An attempt to define the pathophysiological abnormality in patients with nonulcer dyspepsia using a gastric barostat

596

SELECTED

GASTROENTEROLOGY

SUMMARIES

ods of our report

have been concisely

and correctly

summarized

by

Dr. Koretz. Even though

we have no formal major objections

drawn in the summary, First,

we have simply

might

be efficacious

patients

there are some points hypothesized in reducing

with cancer.

to evaluate gastrointestinal induced

in nutritional However,

when

the extent

Dr. Koretz

claims

on chemotherapy

several previous

studies

sample

by other authors, J Clin Oncol

including

previously

review,

patients

hardly

shown.

support

relevant

shown

that

can be reduced

by appropriate

tions

receiving

has reported

complications.” study, TPN

Therefore,

we cannot is unable

to find

However,

in his

that only in 3 of

in infection

rate among

to “favorably

linked

the clinical

or reduce

catheter-related

venous

catheter

in the largest

sepsis

care (Iancet

reported

study

on

the severely malnourished

“had fewer noninfectious

based

to a bad clinical

complica-

increase

in our

data

that

. of a variety of

in patients

is regarded

oncology

As a matter

worsened.

to delay

malnourished

the optimal

delivery

chemotherapy parameters

in actual

dose intensity

warranting

A messenger of the Rothschild

careful family

a progressive

not be

both

clinical

worsening

we have not addressed of chemotherapy,

of the

in our report

this represents

an

teaches

be a “passive”

character.

The story

us that even a messenger

competition.

were the first to know that Napoleon

Through

their

was defeated

news to earn a lot by lending

money

who were not yet aware of the military

can play

messengers,

they

at Waterloo to his enemies successes

pressure pres-

radioscintigraphy.

The

mixed

solid

and liquid

caloric

value of 435 kcal and consisted

labeled

with

1 mCi of 99mTc-sulfur

The protocol the proximal gastric

required

stomach

distending

meal had a

of an egg omelette

colloid

oral placement

after an 8-hour

pressure

and 200 mL of

and in

of their

army.

MARCELLO DE CICCO, M.D.

the intra-abdominal

Five minutes

or high

distending

pressure.

in the upright

position

and at 20-minute

Radionuclide

thereafter pressure,

using

for the first for a further

epigastric

a perception

full-

question-

was scored on a scale of O-6. Two gastric were performed the barostat

One half of the subjects

were studied

in each volunteer,

in position

in the barostat

pressure.

before the meal was 131 If 17

of 2 mm Hg above minimal

This increased

and inflated.

at a low intragastric

and the other half at a high intragastric

the meal (volume

above

scans were per-

every 10 minutes intervals

one with and one without

pressure.

pres-

either a low

(8 mm Hg) pressure

of abdominal

measurements

The volume

corre-

after the comple-

was set to maintain

ness, and nausea were assessed

pressure

intra-

to inflate the bag to

was then set to 2 mm Hg above this level

(2 mm Hg; unchanged)

90 minutes

bag into

This level of pressure

to overcome

tion of the meal, the barostat

formed

of a barostat

fast. The minimal

(the pressure

mL) was then determined.

sponds to that required

mL at a bag pressure

investigation.

may not always

a key role in global

in which

tone were

and changes in intragastric

using

naire. Each sensation

to a patient

in I6 young,

in gastric

were measured

2 hours. The sensations

ap-

of those

would

Changes

sures. Liquid and solid gastric emptying

emptying

oncologists

and assess increment

bag to different

a significant

improvement

were performed

subjects.

by inflating

This does not hold true for patients

indicate

Even though

of

patients

markers

period pressure

the barostat

the minimal

not be related

the nutritional

of fact, many clinical

status.

used that

may

intragastric

for a period of basal recording.

tumors.

by a specific

of a severely

affect

TPN,

our study showed

to deliver

and laboratory

without

Am J Physiol

the physiological

the postcibal

Studies

using a barostat,

sure. The pressure

issue affecting

there is a tendency itself

is not

However,

chemosensitive

not supported

in the presence

chemotherapy

markers.

England,

itself

cancer.

as a critical

practice,

it could

with

with

(although

outcome,

TPN;

aspect

malnutrition

We have shown that in severely malnourished

receiving

nutritional

that

patients

pressure,

emptying.

fruit juice labeled with 400 PCi of “‘In-DTPA.

in infectious

on the current

even if malnutrition

pear to be significantly

changes

outcome

chemotherapy

undergoing

Koretz

well known

Therefore,

chemotherapy.

happy

Dr.

in most

that in current

patient.

emptying.

asymptomatic

were achieved

alter the morbidity

dose intensity outcome

It is otherwise study)

with

to the clinical

chemotherapy

on gastric healthy,

we

venous

tone during

of a symptomatic

230

agree

of Barce-

and gastric

the effects

In addition,

disease states.” We fully

in gastric

on such a matter.

agree

University

among intragastric

The aims of this study were to examine changes

measured

even if this aspect was not analyzed

completely

Sys-

Hospi-

1993;264:G1112-G1117.

can

central

Department,

Autonomous

Spain). Relations

perception,

differences

central

TPN

postcibal

Medicine

and 1386,

is also surprised

. . . with no concomitant

controls

that

Vall d’Hebron,

lona, Barcelona,

significant

Furthermore,

of patients than

TPN

1986; 58: 1378-

difference

TPN (N Engl J Med 1991;325:525-532), group

tem Research Unit and Nuclear

by methodologi-

in our study.

Non-statistically

have previously

Moragas G, Azpiroz F, Pavia J, Malagelada JR (Digestive

such as the small patient

(Cancer

Dr. Koretz

that

be noted

out by us in our report

Dr. Koretz

a firm conclusion

1989;2:1258-1261).

it should

AN ATTEMPT TO DEFINE THE PATHOPHYSIOLOGICAL ABNORMALITY IN PATIENTS WITH NONULCER DYSPEPSIA USING A GASTRIC BAROSTAT

tal General

by TPN.

“it is not news”

design

rate in the TPN group

quoted

and

alterations

corrected

were affected

Dr. Korett

7 studies was a statistically TPN

that

as pointed

1984;2:534-538).

a low infection

and/or

on this subject

approach

and whether

toxicity,

in the experimental

or statistical

myelotoxicity

No. 2

in

were

and grade of chemotherapy-

status,

can be prevented

has no impact cal drawbacks

in reducing

of the nutritional

status

that TPN toxicity

of fact, the aims of our study

of TPN

tract toxicity,

alterations

and not “postulated” chemotherapy-associated

As a matter

the effectiveness

to the conclusions

that need to be clarified.

Vol. 107,

distending

to 413 -C 48 mL after ingestion

of meal,

300 mL), indicating

of

an isobaric

expansion of the barostat or, in other words, accommodation. The accommodative relaxation of the stomach gradually reverted during gastric emptying with the change paralleling solid rather than liquid gastric emptying. proximal gastric tone could be documented

Little change in during the early

period of rapid liquid emptying. The combined effect of eating the meal and increasing the barostat pressure to 8 mm Hg

August 1994

SELECTED SUMMARIES

above the minimal

distending

pressure

resulted

of 692 + 18 mL in the bag. During bag volume again gradually and solid emptying the presence barostat

decreased.

tying. The rate of emptying any significant

abdominal

enced mild to moderate severe discomfort.

acceleration

discomfort

gradually

gastric

accommodation in postcibal

instrument

gastric

the condition

to accommodate

the increase to their

1985;248:G229-G237). almost

any detectable

return

half of the liquid

increase

in proximal

gastric

is sufficient

to ensure

liquid

has a lesser role in gastric

dyspepsia.

in gastric

findings

in the dog observation

occurring

without

tone. As the authors generated

emptying

emptying

vol-

of tone to the proximal

emptying

out, this may mean that either the pressure

the

relaxes to a degree

An interesting

delayed

emptying

to extend

of nonulcer

stomach

The

of the baro-

on the gastric

that the proximal

for the meal is analogous

the time

for the first time.

pressure

et

in a number

shows

they have attempted

to simulate

than is necessary

with

point

by a low gastric

or that of liquids

the proximal than previously

thought. Although

the investigators

bag increased increase

the rate of liquid The

high compliance distended pressure

that

the presence

emptying,

the mechanism

used

study

consists

located

in the proximal

volume

of 1000 mL while keeping

cavity within

by inflating

is effective

throughout

or withdrawing

in maintaining

which the balloon the stomach

the antroduodenal

stomach.

It can be the bag

pressure

in the

this common

cavity

has never been examined. gradient,

of a

air from the balloon.

a constant

resides. Whether pressure

of this

with an earlier variety

in the current

balloon

constant

lar, whether

barostat

of a barostat

to a maximum

This barostat extends

found

most likely differs from that reported

of barostat.

establishing

a constant

and humans

In particu-

which is ultimately

pressure

intragastric

pressure

emptying

of a barostat

the rate of liquid a true

the liquid

The authors

assume

altering

gastric

discomfort,

gastric

compliance of patients

with symptoms Do patients

ante in patients studies,

in patients subjects,

with

suggesting

of the gastric

compliance.

However,

in the postcibal The gastric gastric

require

gastric

empty-

in a group

and normal

(Dig

in the fasting

compared

with

defect

categorized

gastric comph-

state. In these volumes

normal

healthy

than

a defect

rather

Dis Sci 1991;36:52-58,

and gastric

gastric

have reduced

at lower intragastric

Dig

Dis

1991;101:999-1006). patients

compliance

is a powerful

technique

defined.

tool to examine

tion of the stomach

in this group

in patients

is awaited

The symptoms

a pathophysiological

may be a valuable

period

altering

into normal

and

was not measured to explore

proximal

of gastric

emptying

but its effects on the mechanics

need to be further

type of study

without

state. barostat

function,

dyspepsia

distension

dyspepsia

sensory

of

symptoms

of symptoms

Gastroenterology

emptying,

in a subgroup

that a reduced gastric

dyspepsia

dyspepsia

dyspepsia

none of these studies gastric

that this may

have found a normal gastric

an afferent

Sci 1991;36:1249-1254, delayed

without

was perceived

nonulcer

simulate

speculate

of nonulcer

of studies

distension

bag pressures

did produce

the occurrence

with nonulcer

gastric

of may

between

and abdominal

with nonulcer

A number

pressure

emptying

dyspepsia

bag pressure

symptoms

emptying.

cavity

and speculate

of nonulcer

The authors

may produce

This

which could in turn

This effect of displacement

intragastric

nausea,

emptying.

study

of the meal into the

pump,

compliance

ing and that this may explain

compliance?

portion

in the rate of gastric

It is true that a high

of epigastric

A recent

arms of this study.

be the cause of symproms patients.

altered increased

to the one used in

in common

that high

of reduced

the rate

1993; 105:667-674).

emptying.

the lack of difference

between

persisted.

the antral

increase

the high and low pressure

that

in the stomach

of nutrients

bag similar

(Gastroenterology

effect may prime than

the presence

and gastric

in review displaced

rather

showed

the relationship

of the stomach

the entire gastric

related to the pressure

Although

there cavity,

1981;241:G403-G415)

emptying,

that the presence

a situation

throughout

in dogs (Am J Physiol was linearly

of gastric

found

In these studies,

any part of the gastric

(Dig Dis Sci 1988;33:914-918)

the slope

explain

that

pressure.

These studies

fluid

tone. Azpiroz

in review

in humans

gastric

intragastric

thereby

increase

emptying.

into the stomach

cavity.

displacement

gastric dynamics

bag is unknown.

fluid was infused

to fluid entering

antrum

cause limited

is an important

The study

in this study was the relatively

tone

over

relaxation

have used it effectively

studies.

Their first observation

stomach

experi-

decreased

pressure

in proximal

and solids. Furthermore,

ume required

a constant

into the duodenum,

in the barostat

was no impediment

by the barostat.

have also assessed the effect of the presence

(Am J Physiol

to maintain

of barostat,

produced

all subjects

affecting

barostat

variety

On the other hand, during

and distorted

this technique,

use of this technique

In the earlier

the pressure

emptying

in postcibal

changes

and human

stat and changes

by changing

of gastric

and one person experienced

without

The gastric of measuring

of gastric

for the flow of fluid from the stomach

is affected

the study

symptoms

investigators

stomach

Both

increased

that a meal causes receptive

increases

al., who pioneered

greater

sensation.

of liquid emptying,

Comment.

of liquids

by

responsible

did not produce

with the barostat,

conclude

may produce

course

of the pressures.

of solids was marginally

These sensations

of the stomach,

of animal

at either

affected

period.

The authors

is capable

The shapes of the liquid

only. Low bag pressures

distension

the postcibal

the

caused an increase in the rate of liquid emp-

at high bag pressures high pressure

in a volume emptying,

curves were not significantly

of the barostat

pressures

gastric

597

with

with

of patients

explanation, defects

in the gastric

of patients.

nonulcer

with

nonulcer

and the barostat accommoda-

The extension

dyspepsia

of this

in the postcibal

interest. RAVINDER

K. MITTAL, M.D.

GEOFF HEBBARD,

M.D.