Gastric emptying after roux-y and billroth-I gastrectomy depends on viscosity of meal and contractile patterns of small intestine in dogs

The aim of the study was to examine gastrointestinal motility after distal gastrectomy and the influence of meal viscosity on gastric emptying. Gastrointestinal motility and gastric emptying of acaloric meals with different viscosities were measured in normal dogs and after a two-thirds gastrectomy with Billroth-I or Roux-Y gastroenterostomy. After distal gastrectomy, gastric emptying depended on the viscosity of the meal, as in normal dogs. Acaloric viscous meals emptied significantly faster in the Billroth-I than in the Roux-Y group due to different contractile patterns of the duodenum and jejunum. In comparison to normal dogs, gastric emptying of viscous meals was accelerated in the Billroth-I and delayed in the Roux-Y group. Several motility parameters of the stomach and intestine differed between the normal and gastrectomized dogs. Thus, after distal gastrectomy, the viscosity of the meal and the contractile patterns of the small intestine are important determinants of gastric emptying.Studies were supported by the Deutsche Forschungsgemeinschaft, grant Eh 64/3-1.     

Effects of nutrients on gastrointestinal motility and gastric emptying after distal gastrectomy with Roux-Y gastrojejunostomy in dogs

The aim of the study was to clarify whether nutrients are still capable of slowing gastric emptying following Roux-Y gastrectomy, as in normal dogs. Gastrointestinal motility and gastric emptying of acaloric and nutritive meals with different viscosities were measured in normal dogs and after a two-thirds Roux-Y gastrectomy. In gastrectomized dogs low-viscosity nutritive meals emptied unduly rapidly in an initial phase, although the frequency and spread of contractions, ie, the propulsive activity of the jejunal Roux limb were diminished. A slow emptying rate during the following period was due to a long-lasting inhibition of gastric and jejunal motility. Medium-viscosity nutritive meals emptied in gastrectomized dogs as slowly as in normal animals, but this effect was primarily caused by the meal viscosity and only secondarily by the nutrients. It is concluded that following Roux-Y gastrectomy a regulation of gastric emptying is preserved; however, the onset of an effective control is delayed, resulting in a rapid initial emptying of low-viscosity meals.Studies were supported by the Deutsche Forschungsgemeinschaft grant Eh 64/3-1.     

Gastrointestinal motility and gastric emptying after Billroth II gastrectomy in dogs

This study was undertaken to compare the effects of subtotal Billroth II gastrectomy on gastric emptying and gastrointestinal motility with previously published results in intact dogs and in dogs with subtotal Roux-Y gastrectomy. Extraluminal strain gauge transducers were used to study gastrointestinal motility after Billroth II gastrectomy in four conscious dogs. Gastric emptying was measured radiographically. In Billroth II dogs gastric emptying of low-viscosity meals was biphasic with an initial rapid emptying. The addition of nutrients to low-viscosity meals delayed gastric emptying accompanied with reduction in gastric and jejunal motility. Similar to that in Roux-Y dogs, gastric emptying of noncaloric medium-viscosity meals was delayed because of segmenting motor patterns of the jejunal loops, in contrast to the propulsive jejunal motor pattern in intact dogs. Nutrients added to medium-viscosity meals did not change the jejunal motor pattern; gastric emptying was delayed compared with intact dogs. Results show that meal viscosity and jejunal motor pattern influence gastric emptying after Billroth II gastrectomy.This study was supported by the Deutsche Forschungsgemeinschaft, grant Eh 64/3-2.     

Gastric motility measurement by MRI

The motor mechanisms associated with gastric emptying of nutrient liquids are unclear. Gastric emptying and motility were determined in seven healthy volunteers using an MRI technique following ingestion of 500 ml of (1) 10% and (2) 25% dextrose labeled with 1 mM Gd-DOTA. Emptying was determined with transaxial scans and motility during fast coronal scans 1.2 sec apart. Emptying was slower after ingestion of 25% dextrose. Following both meals, proximal gastric diameter remained relatively constant, while antral contractile frequency and depth varied markedly. These variations were greater after 10% dextrose. These studies suggest that antral motility changes contribute to slowing of gastric emptying by nutrient meals.     

Gastric emptying and its relationship to antral contractile activity.

Gastric emptying and antral contractile activity were simultaneously measured in 3 dogs with gastric and duodenal fistulas. Contractile activity was monitored by two force strain gauge transducers on the serosal surface of the antrum of 2 dogs and a single strain gauge transducer on the serosal surface of both the antrum and fundus of the 3rd dog. Both the frequency and force (motility index) of antral contractions were determined for each 1 min period. Gastric emptying and contractile activity were recorded and compared minute by minute with test meals (154 mM saline) of 60, 120, 240, and 480 ml. Although the rate of gastric emptying increased with the frequency and force of antral contractions, up to 67 ml min-1 (mean 6.9 ml min-1) were emptied without measurable antral contractile activity and 0 to 96 ml min-1 (mean 19.4 ml min-1) were emptied during maximal antral activity (minute motility index greater than 119 mm). Antral contractile activity increased with the size of the test meal and decreased expoentially with the rate of gastric emptying. Fundal contractile activity was generally absent during the test meal. These studies suggest that although the antrum has a significant role in the emptying of liquids, other undefined factors may modify its effect on gastric emptying.     

Ghrelin enhances gastric motility through direct stimulation of intrinsic neural pathways and capsaicin-sensitive afferent neurones in rats

BACKGROUND: Ghrelin may stimulate gastric motility via the vagal nerve pathway. However, the mechanism of ghrelin-induced changes in gastrointestinal motility has not yet been clearly defined. The present study was designed to investigate whether ghrelin accelerates gastric emptying via capsaicin-sensitive afferent neurones and directly affects the enteric neuromuscular function. METHODS: Gastric emptying of nutrient solids was assessed after intravenous administration of saline or ghrelin in conscious rats. The effects of ghrelin on gastric emptying were also examined in rats pretreated with capsaicin. Gastric emptying and intestinal transit of non-caloric liquids were evaluated using 51Cr solution. The effects of ghrelin on spontaneous contractile activities of isolated strips from stomach and jejunum were also investigated and the influence of ghrelin on motor responses to carbachol and electrical field stimulation was examined. RESULTS: Ghrelin significantly accelerated gastric emptying of both nutrient solids and non-caloric liquids in conscious rats. The intestinal transit of non-caloric liquids was also enhanced by ghrelin. Pretreatment with capsaicin prevented the ghrelin-induced acceleration of gastric emptying of nutrient solids. Ghrelin did not modulate spontaneous and carbachol-induced contractions of strips of gastric body, gastric antrum and jejunum. However, electrical field stimulation-induced contractions were significantly enhanced by ghrelin in the gastric body. CONCLUSIONS: The results suggest that the stimulatory effects of ghrelin on gastric motility are mediated by direct stimulation of the enteric neural pathway and capsaicin-sensitive afferent neurones.     

Gastric emptying for liquids and solids after distal gastrectomy with Billroth-I reconstruction

BACKGROUND/AIMS: Although distal gastrectomy followed by Billroth-I reconstruction has been a standard surgical procedure for over 100 years, gastric emptying of liquid and solids after this procedure remains poorly understood, despite its contribution to postgastrectomy complications such as dumping syndrome and reflux esophagitis. A simple way to standardize measurement and generate normal values is needed. This study proposed a new, accurate and easy method, "dual phase method", for gastric emptying after distal gastrectomy. METHODOLOGY: Liquid- and solid-phase gastric emptying were measured using a combined test consisting of acetaminophen and sulfamethizole capsule ingestion, respectively. Data from 12 patients (B-I group) who had undergone distal gastrectomy with D2 lymph node dissection and truncal vagotomy followed by Billroth-I reconstruction were compared with those from 14 healthy volunteers (control group). RESULTS: A two-factor repeated measures ANOVA (analysis of variance) demonstrated a highly significant difference in the sequential changes in the serum acetaminophen concentration after ingestion between the two groups (p<0.0001). On the other hand, the sequential changes in the serum sulfamethizole concentration after ingestion was similar in the two groups (p=0.91). CONCLUSIONS: Gastric emptying of liquids is rapid after distal gastrectomy followed by Billroth-I reconstruction. However, emptying of solids is unchanged. The data obtained in this study can be a point of reference for comparing gastric emptying following gastrectomy.     

Effects of enhanced viscosity on canine gastric and intestinal motility

BACKGROUND AND AIM: The aim of this study was to investigate the effect of enhanced viscosity on gastric emptying and gastrointestinal motor and myoelectrical activities in dogs. METHOD: The study was performed in eight healthy female hound dogs chronically implanted with four pairs of gastric and two pairs of intestinal serosal electrodes and a duodenal fistula. Each dog was studied in three sessions and fed with three test meals with different viscosity. Gastric emptying was monitored for 2 h simultaneously with gastric and intestinal myoelectrical recordings. RESULTS: The liquid test meal containing either 0.78% or 1.21% of galactomannan significantly delayed gastric emptying but had no effect on postprandial blood glucose levels in comparison with the meal containing no galactomannan. The liquid test meal containing either 0.78% or 1.21% of galactomannan significantly increased the frequency and strength of intestinal motility but had no effect on intestinal slow wave rhythms. The product with enhanced viscosity had no effect on gastric motor activity or gastric slow waves. CONCLUSION: It was concluded that enhanced viscosity delays gastric emptying, increases postprandial intestinal but not gastric motility, and has no effects on gastric or intestinal slow waves.     

Delayed gastric emptying after distal gastrectomy for gastric cancer

BACKGROUND/AIMS: Gastric surgery may potentiate delayed gastric emptying. The aims of the study were to determine the frequency and causes of delayed gastric emptying in patients who had undergone distal gastrectomy for gastric carcinoma and to assess which factors predispose to its development. METHODOLOGY: 209 patients, who had undergone gastrectomy, were evaluated. RESULTS: Delayed gastric emptying occurred in 4.3% of patients receiving a Billroth-I, and 15.5% of patients receiving a Roux-Y reconstruction (p = 0.01). The patients who had these consecutive symptoms following Roux-Y operation were all clinically diagnosed as having Roux stasis syndrome. The delayed gastric emptying after Roux-Y operation was more frequent in patients receiving extensive lymph node dissection than those receiving conventional dissection (p<0.05). The symptoms spontaneously subsided, and postoperative body weight loss was not significant. CONCLUSIONS: In spite of the strong association between delayed gastric emptying and the Roux-Y procedure, it enables a relatively early return to oral intake.     

Gastric emptying following Finney pyloroplasty and vagotomy

Gastric emptying was evaluated in a series of unanesthetized dogs in the intact state, following Finney pyloroplasty, and with the addition of vagotomy. Sodium chromate labeled test meals of glucose, trisodium citrate, and trisodium citrate-fat were used. Finney pyloroplasty resulted in a trend for delayed emptying of fat from the stomach. The trisodium citrate test meal increased the levels of gastric secretion after pyloroplasty.Association of our previous motility data based on pyloroplasty studies with the current gastric-emptying evaluations indicate that too large a stoma between the antrum and duodenum is an impediment to normal gastric emptying of fatty meals.The authors appreciate the technical assistance of Mr. James E. Copp, Department of Biostatics, Parke, Davis Research Labs.     

Gastric Emptying is Altered with the Presence of Gastritis

Helicobacter pylori infection and gastritis can cause symptoms suggestive of altered gastrointestinal function; however, it is unclear if H. pylori influences gastric motility. This study assessed gastric emptying rates in mouse models of gastritis. Gastritis was induced in C57BL/6 mice via ethanol treatment or via challenge with H. pylori or H. felis. Gastric emptying rates of nutrient and non-nutrient liquids were assessed with the non-invasive ¹³C-breath test, and the results were compared to healthy mice. Gastric emptying of the non-nutrient liquid was unaltered with the presence of gastritis; however, gastric emptying of the nutrient liquid was accelerated after a 4-week infection with H. pylori. H. felis infection and ethanol treatment caused a more severe gastritis and disruptions to the normal gastric emptying. Changes to gastric emptying in mouse models of gastritis are associated with the presence of nutrients. Altered gastric emptying may contribute to symptoms commonly reported in humans with gastritis.     

Effect of the anastomosis-site after Billroth I gastrectomy on the motility of the remnant stomach

BACKGROUND/AIMS: Gastric emptying, in healthy individuals, is a highly regulated process, and plasma cholecystokinin plays a major role in its feedback regulation. However, the hormonal regulation of postprandial gastric emptying of the remnant stomach after distal gastrectomy with Billroth I reconstruction procedure has not been well described. The aim of this study is to characterize the gastroduodenal motility and gastric emptying of the two anastomosis-methods after Billroth I gastrectomy, while assessing the effect of cholecystokinin on the motility of the remnant stomach. METHODOLOGY: Two types of anastomosis (end-to-end, side (posterior wall)-to-end) after Billroth I gastrectomy were measured with strain gauge force transducers, and evaluated as to gastroduodenal motility, gastric emptying, gastrointestinal hormones (cholecystokinin, gastrin), and blood glucose associated with food administration. RESULTS: Remnant stomachs with side-to-end anastomosis showed superior motility as compared to those with end-to-end anastomosis. Plasma cholecystokinin was higher in the end-to-end anastomosis group. No differences as to gastric emptying, levels of plasma gastrin, or blood glucose were observed between the two groups. CONCLUSIONS: Plasma cholecystokinin may explain the difference in motility index between the two groups.     

Gastric emptying rate for solid and for liquid test meals in patients with dyspeptic symptoms after partial gastrectomy and after vagotomy followed by partial gastrectomy

BACKGROUND/AIMS: Gastric emptying rate for solid and for liquid test meals was investigated retrospectively in patients with longstanding epigastric distress after partial gastrectomy, either as primary treatment or after failure of vagotomy for peptic ulcer in order to find an explanation for the postoperative symptoms. METHODOLOGY: Radionuclide-labeled liquid and solid test meals were used to evaluate gastric emptying rate, at least one year after surgery. RESULTS: The lag phase for liquid test meals disappeared in all operated patients. Partial gastrectomy usually lead to fast emptying but this resective procedure, if performed after vagotomy, lead to stasis in a significant number of patients. Gastric emptying rate for solids increased in only a few of these symptomatic patients. In most of them however, there was a normal to decreased emptying rate. If a vagotomy had preceded the resective procedure, gastric emptying rate decreased significantly. CONCLUSIONS: In all these symptomatic patients, gastric emptying had been disturbed for at least one type of test meal. This makes investigation for both meals necessary, especially since there is a lack of correlation. Furthermore, if vagotomy fails to prevent ulcer recurrence, one should carefully consider all options before performing partial gastrectomy since gastric emptying rate after these consecutive procedures worsens considerably.     

Disordered gastric motor function in diabetes mellitus

Summary The application of novel investigative techniques has demonstrated that disordered gastric motility occurs frequently in diabetes mellitus. Gastric emptying is abnormal in about 50% of diabetic patients and delay in gastric emptying of nutrient-containing meals is more common than rapid emptying. The blood glucose concentration influences gastric motility in diabetes. In IDDM patients, gastric emptying is retarded during hyperglycaemia and may be accelerated by hypoglycaemia. Gastroparesis therefore does not necessarily reflect irreversible autonomic neuropathy and blood glucose concentrations must be monitored when gastric motility is evaluated in diabetic patients. There is a poor relationship between gastric emptying and gastrointestinal symptoms and the mechanisms by which abnormal motility causes symptoms are unclear. The introduction of new gastrokinetic drugs has improved therapeutic options for the management of symptomatic patients with gastroparesis considerably. The contribution of disordered gastric emptying to poor glycaemic control is unclear, but the demonstration that the rate of gastric emptying is a major factor in normal blood glucose homeostasis suggests that this is likely to be significant.Abbreviations IDDM insulin-dependent diabetes mellitus - NIDDM non-insulin-dependent diabetes mellitus     

Ileojejunal Transposition Delays Gastric Emptying and Decreases Fecal Water Content in Dogs withTotal Colectomy

PURPOSE: The aim of the study was to investigate the effect of ileojejunal transposition, in which the distal ileum is interposed isoperistaltically into the proximal jejunum, on gastric emptying, gastrointestinal motility, and fecal water content in dogs with total colectomy. METHODS: Dogs were divided into three groups: dogs with intact colons (control), total colectomy alone (sham operated group), or total colectomy and ileojejunal transposition group. The alimentary tract was reconstructed by ileal J-pouch-rectal anastomosis. Gastric emptying was measured by a validated freeze-drying method, and gastrointestinal motility was measured by strain gauge force transducers. Plasma peptide YY was measured by specific radioimmunoassay. Fecal water content was measured in dogs with total colectomy. RESULTS: Gastric emptying of solids in the ileojejunal transposition group was delayed longer than 120 minutes after meal ingestion compared with that in the sham operated group. The duration of the digestive state was prolonged in the ileojejunal transposition group, only when compared with the control group. Plasma peptide YY was increased in the ileojejunal transposition group compared with the sham operated group. Fecal water content was decreased in the ileojejunal transposition group compared with the sham operated group. CONCLUSIONS: Ileojejunal transposition delays gastric emptying of solids and decreases fecal water content in dogs with total colectomy, indicating that ileojejunal transposition might be able to improve intractable watery diarrhea after total colectomy.     

Gastric emptying in diabetes mellitus: relationship to blood-glucose control.

The application of novel investigative techniques has established that disordered gastric motility is a frequent complication of diabetes mellitus. Thus, gastric emptying of solid or nutrient liquid meals is abnormal in 30% to 50% of randomly selected outpatients with long-standing type 1 or type 2 diabetes. Delayed gastric emptying occurs more frequently than rapid emptying. There is increasing evidence that disordered gastric motility has a major impact on the management of patients with diabetes mellitus by leading to gastrointestinal symptoms and poor glycemic control. Although both gastroparesis and upper gastrointestinal symptoms have been attributed to irreversible autonomic damage, it is now clear that acute changes in the blood-glucose concentration have a major effect on both gastrointestinal motor function and the perception of sensations arising in the gut. For example, there is an inverse relationship between the rate of gastric emptying and the blood-glucose concentration, so that gastric emptying is slower during hyperglycemia and accelerated during hypoglycemia. This article reviews some issues in the etiology, diagnosis, and management of problems associated with gastric emptying in elderly persons with diabetes mellitus.     

Nitric oxide mediates mechano- and chemoreceptor-activated intestinal feedback control of gastric emptying

The effect of nitric oxide (NO) synthase inhibition on the gastric emptying of nutrient and nonnutrient meals was investigated in nine dogs. The inhibition of NO synthase delayed the gastric emptying time of both nutrient and nonnutrient meals, but the percentage delay of nutrient meals was significantly greater than that of nonnutrient meals. The inhibition of NO synthase during the emptying of nonnutrient meals enhanced mainly the amplitude of antral, pyloric, and distal duodenal contractions. However, NO synthase inhibition during the emptying of nutrient meals stimulated several spatial and temporal parameters of gastropyloroduodenal contractions. We conclude that NO is one of the neurotransmitters of intestinal feedback that regulates the gastric emptying of both nutrient and nonnutrient meals. The nature and intensity of intestinal feedback by the stimulation of both chemo- and mechanoreceptors by nutrient meals is different from that by the stimulation of mechanoreceptors only by the nonnutrient meals.Supported in part by grants from the Department of Veterans Affairs Research Service and National Institutes of Diabetes, Digestive and Kidney Diseases, DK32346.     

Gastric dysmotility after liquid bolus ingestion in systemic sclerosis: an ultrasonographic study

Gastric involvement appears quite commonly in systemic sclerosis (SSc). The aim of this study was to evaluate gastric wall motility using ultrasonography, a noninvasive method able to track both filling and emptying of fundus and antrum. The study was performed in 20 SSc patients and 20 healthy control subjects. Gastric filling and emptying were evaluated by transabdominal ultrasonography, measuring changes in fundus and antral areas over a 1-h period after ingestion of a liquid bolus (500 ml of mineral water). Areas of both gastric fundus and antrum at basal evaluation were found to be smaller in SSc patients than in healthy controls. Gastric filling was significantly reduced after ingestion of liquid bolus. Gastric emptying was delayed both in fundus and antrum. No significant differences of gastric wall motility have been observed in different subsets of SSc patients. Our findings show that gastric dysmotility is frequent and severe in SSc patients, contributing to the gastrointestinal disturbances which are very common in this disease.     

Inhibitory remnant stomach motility by duodenal distention after B-I gastrectomy

BACKGROUND/AIMS: Although control of gastric motility is a highly regulated process, B-I gastrectomy causes accelerated gastric emptying. We found few reports so far concerned with the mechanical effect of balloon distention of the duodenum on the remnant stomach in B-I dogs. METHODOLOGY: Four weeks after conventional distal gastrectomy with B-I reconstruction procedure, a balloon was inserted into the duodenum, and strain gauge force transducers (SGTs) were sutured onto the wall of the gastric remnant and duodenal serosa in beagles. After a two-week postoperative recovery period, gastro-duodenal motility was measured with SGTs prior to distention, during distention, and after evacuation of the balloon. The motility index (MI) was calculated every 30 minutes. RESULTS: Upon duodenal distention with 4 mL of water, motility of gastric remnant was significantly inhibited, however, no reduction in duodenal MI was observed. The response was maintained for as long as duodenal distension continued. Ninety minutes after evacuation of the balloon, MI returned to predistension levels. Increased plasma levels of cholecystokinin (CCK) were observed upon distention of the duodenal balloon. CONCLUSIONS: Motility of the remnant stomach in B-I dogs was inhibited by duodenal distension. Increased levels of plasma CCK during distention might play a role in this feedback mechanism.     

Gastric emptying of mixed solid-liquid meal in patients with intestinal pseudoobstruction

Gastric emptying of solids and liquids was evaluated simultaneously in 11 patients with intestinal pseudoobstruction. Despite a normal upper gastrointestinal series in most patients, over two thirds of the patients had abnormal gastric emptying of solids and/or liquids. Half these patients exhibited delayed emptying of solids and accelerated emptying of liquids. Alterations in motility patterns were observed in the four patients tested including decreased frequency or absence of migrating motor complexes originating in the stomach, shortening or absence of phase I, and loss of distinct fasted and fed patterns. Both basal values and mean postprandial increments in serum gastrin concentrations were lower in the patients, whereas no significant difference was found for pancreatic polypeptide concentrations when compared to normals. Our findings emphasize the functional heterogeneity of patients with intestinal pseudoobstruction. In addition, in contrast to previous reports which used barium meals to access gastric function, we observed a high prevalence of gastric emptying disturbances in these patients, suggesting that the motility disturbance is not restricted to the small intestine.