NUCLEAR MEDICINE SERVICES. GASTRIC EMPTYING (Solid and Liquid) Overview

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1 NUCLEAR MEDICINE SERVICES SUBJECT: GASTRIC EMPTYING (Solid and Liquid) Overview Radionuclide studies of gastric emptying and motility are the most physiologic studies available for studying gastric motor function. The study is noninvasive, uses a physiologic meal (solids with/without liquids), and is quantitative. Serial testing can determine the effectiveness of therapy. Indications A. Postprandial: 1. Nausea, vomiting 2. Upper abdominal discomfort, bloating 3. Chronic aspiration B. Suspected gastroparesis C. Poor diabetic control D. Gastroesophageal reflux E. Following response to therapy for previously documented motility disturbances. F. Diagnosis of functional gastric dysmotility. Examination Time Variable, ranges from 2-4 hours. Patient Preparation 1. NPO 4 hours before imaging. It is preferable to be NPO after midnight, and then administer radiolabeled meal in the morning. 2. Diabetic should be instructed to bring insulin with them. The dose of insulin is to be adjusted when meal is given. If the patient cannot tolerate standard solid or liquid meal study, the procedure should not be done. 3. Patient must be off of motility drugs including: reglan, domperidine, cisapride, or erythomycyn Equipment & Energy Windows Gamma camera: large field of view. Collimator: - Medium energy for solid and liquid (In-111 DTPA) - VXGP or LEHR if solid only study Energy window: Solid & Liquid 10% window centered at 140 kev for Tc-99m and at 171 kev for In-111. Solid Only - 20% window centered at 140 kev for Tc-99m Computer. Liquid Only - 20% window centered at 140 kev for Tc-99m Computer. Radiopharmaceutical, Dose, & Technique of Administration Radiopharmaceutical: ADULT: Pediatric dose base on weight Solid Study: 750 uci Tc-99m sulfur colloid labeled egg substitute 4oz. Liquid Study: 500 uci Tc99m DTPA ***Dual phase Liquid Study: (300 uci In-111 DTPA) INFANT: breast milk or equivalent Liquid(solid)Study: 100 uci Tc99m SC 3oz formula for 0-3 months old

2 4oz formula for 3-6 months old 5oz formula for 6 months and older Technique of administration: Oral or G Tube Patient Position & Imaging Field Patient position: Adults: Standing (static images) or supine (dynamic images) (camera dependent) Infants: Supine (static images) mark belly button for accurate placement Imaging field: Upper abdomen. Food Preparation Protocol **Taugas*** SOLID PHASE: Food Supplies: 4oz egg substitute, 2 pats of butter, 4oz water, two slice bread. Pediatric: 2oz egg substitute, 1 pat of butter, 2-4oz water, one slice bread. Heat up pan on medium heat on the hot plate in the hot lab. A. In Styrofoam cup mix egg substitute thoroughly. B. Add your Tc into the raw egg substitute and mix a little more. C. Use one pat of butter in heated pan. When melted, pour in the mixed egg. D. Cook over medium heat. You can cook like an omelet or like scrambled egg. E. Toast bread. F. Put Tc99m DTPA in cup of water.(in-111 DTPA if dual phase) ***Water and Tc-99m DTPA only if Liquid study is indicated. G. Serve egg, bread and water immediately. ***The meal may be eaten as a sandwich to decrease the time required for ingestion; if preferred, the eggs and toast may be eaten separately. LIQUID PHASE: Food Supplies: 4-6 oz. Water or juice. For adult patients put Tc99m DTPA in the cup of water or juice. For pediatric patients, put Tc99m S.C. in appropriate amount of formula or breast milk. ***make sure parents bring their own formula, and a disposable bottle that can be stored in decay storage.*** Acquisition Protocol A Serial Static Imaging 1. Tell the patient to eat the meal as quickly as possible. (Under 10 minutes preferable) 2. Note the length of time from when the patient started eating to when the images started. 3. Note how much food the patient ate.(should eat all portions) Solid Phase: 1. Record the Position on the computer and just return the patient to the same spot each time. 2. Acquire serial 1-minute anterior and posterior digital images at 0 minutes, 30 minutes, 60 minutes, 120 minutes, and 240 minutes. 3. The patient should remain quiescent between image acquisitions because exercise decreases gastric emptying times. 4. Patient should remain NPO for the duration of exam. B. Dynamic Imaging: *Use this study ONLY when unable to do upright serial static images! 1. Immediately after eating have the patient lie down on the camera bed (dual- 2

3 headed camera only). 2. In the Gastric program, select the first study, which is Dynamic. 3. Begin imaging immediately. 4. This scan will run for 60 minutes at 60 sec a frame minute images at 2 and 4 hours. C. Liquid phase: 1. Place the patient in a 45 degree supine position. If patient is unable to tolerate standard positioning, the position used must be clearly noted. Patient may be seated or supine for exam. 2. Acquire serial 60 second per frame dynamic digital images for 30 minutes. D. Pedatric imaging: Infant-6months Acquire serial 1-minute anterior and posterior digital images at 0, 15, 30, 45, and 60 minutes, then every 30 minutes after the first hour until the activity remaining is less than 50%. This allows for a true T ½. Time point TABLE 2 Normal Limits for Gastric Retention Lower limit (a lower value suggests abnormally rapid gastric emptying) Upper limit (a greater value suggests abnormally delayed gastric emptying) 0.5h 70% 1.0h 30% 90% 2.0h 60% 3.0h 30% 4.0h 10% Data are from Am J Gastroenterol. 2007;102:1 11. *Normal values for solid phase up to 52% retention at 2hrs, up to 10% retention at 4 hrs. *Journal Nuclear Medicine vol.48 no.4 April 2007 pages *Normal values for Liquid phase- T ½ of 7 to 20min For the 30 healthy subjects, the liquid water half-emptying time ranged from 6 to 20 min ( min). The T1/2 exponential-fit clearance rate ranged from 7 to 19 min ( min). (THE JOURNAL OF NUCLEAR MEDICINE Vol. 50 No. 5 May 2009 LIQUID GASTRIC EMPTYING Ziessman et al. pg727 Harvey A. Ziessman1, Ankit Chander1, John O. Clarke2, Alison Ramos1, and Richard L.Wahl1) Normal range for Tc-99m-sulfur colloid labeled instant oatmeal is up to approximately 1 hour (12). It should be remembered that gastric emptying is affected by meal composition, volume, and calorie content. As well as proportions of fat, carbohydrate and protein, gender and patient age (19-22). ***There is approximately 8% scatter from Tc-99m into the In-111 window and 23% scatter from In-111 into the Tc- 99m window. Data Processing Phillips EBW software. See Processing protocol book. Optional Maneuvers Gastric emptying can be analyzed by methods other than determining the halftime of emptying (24-27). 3

4 Diagnosis and treatment of gastric emptying dysfunction can be performed at one sitting (28). Evaluation of antral contractions: Serial 1 second images for 4 minutes are obtained after each static image. The images are analyzed to produce a record of the frequency and amplitude of antral contraction (29,30). Radiation Dosimetry Principal Radiation Emission Data - Tc-99m (31) Physical half-life = 6.01 hours. Radiation Mean % per disintegration Mean energy (kev) Gamma Dosimetry - Tc-99m-Sulfur Colloid Solid Meal (32) Organ rads/1 mci mgy/37 MBq Large intestine Small intestine Stomach Ovaries Whole body Testes References 1. Datz FL, Christian PE, Hutson WR, et al: Physiological and pharmacological interventions in radionuclide imaging of the tubular gastrointestinal tract. Sem Nucl Med 21: , Domstad PA, Kin EE, Coupal JJ, et al: Biologic gastric emptying time in diabetic patients, using Tc-99m-labeled resin-oatmeal with and without metoclopramide. J Nucl Med 21: , Christian PE, Datz FL, Moore JG: Gastric emptying studies in the morbidly obese before and after gastroplasty. J Nucl Med 27: , Velchik MG, Kramer FM, Stunkard AJ, et al: Effect of the Garren-Edwards Gastric Bubble on gastric emptying. J Nucl Med 30: , Goo RH, Moore JG, Greenberg E, et al: Circadian variation in gastric emptying of meals in humans. Gastroenterology 93: , 6. Wright RA, Thompson D, Syed I: Simultaneous markers for fluid and solid gastric emptying: New variations on an old theme. J Nucl Med 22: , Knight LC, Malmud LS: Tc-99m-ovalbumin labeled eggs: Comparison with other solid food markers in vitro. J Nucl Med 22:P28, McCallum RW, Saladino T, Lange R: Comparison of gastric emptying rates of intracellular and surface-labeled chicken liver in normal subjects. J Nucl Med 21:P65, Horowitz M, Maddox AF, Wishart JM, et al: Relationships between oesophageal transit and solid and liquid gastric emptying in diabetes mellitus. Eur J Nucl Med 18: , Leb G, Lipp RW: Criteria for labeled meals for gastric emptying studies in nuclear medicine. Eur J Nucl Med 20: , Fitzpatrick ML, Alderson AM: Solid food label for measurement of gastric emptying. [Letter] Br J Radiol 52: , Klingensmith WC: Unpublished data. 13. Taillefer R, Souesnard JM, Beauchamp G, et al: Comparison of technetium-99m sulfur colloid and technetium-99m albumin colloid labeled solid meals for gastric emptying studies. Clin Nucl Med 12: , 14. Heyman S, Reich H: Gastric emptying of milk feedings in infants and children: Anterior versus conjugate counting. Clin Nucl Med 22: , Datz FL: Considerations for accurately measuring gastric emptying. J Nucl Med 32: , Fahey FH, Ziessman HA, Collen MJ, et al: Left anterior oblique projection and peak-to-scatter ratio for attenuation compensation of gastric emptying studies. J Nucl Med 30: , Ford PV, Kennedy RL, Vogel JM: Comparison of left anterior oblique, anterior and geometric mean methods for determining gastric emptying times. J Nucl Med 33: ,

5 18. Moore JG, Datz FL, Christian PE. Exercise increases solid meal gastric emptying rates in men. Dig Dis Sci 33: , Kroop HS, Long WB, Alavi A, et al: Effect of water and fat on gastric emptying of solid meals. Gastroenterology 77: , Datz FL, Christian PE, Moore JG: Gender-related differences in gastric emptying. J Nucl Med 28: , 21. Spencer RP: Effect of volume on gastric emptying: A new theory, and a study by radionuclide techniques. J Nucl Med 22:P28, Datz FL, Christian PE, Moore JG: Loss of liquid-solid discrimination in gastric emptying of aged subjects. J Nucl Med 22:P28-29, Fisher RS, Malmud LS, Bandini R, et al: Gastric emptying of a physiologic mixed solid-liquid meal. Clin Nucl Med 7: , Ziessman HA, Atkins FB, Vemulakonda US, et al: Lag phase quantification for solid gastric emptying studies. J Nucl Med 37: , Yung BCK, Sostre S: Lag phase in solid gastric emptying: Comparison of quantification by physiological and mathematical definitions. J Nucl Med 34: , Urbain JLC, Vekemans MC, Bouillon R, et al: Characterization of gastric antral motility disturbances in diabetes using a scintigraphic technique. J Nucl Med 34: , Christian PE, Datz FL, Moore JG: Confirmation of short solid-food lag phase by continuous monitoring of gastric emptying. J Nucl Med 32: , Eikman EA, Brady P, Tenorio L, et al: Delayed gastric emptying: A comprehensive test for diagnosis and assessment of treatment. J Nucl Med 31:800, Urbain JLC, Charkes ND: Recent advances in gastric emptying scintigraphy. Sem Nucl Med 25: , Urbain JLC, Vekemans MC, Parkman H, et al: Dynamic antral scintigraphy to characterize gastric antral motility in functional dyspepsia. J Nucl Med 36: , Tc-99m: In MIRD: Radionuclide Data and Decay Schemes, DA Weber, KF Eckerman, AT Dillman, JC Ryman, eds, Society of Nuclear Medicine, New York, 1989, pp Siegel JA, Wu LK, Knight LC, et al: Radiation dose estimate for oral agents used in upper gastrointestinal disease. J Nucl Med 24: , Normal Findings > Heyman S: Gastric emptying in children. J Nucl Med 39: , > Villanueva-Meyer J, Swischuk SLE, Cesani F, et al: Pediatric gastric emptying: Value of right lateral and upright positioning. J Nucl Med 37: , > Kao CH, ChangLai SP, Chieng PU, et al: Gastric emptying in male neurologic trauma. J Nucl Med 39: , > Christian PE, Datz FL, Moore JG: Gastric emptying studies in the morbidly obese before and after gastroplasty. J Nucl Med 27: , > Datz FL, Christian PE, Moore JG: Gender-related differences in gastric emptying. J Nucl Med 28: , > Urbain JLC, Vantrappen G, Janssens J, et al: Intravenous erythromycin dramatically accelerates gastric emptying in gastroparesis diabeticorum and normals and abolishes the emptying discrimination between solids and liquids. J Nucl Med 31: , > Casson AG, Powe J, Inculet R, et al: Functional results of gastric interposition following total esophagectomy. Clin Nucl Med 12: , > Gryback P, Naslund E, Hellstrom PM, et al: Gastric emptying of solids in humans: Improved evaluation by Kaplan-Meier plots, with special reference to obesity and gender. Eur J Nucl Med 23: ,