Divisin f Nuclear Medicine Prcedure / Prtcl GASTRIC EMPTYING CPT CODE: 78264 UPDATED: FEBRUARY 2013 Indicatins: Patient Prep: Scheduling: This examinatin: Is indicated in patients with diabetes and thse with cmplaints f nausea, vmiting, and early satiety Can demnstrate abnrmal gastric emptying Serial imaging can demnstrate the respnse t drug therapy (e.g. metclpramide) Patients shuld be fasting a minimum f 6 hurs, preferably an vernight fast. Fr infants, the nrmal time between feedings will be a sufficient fast. Patients shuld avid smking the mrning f the test and thrugh test cmpletin. Insulin may be taken as usual. Insulin-dependent diabetic patients shuld bring their glucse mnitrs and insulin with them. The serum glucse level at the time f meal ingestin shuld be recrded and included in the final reprt. Diabetic patients shuld mnitr their glucse level and adjust their mrning dse f insulin as needed fr the prescribed meal. The glucse level shuld be < 275 mg/dl the mrning f the test. Insulin can be given befre the test t lwer the bld glucse level. Premenpausal wmen shuld ideally be studied n days 1 10 f their menstrual cycle, if pssible, t avid the effects f hrmnal variatin n gastrintestinal mtility. Fd sensitivities including gluten allergy are t be nted and bread exchanged. Hwever, requested changes in test meal must be cnfirmed with referring and a Nuclear Medicine physician at the time f prtcling. Allergies t egg whites are very rare and this is different t egg ylks where allergies exist. Prkinetic agents such as metclpramide, tegaserd, dmperidne, and erythrmycin are generally stpped 2 days befre the test unless the test is dne t assess the efficacy f these drugs. Medicatins that delay gastric emptying, such as piates r antispasmdic agents, shuld generally als be stpped 2 days befre testing. Sme ther medicatins that may have an effect n the rate f gastric emptying include atrpine, nifedipine, prgesterne, ctretide, thephylline, benzdiazepine, and phentlamine. The Nuclear Pharmacist will d a medicatin review prir t scheduled appintment and discuss with faculty any medicatins nt stpped. Faculty will determine if the study shuld prceed r nt. Faculty will give any additinal instructins r cancel ntificatin t a Senir Nuclear Medicine Technlgist. If the patient is n medicatins fr nausea and/r vmiting, then the Nuclear Medicine physician will need t determine if the medicatins shuld be cntinued. If nt the Nuclear Medicine physician will advise hw lng the patient shuld be ff the medicatin. Ondansetn can be given fr nausea; this has little effect n the gastric emptying. This study is brken up int 5 appintments and requires 4 hurs ttal time. 1. 45 minutes: Test explanatin and eating the meal with the first set f images at abut the 30 minute pint 2. Returning at 1, 2, 3, and 4 hurs pst-meal fr additinal sets f images 3. Each imaging set will be scheduled fr 15 minutes This study has a strict fd intake fr adult patients f 2 scrambled egg whites (Egg Beaters), bread, and water. If patient cannt cmply, referring physician will need t cntact Nuclear Medicine Faculty (reading rm), but the Natinal Standard nrmal ranges will nt apply. \\r-radnas\grups\nucleargrup\protocols\gi\gastric Empty-Current.dc
The alternate meal uses atmeal instead f scrambled egg whites, and can be used if needed if assessing pre- and pst-medicatin changes. The alternate meal is nt recmmended. Infants: D nt fllw the timing described abve. They will be seen fr abut 2.5 hurs with images every 15 minutes. The infant s wn frmula is used. Vlume is same as used fr a nrmal feeding. Try t schedule the start f the exam t be the beginning f the nrmal feeding interval. Due t the duratin f this exam, Wednesday in Rm B will be the rutine day this exam is ffered. If there is a different need, a phne message will be t be submitted t see if by chance the required times are available n anther camera. Radipharmaceutical & Dse: All patients: The standard adult dse is 0.5 mci +/- 20% (0.4-0.6 mci, Tc-99m sulfur cllid adjusted fr weight per nmgram/nmis). Minimum dse is 0.1 mci fr all patients. This will be added int the meal as described belw. Meal Includes 118 milliliters (4 z.) f liquid egg whites (e.g. Eggbeaters [CnAgra Fds, Inc.] r an equivalent generic liquid egg white) Tw slices f white bread (if gluten allergy, then rice bread will be substituted) 30 grams f jam r jelly 120 milliliters f water Meal Preparatin Test meal shuld be prepared after patient arrives in the department Mix the 99mTc-sulfur cllid int the liquid egg whites Ck the liquid egg whites in a ht nnstick skillet r in a Nuclear Medicine dedicated micrwave ven. Stir the liquid egg whites nce r twice during cking and ck until firm t the cnsistency f an melet. Bread can be tasted if a taster is available, if the patient desires * The liquid egg whites (e.g. Eggbeaters [CnAgra Fds, Inc.] r an equivalent generic liquid egg white) can be btained frm Nutritin Services frm their bulk supply in a Styrfam cup alng with the ther meal items. Alternate Meals Infants Nuclear Medicine technlgist will mix dse f 99mTc-sulfur cllid with ½ the vlume f a nrmal feeding f frmula r milk. A secnd amunt f unlabeled frmula r milk, ½ the vlume f a nrmal feeding, shuld be in hand when feeding the infant t cmplete the nrmal vlume. Fr Egg Allergy r Intlerance Instant atmeal replaces the scrambled egg whites in the standard meal as prtcled by the Nuclear Medicine clinician. The ther items remain as described abve. The Nuclear Medicine Pharmacy will btain ht water either frm the tap r heated by whatever means are available in the Nuclear Pharmacy. The Tc-99m sulfur cllid will be added t the dry atmeal* and then 100 milliliters ht water will be added with gentle stirring. * Packets f instant atmeal are available frm Nutritin Services alng with the ther meal items. The nrmal ranges f this test have been validated in literature nly with scrambled egg whites nly. The use f the alternate meal means the validated ranges are nt applicable. Hwever, use f the alternate meal t assess pre- and pst-medicatin changes is pssible. The alternate meal must be used fr bth pre- and pst-assessments. \\r-radnas\grups\nucleargrup\protocols\gi\gastric Empty-Current.dc
Imaging Device: Fr upright imaging: GE Infinia r GE MPS with LEHR cllimatin Fr supine imaging using the camera s table: GE Infinia r Millennium VG with LEHR cllimatin Fr supine n a bed r cart imaging: GE MPS with LEHR clllimatin Data Acquisitin: Matrix: 256 x 256 in wrd mde Time: 1 min/image Start imaging at the cmpletin f the meal May use predefined acquisitin prtcl, Gastric Empty Upright Dual, fr sequential imaging and Gastric Empty Supine Dual fr simultaneus imaging Views: See Imaging Prcedure belw Imaging Prcedure: Rutine Adult/Child Have the patient eat all f the test meal in 10 minutes r less. Recrd hw lng the patient tk t eat the meal; enter this time int the HealthLink/Radiant Study ntes. The meal may be eaten as a sandwich t decrease the time required fr ingestin; if preferred, the eggs and tast may be eaten separately. If all f the fd cannt be eaten, the patient shuld eat all f the eggs cntaining the radipharmaceutical (r alternative meal), and as much f the rest f the test meal as pssible. Recrd hw much f the meal was nt eaten; a visual assessment is sufficient. Time zer is when the patient finishes eating the meal. The imaging set includes Psterir and Anterir views Imaging shuld be perfrmed upright, but can be perfrmed supine if the patient cannt stand fr the required time. All images are t be taken the same way. Each image shuld cntain the distal esphagus, stmach, and prximal small bwel. Upright: The anterir and psterir views will be taken sequentially, NOT simultaneusly, fr all upright imaging. Minimal time shuld be taken t turn the patient between the anterir and psterir views. Supine n camera table: The anterir and psterir views will be taken simultaneusly n a dual head camera. Supine imaging cannt be dne n a single head camera; the time t rtate the head arund is t lng. Supine n a bed r transprt cart: Fr patients wh cannt be transferred t the imaging table, a single 45 degree LAO view will be taken fr each interval. Fllw up studies shuld be perfrmed the same as the first study. The first image is taken immediately after the meal is cnsumed. Then image the patient at 1, 2, 3, and 4 hurs plus r minus 10 minutes. Remember, time zer is when the patient finished eating the meal. View names shuld be prjectin x minutes, prjectin 1-hur, prjectin 2-hur, prjectin 3-hur, and prjectin 4-hur. During the wait times, allw the patient t get up and walk abut between acquisitins. They may nt eat r drink anything during this time. Infant Have the infant drink labeled frmula r milk. When the infant is dne with the labeled frmula r milk, give them the unlabeled prtin t drink. The unlabeled prtin is used t wash dwn residual esphageal activity. Feed the patient in an upright psitin. If infant is unable t drink, have the ward r clinic persnnel insert an NG tube, if directed t by the Nuclear Medicine Faculty. This tube is pulled after feeding befre imaging is cmpleted by whmever inserted it. The first image is taken immediately after the infant finishes the unlabeled prtin. Imaging thereafter per 15 minutes btaining anterir and psterir images, as abve. The scan is cmplete by the next nrmal feeding (t prevent crying frm hunger) Ttal scan time is apprximately 2.5 hurs depending n the current feeding schedule \\r-radnas\grups\nucleargrup\protocols\gi\gastric Empty-Current.dc
Imaging Variatins Alternate scan terminatin pints Bring any cncerns abut timing t the Nuclear Medicine Faculty Patient vmiting after the meal is cnsumed ends the study Other alternate meals and times nt defined here will be defined by the prtcling MD prir t scheduling Data Analysis: Use Gastric Emptying prtcl n GE Xeleris wrkstatin. Fllw n-screen instructins fr ROI placement. The ROI shuld include any visualized activity in the fundic (prximal) and antral (distal) regins f the stmach. Adjust the ROI with care t avid including activity frm adjacent small bwel, if pssible. The prcessing prtcl uses a gemetric mean when tw views, anterir and psterir, are used. The gemetric calculatin is the square rt f the prduct f the anterir and psterir cunts, SQRT(A * P). Time decay must be taken int accunt back t time zer, GE prcessing prtcl accunts fr decay. Create a save screen using the clr mde f the cmpeted prcessed data and curve. The final results, each time pint, are expressed as a percent f cunts remaining in the stmach with the ttal crrected cunts at time zer being 100%. PACS: Create a save screen using the B/W mde f the five images with ROI s and curves. Anntatin includes rientatin and image timing if the image labels are nt used. Send all save screens and raw data t PACS. Interpretatin: The final results are expressed as the percentage remaining in the stmach at each time pint with the ttal gastric cunts taken frm the time zer image as 100%. This prtcl is based n the SNM Prcedure Guideline fr Adult Slid-Meal Gastric-Emptying Study 3.0*, 2/8/2009, the nrmal limits are shwn in the table belw frm the SNM prcedure. The nrmal ranges f this test, described in Table 2 belw, have been validated in literature with scrambled egg whites nly. The nrmal range shuld be dictated alng with the final results. The use f the alternate meal means the validated ranges are nt valid. Hwever, use f the alternate meal t assess pre- and pst-medicatin changes is pssible. The alternate meal must be used fr bth pre- and pst-assessments \\r-radnas\grups\nucleargrup\protocols\gi\gastric Empty-Current.dc
Cmments: Bibligraphy: A Nuclear Medicine staff r resident physician shuld be cnsulted t determine if additinal views are indicated, r if the patient cannt ingest test meal. Prcedure Guideline fr Adult Slid-Meal Gastric-Emptying Study 3.0*, 2/8/2009 frm the Sciety f Nuclear Medicine. Reviewed By: S. Perlman, D. Fuerbringer, S. Knishka Sctt B. Perlman, MD, MS Derek Fuerbringer, CNMT Sctt Knishka, RPh, BCNP Chief, Nuclear Medicine Manager, Nuclear Medicine Radipharmacist \\r-radnas\grups\nucleargrup\protocols\gi\gastric Empty-Current.dc