Physician Texas Tech University Health Sciences Center El Paso, TX
Alejandro Robles, MD, Jesus Diaz, MD, Majd Michael, MD, Marvin Friedman, PhD, Richard McCallum, MD, FACG; Texas Tech University Health Sciences Center, El Paso, TX
Introduction: Rumination syndrome (RS) is characterized by effortless postprandial regurgitation that occurs within 30 minutes of meal ingestion. Intragastric meal distribution (IMD) has been recently defined in normal and abnormal subjects in an attempt to provide additional information on fundic accommodation (FA). Our objective was to define whether IMD plays a role in patients with RS by means of: 1) FA analysis, and 2) fundic emptying (FE) in the initial 30 minutes and time to half-emptying (t½) compared to healthy subjects. Methods: Twenty-two patients with RS underwent gastric emptying scintigraphy (GES) with a standardized solid meal. Normal gastric emptying (NGE) was defined as < 10% retention at 4 hours and delayed gastric emptying (DGE) as > 10% retention. IMD was obtained immediately after meal consumption by defining a region of interest (ROI) in the proximal stomach and obtaining the ratio of the activity present in the proximal stomach to that of the total stomach. The cutoff ratio for abnormal IMD has been established as < 0.568. We also analyzed FE in the initial 30 minutes generated by proximal ROI corrected for decay. A study in 24 normal subjects by our research group, found that IMD averaged 67% ± 14 (range 49-93). The mean FE at 30 minutes was 22% (normal limits 0% - 47%); the lowest value was 12%, and the average proximal t½ was 65 minutes with 40 and 86 minutes as the lower and upper limits of normal, respectively. Results: From a total of 22 patients with RS, 13 (59%) had NGE and a mean IMD ratio on immediate images of 0.728 (range 0.483-1.0). The mean FE at 30 minutes was 30% (range 6%-55%), and the average t½ was 67 minutes (range 26-134); all within normal limits (Figure 1-2). The 9 patients with RS and DGE had a mean IMD ratio on immediate images of 0.739 (range 0.339-1.0). The mean FE at 30 minutes was 20% (range 0-45%), and the average t½ was 224 minutes (range 38-1200), with 4 patients having a prolonged t½. The difference in IMD in the NGE and DGE subgroups was not statistically significant (P=0.91), nor was the difference in FE at 30 minutes (P=0.22). Discussion: 1) Patients with RS can present with either NGE or DGE. 2) Fundic accommodation, intragastric meal distribution, and fundic emptying (FE) on immediate images were normal in both NGE and DGE subgroups. 3) FE analysis in NGE and DGE showed similar results at 30 minutes; the usual time duration when RS regurgitation is occurring. 4) We conclude that RS cannot be explained by abnormal fundic function.
Figure 1: GES results of a 26 y/o female with rumination syndrome demonstrating normal gastric emptying at all time points. Note that the intragastric meal distribution is mostly in the proximal stomach (immediate image); the meal then empties distally at the appropriate speed and is not abnormally retained in the proximal stomach during the next 30 minutes.
Figure 2: Intragastric meal distribution in the same 26 y/o female patient. A) Region of interest (ROI) encompasses the entire stomach. B) ROI over the proximal stomach with lower margin at the level of the incisura angularis. The fundic accommodation is 0.77 (normal 0.67) on the immediate images. Fundic emptying at 30 minutes was 20%.
Disclosures: Alejandro Robles indicated no relevant financial relationships. Jesus Diaz indicated no relevant financial relationships. Majd Michael indicated no relevant financial relationships. Marvin Friedman indicated no relevant financial relationships. Richard McCallum indicated no relevant financial relationships.