Fractional gastric analysis in 200 cases of duodenal ulcer

The fractional gastric analysis has been subjected to a critical review in 200 carefully selected cases of duodenal ulcer. The fasting residuum in many cases is characteristic. The quantity of the residuum is greater than normal, averaging 67 c.c. It might be described as a thin, watery opalescent fluid often having a faint greenish or bluish tint. In 39 per cent of cases the residuum contained gross bile, a much greater incidence than in normal individuals. Fifty-seven and five-tenths per cent of cases had a fasting hyperacidity. Biliary regurgitation probably reduced this figure somewhat. The average fasting acidity was: hydrochloric acid, 28; total acidity 42.4.A postprandial hyperacidity was present in 84 per cent of cases. This percentage is slightly higher than any previous series reported. Because of the size of this series, we feel it more nearly represents the actual acidity in patients having duodenal ulcer who have not been subjected to operation. The finding of subnormal acidity is so infrequent (8 per cent) in duodenal ulcer that one should hesitate before making a positive diagnosis of ulcer of the duodenum if the acidity is subnormal. The type of acid curve with a terminal ascent originally described by Rehfuss was present in the great majority of cases. This is of decided diagnostic import.The review stresses the significance of delayed motility as determined by the fractional analysis in study of the patient with duodenal ulcer. Hypermotility was very infrequent, occurring in only 2.5 per cent of cases. One hundred and eight cases (54 per cent) showed various grades of motor delay. The importance of examination of the two-hour extraction as well as the fasting residuum from the stand-point of motor delay is shown. The increase in the quantity of fasting juice or the presence of microscopic or gross food in the overnight residuum has been stressed by many observers. Very little attention has been given to the determination of motility at two hours. In many instances the hypomotility is insufficient to cause an excessive quantity of morning residue but the stomach will be unable to evacuate a normal test load within the two-hour period. A normally emptying stomach should contain less than 25 c.c. of fluid and 5 c.c. of food sediment two hours after the ingestion of the test meal. For purposes of analysis we considered 50 c.c. of juice and 10 c.c. of food the upper limit of normal.That the fractional gastric analysis carried out as described is a more delicate measure of gastric motor impairment than the ordinary six-hour roentgenologic observation is obvious from the study. Gastric retention by the fractional analysis was present in 54 per cent of cases. Thirty-one per cent had evidence of retention by barium meal. A common practice of interpreting a fractional gastric analysis in terms of acidity only and ignoring the evidence of motor insufficiency is to be deplored. The test is the most reliable method of testing the motor function of the stomach in routine clinical practice.Bile in the fasting stomach is a frequent finding in duodenal ulcer. It was present only in the fasting residue in 51 cases. Thirty-six additional cases had bile in more than 4 of the postmeal fractions. The fasting contents containing bile were more often hyperacid than the residuums free from bile. It seems probable that the presence of the duodenal ulcer may be responsible for the bile reflux independently of hyperacidity. The postprandial acidity is lower in the group of cases with bile than in the bile-free cases, probably due to the factor of neutralization. The percentage of cases of duodenal ulcer with hyperacidity would probably be greater if it were not for this tendency to biliary regurgitation. We are convinced that the incidence of biliary regurgitation is much greater in duodenal ulcer than in individuals without disease in the pyloroduodenal region.The literature contains very little of value bearing on the effect of medical treatment in cases of duodenal ulcer as determined by the method under discussion. The test was repeated in many cases at varying intervals after the institution of recognized methods of medical treatment. The incidence of cases having an ulcer relapse is recorded. The degree of gastric acidity seems to bear no relationship to the tendency to recurrence of symptoms. That is, relapses were not more frequent in cases showing extreme hyperacidity at the time of original examination than in cases with lesser grades of acidity. However, if repeated examinations show a tendency for the acidity to mount even higher, a recurrence should be anticipated. The majority of cases showing this tendency developed a return of symptoms.Frequent fractional tests for the determination of gastric motility are of decided importance in prognosis and of great assistance in making a decision as to the method of treatment to be employed. During the active stage of treatment, examinations of the fasting residuum may show a gradual reduction in quantity, even approximating the normal. At the same time the fractional test meal will show a persistence of gastric motor delay. If after four to six weeks of a strict hospital regimen, the fractional test shows a Grade II or greater delay, medical treatment is doomed to failure and surgery had better be advised.