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Investigation of Dysphagia After Antireflux Surgery by High-resolution Manometry: Impact of Multiple Water Swallows and a Solid Test Meal on Diagnosis, Management, and Clinical Outcome. - Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association
Management of patients with dysphagia, regurgitation, and related symptoms after antireflux surgery is challenging. This prospective, case-control study tested the hypothesis that compared with standard high-resolution manometry (HRM) with single water swallows (SWS), adding multiple water swallows (MWS) and a solid test meal increases diagnostic yield and clinical impact of physiological investigations.Fifty-seven symptomatic and 12 asymptomatic patients underwent HRM with SWS, MWS, and a solid test meal. Dysphagia and reflux were assessed by validated questionnaires. Diagnostic yield of standard and full HRM studies with 24-hour pH-impedance monitoring was compared. Pneumatic dilatation was performed for outlet obstruction on HRM studies. Clinical outcome was assessed by questionnaires and an analogue scale with "satisfactory" defined as at least 40% symptom improvement requiring no further treatment.Postoperative esophagogastric junction pressure was similar in all groups. Abnormal esophagogastric junction morphology (double high pressure band) was more common in symptomatic than in control patients (13 of 57 vs 0 of 12, PÂ = .004). Diagnostic yield of HRM was 11 (19%), 11 (19%), and 33 of 57 (58%), with SWS, MWS, and solids, respectively (P < .001); it was greatest for solids in patients with dysphagia (19 of 27, 70%). Outlet obstruction was present in 4 (7%), 11 (19%), and 15 of 57 patients (26%) with SWS, MWS, and solids, respectively (P < .009). No asymptomatic control had clinically relevant dysfunction on solid swallows. Dilatation was performed in 12 of 15 patients with outlet obstruction during the test meal. Symptom response was satisfactory, good, or excellent in 7 of 12 (58%) with no serious complications.The addition of MWS and a solid test meal increases the diagnostic yield of HRM studies in patients with symptoms after fundoplication and identifies additional patients with outlet obstruction who benefit from endoscopic dilatation.Copyright Â© 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
Fat emulsion intragastric stability and droplet size modulate gastrointestinal responses and subsequent food intake in young adults. - The Journal of nutrition
Intragastric creaming and droplet size of fat emulsions may affect intragastric behavior and gastrointestinal and satiety responses.We tested the hypotheses that gastrointestinal physiologic responses and satiety will be increased by an increase in intragastric stability and by a decrease in fat droplet size of a fat emulsion.This was a double-blind, randomized crossover study in 11 healthy persons [8 men and 3 women, aged 24 Â± 1 y; body mass index (in kg/m(2)): 24.4 Â± 0.9] who consumed meals containing 300-g 20% oil and water emulsion (2220 kJ) with 1) larger, 6-Î¼m mean droplet size (Coarse treatment) expected to cream in the stomach; 2) larger, 6-Î¼m mean droplet size with 0.5% locust bean gum (LBG; Coarse+LBG treatment) to prevent creaming; or 3) smaller, 0.4-Î¼m mean droplet size with LBG (Fine+LBG treatment). The participants were imaged hourly by using MRI and food intake was assessed by using a meal that participants consumed ad libitum.The Coarse+LBG treatment (preventing creaming in the stomach) slowed gastric emptying, resulting in 12% higher gastric volume over time (P < 0.001), increased small bowel water content (SBWC) by 11% (P < 0.01), slowed appearance of the (13)C label in the breath by 17% (P < 0.01), and reduced food intake by 9% (P < 0.05) compared with the Coarse treatment. The Fine+LBG treatment (smaller droplet size) slowed gastric emptying, resulting in 18% higher gastric volume (P < 0.001), increased SBWC content by 15% (P < 0.01), and significantly reduced food intake by 11% (P < 0.05, equivalent to an average of 411 kJ less energy consumed) compared with the Coarse+LBG treatment. These high-fat meals stimulated substantial increases in SBWC, which increased to a peak at 4 h at 568 mL (range: 150-854 mL; P < 0.01) for the Fine+LBG treatment.Manipulating intragastric stability and fat emulsion droplet size can influence human gastrointestinal physiology and food intake.
A prospective randomised study comparing oral (13)C-bicarbonate tracer technique versus indirect calorimetry for measurement of energy expenditure in adults. - e-SPEN journal
Accurate assessment of energy expenditure (EE) is important in guiding nutritional therapy but current methods are unsatisfactory. This study compared the oral (13)C-bicarbonate tracer (BT) technique using the IRISÂ® system (Wagner, Germany) against indirect calorimetry (IC, ventilated-hood) to measure CO2 output (VCO2) and thus estimate EE.Ten overnight-fasted healthy male volunteers were randomised to studies at rest or mild exercise in a crossover manner. During each study BT-IRISÂ® and IC were used simultaneously to measure VCO2 and thus EE. Participants ingested a drink labelled with 50mg (13)C-bicarbonate and breath samples were collected every 5 min for 180 min and analysed using IRISÂ®. Bland-Altman plots were used to assess agreement between the two techniques in measurements of VCO2 (L/day) and estimates of EE (kJ/day).Mean Â± SE age and BMI of participants were 21.1 Â± 1.1 yrs and 23.6 Â± 0.6 kg/m(2). Both at rest and exercise, there was small bias but overall poor agreement between the two techniques as evident by the wide 95% limits of agreement in measurements of VCO2 and EE: rest VCO2 (bias 1.4, SD 93, 95% limits of agreement -180 to 183), rest EE (-8.3, 1830, -3595 to 3578), exercise VCO2 (49.3, 66.1, -80.4 to 178.9) and exercise EE (1083, 1944, -2727 to 4893). Furthermore, there was also evidence of systematic error in these measurements.Prior to clinical application, further optimisation of the BT-IRISÂ® system should be undertaken, given the poor agreement with IC in measuring VCO2 and estimating EE.
A randomized crossover study of the effects of glutamine and lipid on the gastric emptying time of a preoperative carbohydrate drink. - Clinical nutrition (Edinburgh, Scotland)
Supplementing preoperative carbohydrate drinks with glutamine may lead to benefits in addition to reducing insulin resistance, but amino acids may delay gastric emptying (GE). The effects of supplementing a preoperative carbohydrate drink (CCD) with glutamine or lipid on GE were studied.Ten healthy male volunteers ingested 410Â ml of one of three isocaloric-isovolumetric carbohydrate-based drinks labelled with (99m)Tc-DTPA: CCD (preOp(Â®), Nutricia, UK, 50Â g carbohydrate), CCD/G (preOp(Â®), 36Â g carbohydrateÂ +Â 15Â g glutamine) or CCD/L (preOp(Â®), 36Â g carbohydrateÂ +Â 7Â g lipid) in this randomized, blinded, three-way crossover study. After baseline measurements, GE was measured scintigraphically and blood sampled for insulin, glucose and glucagon-like peptide 1 (GLP-1) at 20Â min intervals for 240Â min.Mean (95% CI) T(90) GE times for CCD, CCD/G and CCD/L were 101 (87-115), 95 (84-107) and 87 (72-102) min, respectively. At 40Â min postprandially, mean (SEM) concentrations of glucose (mmol/l) and insulin (mIU/l) were 7.5 (0.5) and 35 (5) for CCD; 6.2 (0.2) and 28 (4) for CCD/G; and 7 (0.3) and 31 (5) for CCD/L, respectively. There were no differences in postprandial GLP-1 concentrations.Glutamine and lipid supplementation did not prolong the GE of CCD but did 'blunt' postprandial glucose and insulin responses, independent of GLP-1 concentrations. Registered under ClinicalTrials.gov Identifier no. NCT00943020.Copyright Â© 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: a randomised double-blind, crossover study. - Clinical nutrition (Edinburgh, Scotland)
Preoperative starvation has many undesirable effects but the minimum length of fasting is limited by gastric emptying, which may be dependent on nutrient content, viscosity and osmolarity of the feed. We compared the gastric emptying of two types of preoperative metabolic preconditioning drinks [Oral Nutritional Supplement (ONS) (Fresenius Kabi, Germany) and preOp (Nutricia Clinical Care, UK)] in healthy volunteers.Twenty (10 male, 10 female) healthy adult volunteers were studied on 3 separate occasions in a randomised crossover manner. Volunteers ingested 400 ml preOp, which is a clear carbohydrate drink (CCD) (50 g carbohydrate, 0 g protein), 70 g ONS (50 g carbohydrate and 15 g glutamine) dissolved in water to a total volume of 400 ml (ONS400) and 300 ml (ONS300). Gastric emptying time was measured using magnetic resonance imaging.Mean (95% CI) T(50) and T(100) gastric emptying times for CCD were significantly lower (p<0.001) compared with ONS400 and ONS300. T(50) was 47 (39-55), 78 (69-87) and 81 (70-92)min for CCD, ONS400 and ONS300 respectively. Correspondingly T(100) was 94 (79-110), 156 (138-173) and 162 (140-184)min. Residual gastric volumes returned to baseline 120 min after CCD and 180 min after ONS400 and ONS300.The faster gastric emptying for CCD compared to ONS400 and ONS300 signifies that gastric emptying may be more dependent on nutrient load than volume or viscosity in healthy volunteers. While it is safe to give CCD 2h preoperatively, ONS400 and ONS300 should be given at least 3h preoperatively.
Effect of intragastric acid stability of fat emulsions on gastric emptying, plasma lipid profile and postprandial satiety. - The British journal of nutrition
Fat is often included in common foods as an emulsion of dispersed oil droplets to enhance the organoleptic quality and stability. The intragastric acid stability of emulsified fat may impact on gastric emptying, satiety and plasma lipid absorption. The aim of the present study was to investigate whether, compared with an acid-unstable emulsion, an acid-stable fat emulsion would empty from the stomach more slowly, cause more rapid plasma lipid absorption and cause greater satiety. Eleven healthy male volunteers received on two separate occasions 500 ml of 15 % (w/w) [13C]palmitate-enriched olive oil-in-water emulsion meals which were either stable or unstable in the acid gastric environment. MRI was used to measure gastric emptying and the intragastric oil fraction of the meals. Blood sampling was used to measure plasma lipids and visual analogue scales were used to assess satiety. The acid-unstable fat emulsion broke and rapidly layered in the stomach. Gastric emptying of meal volume was slower for the acid-stable fat emulsion (P < 0.0001; two-way ANOVA). The rate of energy delivery of fat from the stomach to the duodenum was not different up to t = 110 min. The acid-stable emulsion induced increased fullness (P < 0.05), decreased hunger (P < 0.0002), decreased appetite (P < 0.0001) and increased the concentration of palmitic acid tracer in the chylomicron fraction (P < 0.04). This shows that it is possible to delay gastric emptying and increase satiety by stabilising the intragastric distribution of fat emulsions against the gastric acid environment. This could have implications for the design of novel foods.
The effects of bolus and continuous nasogastric feeding on gastro-oesophageal reflux and gastric emptying in healthy volunteers: a randomised three-way crossover pilot study. - Clinical nutrition (Edinburgh, Scotland)
Nasogastric feeding may result in gastro-oesophageal reflux and, therefore, increase the risk of aspiration. This may be greater when feeds are administered via a bolus than by infusion. We aimed to measure gastric emptying time and quantify gastro-oesophageal reflux in healthy volunteers given a liquid feed via an oral bolus (OB), a nasogastric tube bolus (TB) and a nasogastric tube drip (TD).Twelve male volunteers participated in three separate studies (OB, TB and TD) in random order, each 3 days apart. The feed consisted of 220 ml Ensure Plus (1.5 kcal/ml), labelled with 12 MBq (99m)Tc DTPA. The OB and TB were given over 5 min and the infusion rate for the TD was 55 ml/h. Gastric emptying time was measured using gamma scintigraphy. Gastro-oesophageal reflux was observed continuously until the stomach was empty, using a multichannel intraluminal impedance catheter.Mean (95% CI) T(50) gastric emptying times for the OB and TB studies were 41.3 (36.5-46.2) min and 36.2 (30.6-41.8) min respectively (p=0.19). The stomach emptied at a rate equal to the infusion rate in the TD studies. Median (IQR) number of reflux episodes for the OB, TB and TD studies were 4.5 (2.0-6.0), 3.0 (2.0-4.75) and 2.0 (0.25-6.25) respectively. Median (IQR) total duration of reflux for the OB, TB and TD studies were 38 (20-242), 49 (17-71) and 36 (1-125) s respectively (p=NS).The lack of difference in gastro-oesophageal reflux between bolus and continuous feeding indicates that in healthy volunteers both methods are equally safe with respect to the risk of aspiration.
Magnetic resonance imaging of the behaviour of oil-in-water emulsions in the gastric lumen of man. - The British journal of nutrition
Pre-processed foods often contain a high percentage of lipid, present as emulsions stabilised with various surface-active agents. The acidic gastric environment can affect the behaviour of such emulsions, modifying the lipid spatial distribution and, in turn, the rate of gastric emptying and nutrient delivery to the gut. The aim of the present study was to use echo-planar magnetic resonance imaging (EPI) to determine the behaviour of model olive oil emulsions during gastric processing. Six healthy male volunteers were intubated nasogastrically on two separate occasions and fed 500 ml 15 % (w/w) olive oil-in-water, surfactant-stabilised emulsions designed to have identical droplet size distribution and which were either stable or unstable under gastric acid conditions. EPI was used to assess the oil fraction of the intragastric emulsions, gastric emptying and to visualise the spatial distribution of the oil at 10, 30 and 50 min postprandially. The in vivo imaging measurements of the oil volume fraction of the emulsions correlated well (r 0.66, acid-stable; r 0.52, acid-unstable) with that assayed in the gastric aspirates. Compared with the acid-stable emulsion, the acid-unstable emulsion in the gastric lumen rapidly separated into lipid-depleted 'aqueous' and lipid layers. Phase separation in the acid-unstable meal allowed the oil-depleted component to empty first and more rapidly than the stable emulsion as determined by the gastric emptying curves. These pilot data suggest that gastric processing and emptying of high-fat foods could be manipulated by careful choice of emulsifier.
Impact of bitter taste on gastric motility. - European journal of gastroenterology & hepatology
Unexplained nausea and vomiting is often associated with delayed gastric emptying in patients with functional dyspepsia. We hypothesized that the experience of an unpleasant, nauseating taste could lead to a delay in gastric emptying.Sixteen healthy women consumed a bland liquid test meal on three separate study days. On two of the study days subjects sham fed either a bitter tasting, modified Slim-Fast bar or one with a pleasant strawberry flavour. The time for 50% gastric emptying (GE(50)) was non-invasively assessed by electrical impedance tomography and antral motility by electrogastrography (EGG).Gastric emptying was significantly delayed by sham feeding the bitter compared with the pleasant bar, GE(50) 24.7+/-3.9 versus 17.2+/-1.8 min, P<0.05. EGG power rose significantly during both the pleasant (basal 1.46+/-0.07 to 2.33+/-0.14 log(10) microV(2)/min, P=0.000) and the bitter sham feed (basal 1.64+/-0.09 to 2.35+/-0.11 log(10) microV(2)/min, P=0.000).An unpleasant bitter taste delays gastric emptying but does not significantly impair antral motility.
Monitoring of gallbladder and gastric coordination by EPI. - Journal of magnetic resonance imaging : JMRI
To assess for the first time the potential of echo-planar magnetic resonance imaging (EPI) for measuring simultaneously both gallbladder and gastric emptying.Eight healthy subjects ingested 500 mL of an acid-stable liquid test meal containing 15% olive oil and flavoring. Every 20 minutes for three hours thereafter, a rapid EPI multislice set was acquired across the whole abdomen, using a dedicated whole-body 0.5-T EPI scanner.The bile in the gallbladder and the test meal in the stomach appeared bright in the EPI images, aiding localization and region of interest analysis. We measured the gallbladder emptying curve and fitted the data to a simple analytical model. The mean fasted gallbladder volume was 25 +/- 4 mL, comparable to previously published MRI and ultrasound values. Gastric emptying data fitted well to a linear model linear (R2 = 0.99), and we observed an exponential (R2 = 0.98) relationship between gallbladder and gastric volumes for the first 90 minutes.This study shows the potential of EPI to monitor simultaneously and noninvasively the emptying of the gallbladder and of the gastric lumen. No contrast enhancing agents are needed. This method could overcome the limitations of previous gamma scintigraphy and ultrasound techniques.
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