

Ancona

Pescara-Chieti

Bari

San Giovanni R.San Giovanni R.Napoli

Torino

IGGET project (from 2005, ongoing)

OBT-Sofar