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Endoscopy plays an important role in the diagnosis and treatment of postoperative complications of gastric cancer. Endoscopic intervention can avoid the second operation and has attracted wide attention. Early gastric anastomotic bleeding after gastrectomy is the most common. With the development of technology, emergency endoscopy and endoscopic hemostasis provide a new treatment approach. According to the specific circumstances, endoscopists can choose metal clamp to stop bleeding, electrocoagulation hemostasis, local injection of epinephrine or sclerotherapy agents, and spraying specific hemostatic agents. Anastomotic fistula is a serious postoperative complication. In addition to endoscopically placing the small intestine nutrition tube for early enteral nutrition support treatment, endoscopic treatment, including stent, metal clip, OTSC, and Over-stitch suture system, can be chosen to close fistula. For anastomotic obstruction or stricture, endoscopic balloon or probe expansion and stent placement can be chosen. For esophageal anastomotic intractable obstruction after gastroesophageal surgery, radial incision of obstruction by the hook knife or IT knife, a new method named ERI, is a good choice. Bile leakage caused by bile duct injury can be treated by placing the stent or nasal bile duct. In addition, endoscopic methods are widely used as follows: abdominal abscess can be treated by the direct intervention under endoscopy; adhesive ileus can be treated by placing the catheter under the guidance of endoscopy to attract pressure; alkaline reflux gastritis can be rapidly diagnosed by endoscopy; gastric outlet obstruction mainly caused by cancer recurrence can be relieved by metal stent placement and the combination of endoscopy and X-ray can increase success rate; pyloric dysfunction and spasm caused by the vagus nerve injury during proximal gastrectomy can be treated by endoscopic pyloromyotomy, a new method named G-POEM, and the short-term outcomes are significant. Endoscopic submucosal dissection (ESD) allows complete resection of residual gastric precancerous lesions, however it should be performed by the experienced endoscopists.

Introduction: Single-photon emission computed tomography (SPECT) myocardial perfusion imaging is an accepted method for reflecting the pathophysiological significance of lesions detected by coronary angiography. However, it has an inherent drawback in terms of false-positive perfusion defects for the inferior myocardial wall. To overcome this problem, different acquisition techniques have been proposed, including the computed tomographic-based attenuation correction method. In this respect, a new imaging technique, left supine lateral position SPECT myocardial perfusion imaging with technetium-99m methoxyisobutylisonitrile (Tc-99m MIBI), has been proposed to eliminate this problem and its value has been investigated in this report., Materials and Methods: Sixty-two patients were prospectively and randomly enrolled in this study. They underwent Tc-99m MIBI SPECT in the supine, prone, left lateral, and sitting positions after an adequate stress test on the same day.The presence and extent of defects on stress images were noted in the supine image data set for the 11 myocardial segments, which were then labeled as 1 or 0 if a defect was present or absent, respectively. This evaluation sequence was repeated in all other image data sets. When defects persisted in other scan positions it was regarded as true positive, and when they were resolved they were regarded as false positive. By this means, the percentages of resolving perfusion defects by that imaging position were calculated for each observer per positional pair under comparison., Results: From six interpretations carried out by the nuclear medicine physicians, 6×11×3=198 four-fold tables in 11 segments were analyzed for discrepancies between position pairs. In 31 of 33 discrepant interpretations, defects observed in any of the other positions were resolved in the lateral position. Only in two evaluations of one observer were the discrepancies against lateral positioning for the anterior wall. If the inferior wall was considered alone, it was clearly obvious that lateral positioning was more accurate than the other positions.Intraobserver evaluation showed the methodology to be highly reproducible.The SPECT findings were concordant with coronary angiography results in selected patients., Conclusion: Visual and quantitative evaluations of the variation in inferior wall activity lead us to suggest that SPECT imaging with Tc-99m MIBI be performed in the left lateral position to allow better visualization of the inferior and septal walls in those departments not able to utilize computed tomographic attenuation correction.

Unlabelled: Enterogastric reflux (EGR) is the reflux of duodenal contents into the stomach. Hepatobiliary scintigraphy provides physiologic assessment of the biliary system and was used to test the hypothesis that presence and timing of EGR may be associated with infusion of sincalide, a surrogate of endogenous cholecystokinin., Methods: One hundred fifty-seven hepatobiliary scintigraphy studies were retrospectively reviewed. Data included EGR incidence on initial reports, incidence after masked second reads, and time of EGR onset in relation to sincalide infusion. EGR cases were then classified according to onset on pre-, post-, or both presincalide and postsincalide imaging., Results: Time of EGR onset at 19-24 minutes after start of a 15-min sincalide infusion differed significantly from normal (p<0.0001). EGR was initially reported in 14 of 157 cases (8.9%) but found in 38 of 157 cases on masked second reads (24.2%), corresponding to a 15.3% discrepancy rate., Conclusion: The temporal association of EGR onset with sincalide infusion may identify patients with EGR mimicking chronic cholecystitis or biliary dyskinesia. A novel classification schema was therefore developed as a framework for future research, utilizing EGR onset in relation to pre-, post-, or both presincalide and postsincalide imaging as a hypothetical biomarker of clinically significant EGR., (© 2014 by the Society of Nuclear Medicine and Molecular Imaging, Inc.)

Ultrasonography has been widely used to evaluate duodenogastric reflux (DGR). But to the best of our knowledge, no automatic analysis system was developed to realize the quantitative computer-aided analysis. In this paper, we propose a system to perform the automatic detection of DGR in the ultrasonic image sequences by applying the automatic motion analysis. The motion field is estimated based on image velocimetry. Then, an intelligent motion analysis is applied. For the DGR detection, the motion and structural information is combined to analyze the transploric motion of the fluid. In order to test the performance of the proposed system, we designed the experiment with the real and synthetic ultrasonic data. The proposed system achieved a good performance in the DGR detection. The automatic results were accordant with the gold standard in analyzing the fluid motion. The proposed system is supposed to be a promising tool for the study and evaluation of DGR.

Aim: To assess the diagnostic value of a combination of intragastric bile acids and hepatobiliary scintigraphy in the detection of duodenogastric reflux (DGR)., Methods: The study contained 99 patients with DGR and 70 healthy volunteers who made up the control group. The diagnosis was based on the combination of several objective arguments: a long history of gastric symptoms (i.e., nausea, epigastric pain, and/or bilious vomiting) poorly responsive to medical treatment, gastroesophageal reflux symptoms unresponsive to proton-pump inhibitors, gastritis on upper gastrointestinal (GI) endoscopy and/or at histology, presence of a bilious gastric lake at > 1 upper GI endoscopy, pathologic 24-h intragastric bile monitoring with the Bilitec device. Gastric juice was aspirated in the GI endoscopy and total bile acid (TBA), total bilirubin (TBIL) and direct bilirubin (DBIL) were tested in the clinical laboratory. Continuous data of gastric juice were compared between each group using the independent-samples Mann-Whitney U-test and their relationship was analysed by Spearman's rank correlation test and Fisher's linear discriminant analysis. Histopathology of DGR patients and 23 patients with chronic atrophic gastritis was compared by clinical pathologists. Using the Independent-samples Mann-Whitney U-test, DGR index (DGRi) was calculated in 28 patients of DGR group and 19 persons of control group who were subjected to hepatobiliary scintigraphy. Receiver operating characteristic curve was made to determine the sensitivity and specificity of these two methods in the diagnosis of DGR., Results: The group of patients with DGR showed a statistically higher prevalence of epigastric pain in comparison with control group. There was no significant difference between the histology of gastric mucosa with atrophic gastritis and duodenogastric reflux. The bile acid levels of DGR patients were significantly higher than the control values (Z: TBA: -8.916, DBIL: -3.914, TBIL: -6.197, all P < 0.001). Two of three in the DGR group have a significantly associated with each other (r: TBA/DBIL: 0.362, TBA/TBIL: 0.470, DBIL/TBIL: 0.737, all P < 0.001). The Fisher's discriminant function is followed: Con: Y = 0.002TBA + 0.048DBIL + 0.032TBIL - 0.986; Reflux: Y = 0.012TBA + 0.076DBIL + 0.089TBIL - 2.614. Eighty-four point zero five percent of original grouped cases were correctly classified by this method. With respect to the DGR group, DGRi were higher than those in the control group with statistically significant differences (Z = -5.224, P < 0.001). Twenty eight patients (59.6%) were deemed to be duodenogastric reflux positive by endoscopy, as compared to 37 patients (78.7%) by hepatobiliary scintigraphy., Conclusion: The integrated use of intragastric bile acid examination and scintigraphy can greatly improve the sensitivity and specificity of the diagnosis of DGR.

Objective: To develop a software tool for quantification of liver and gallbladder function, and to assess the repeatability and reproducibility of measurements made with it., Materials and Methods: The software tool developed with the JAVA programming language uses the JAVA2 Standard Edition framework. After manual selection of the regions of interest on a 99mTc hepatic iminodiacetic acid study, the program calculates differential hepatic bile flow, basal duodeno-gastric bile reflux (B-DGBR), hepatic extraction fraction (HEF) of both the lobes with deconvolutional analysis and excretion half-time with nonlinear least squares fit. Gallbladder ejection fraction, ejection period (EP), ejection rate (ER), and postcholecystokinin (CCK) DGBR are calculated after stimulation with CCK-8. To assess intra-observer repeatability and intra-observer reproducibility, measurements from 10 normal participants were analyzed twice by three nuclear medicine technologists at the primary center. To assess inter-site reproducibility, measurements from a superset of 24 normal participants were also assessed once by three observers at the primary center and single observer at three other sites., Results: For the 24 control participants, mean+/-SD of hepatic bile flow into gallbladder was 63.87+/-28.7%, HEF of the right lobe 100+/-0%, left lobe 99.43+2.63%, excretion half-time of the right lobe 21.50+6.98 min, left lobe 28.3+/-11.3 min. Basal DGBR was 1.2+/-1.0%. Gallbladder ejection fraction was 80+/-11%, EP 15.0+/-3.0 min, ER 5.8+/-1.6%/min, and DGBR-CCK 1.3+/-2.3%. Left and right lobe HEF was virtually identical across readers. All measures showed high repeatability except for gallbladder bile flow, basal DGBR, and EP, which exhibited marginal repeatability. Ejection fraction exhibited high reproducibility. There was high concordance among the three primary center observers except for basal DGBR, EP, and ER. Concordance between the primary site and one of the other sites was high, one was fair, and one was poor., Conclusion: New United States Food and Drug Administration-approved personal computer-based Krishnamurthy Hepato-Biliary Software for quantification of the liver and gallbladder function shows promise for consistently repeatable and reproducible results both within and between institutions, and may help to promote universal standardization of data acquisition and analysis in nuclear hepatology.

Purpose: To assess the effects of Roux-en-Y jejunal limb length on gastric emptying and enterogastric reflux., Methods: Seventy male Wistar rats were submitted to antrectomy with Roux-en-Y reconstruction and then were divided into two groups of 35 animals. Group A, short limb (7.5 cm) and Group B, standard limb (15 cm). Group A and B were subdivided into five subgroups each in order to study enterogastric reflux at 30 and 60 minutes and to evaluate gastric emptying at 5, 10 and 15 minutes. In order to measure gastric emptying and enterogastric reflux, radiotracers 99m Tc-Phytate and 99m Tc-DISIDA were respectively used., Results: For gastric emptying, the radiotracer concentration was lower in Group A than in Group B after five minutes. The enterogastric reflux was present, but there were no significant differences between enterogastric reflux indexes concerning both A and B Groups., Conclusion: A standard Roux limb, besides being unable to protect the stomach from the enterogastric reflux, may become a functional barrier for gastric emptying.

We present a patient with a large hiatal hernia resulting in duodenogastric reflux that was seen as abnormal activity below and behind the heart (retrocardiac) on SPECT images and on (99m)Tc-tetrofosmin cardiac SPECT raw-data projection images. Incidental findings such as extra- and retrocardiac activity in the thorax and abdomen should be included on all comprehensive cardiac SPECT reports.

Background/aims: Persistence of dyspeptic symptoms after choledochoduodenostomy (CDD) is common. There is evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR after CDD., Methodology: A total of 6 patients who had undergone cholecystectomy with a standard side-to-end CDD for choledocholithiasis or Lemmel syndrome were studied by symptom evaluation, biliary scintigraphy and endoscopy at least 6 months after surgery. Duodenogastric reflux was quantified using continuous intravenous infusion of 99mTc-HIDA., Results: The incidence of DGR after CDD was 67% compared to healthy control. In the majority of the patients the DGR was mild to moderate, but not with the clinical symptoms., Conclusions: 99mTc-HIDA scanning of the hepatobiliary system is a reasonable and reliable method for the quantitative evaluation of DGR. CDD is associated with a high incidence of DGR, but its occurrence does not produce significant clinical symptoms.

The study was aimed at defining the informative value of dynamic hepatobiliary scintigraphy (HBSG) in the evaluation of duodenal reflux in patients with postgastrectomic disorders after reconstructive surgery. HBSG was performed in 23 patients. After intravenous injection of 99mTc bromeside in a dose of 74-80 MBq, the areas concerned were identified in the projection of the liver, gallbladder, hepaticocholedochus, duodenum, and stomach for 120 minutes with 60-min cholagogic breakfast. Histrograms were plotted in the activity-time coordinates; hepatic function, gallbladder contractility, and hepaticocholedochal patency were evaluated; the duodenal motor function index and the gastroduodenal reflux were estimated. HBSG is physiological, which makes it possible to reveal duodenal motor-and-evacuation disorders, to specify the reason for poor outcomes of gastrectomy, to objectively evaluate the severity of postgastrectomic disorders, and to determine further treatment policy for this difficult group of patients.

Purpose: To evaluate the efficiency of Roux-en-Y reconstruction (RY) after distal gastrectomy we compared postoperative physiological functions and disorders among patients who underwent RY, conventional Billroth I reconstruction (BI), or Billroth II reconstruction (BII)., Methods: The subjects were 91 patients who had undergone distal gastrectomy for gastric cancer more than 1 month earlier. To examine the severity of gastroesophageal reflux, acid reflux and alkali reflux were assessed, and to examine the severity of duodenal reflux into the remnant stomach, biliary scintigraphy was performed. The degree of inflammation in the esophagus and remnant stomach was examined by endoscopy. Questionnaires on postoperative complaints were sent out to the patients to determine how serious their reflux symptoms were., Results: Both acid and alkali reflux were mild in the RY group. Biliary reflux into the remnant stomach, as assessed by biliary scintigraphy, was significantly less severe in the RY group than in the BI and BII groups. Endoscopy showed that inflammation of the lower esophagus and remnant stomach was much less severe in the RY group than in the BI and BII groups. According to the questionnaire survey, none of the patients in the RY group reported any reflux symptoms., Conclusions: In this series, RY was found to be a superior reconstruction method after distal gastrectomy since it was rarely accompanied by the reflux of duodenal juice into the remnant stomach or gastric reflux into the lower esophagus.

Background: It has been suggested that symptoms from bile reflux gastritis are related to the frequency and degree of enterogastric reflux (EGR)., Methods: Patients with history of upper gastrointestinal surgery or cholecystectomy as well as control patients were studied. Presence of EGR, degree of EGR, and gastric bile emptying time were assessed and quantified via 99mTC scintillation imaging and then compared between symptomatic and asymptomatic patients., Results: Patients with vagotomy and pyloroplasty, Billroth I, Billroth II, and cholecystectomy demonstrated statistically higher degrees of EGR compared with controls. Although asymptomatic and symptomatic patients with a history of upper gastrointestinal or biliary surgery demonstrated no statistically significant differences between incidence of EGR and degree of EGR, there was a statistically significant difference in gastric emptying time., Conclusions: Delayed gastric emptying time, not frequency or extent of EGR, was associated with the symptoms of bile reflux in patients who had previous upper gastrointestinal or biliary operations.

99mTc-labeled myocardial perfusion agents are excreted through the hepatobiliary system and can be used in the evaluation of the duodenogastric reflux that occurs during routine cardiac imaging. The resultant gastric activity can overlap the inferior wall of the left ventricle (LV) and can thus mimic reverse redistribution of the LV inferior wall on dual-isotope SPECT. We report a case of significant gastric activity, which leads to abnormally low LV ejection fraction and akinesis of the LV wall in addition to the appearance of reverse redistribution. This case report illustrates that care should be taken in the performance and interpretation of (99m)Tc-tetrofosmin SPECT in the presence of duodenal reflux. This condition could be mistaken for reverse redistribution in the inferior wall of the LV with concomitant underestimation of the LV and regional wall motion.

Objective: To develop a non-invasive method for evaluating gastric emptying and duodenogastric reflux stroke volumes using three-dimensional (3D) guided digital color Doppler imaging., Methods: The technique involved color Doppler digital images of transpyloric flow in which the 3D position and orientation of the images were known by using a magnetic location system., Results: In vitro, the system was found to slightly underestimate the reference flow (by average 8.8%). In vivo (five volunteers), stroke volume of gastric emptying episodes lasted on average only 0.69 s with a volume on average of 4.3 ml (range 1.1-7.4 ml), and duodenogastric reflux episodes on average 1.4 s with a volume of 8.3 ml (range 1.3-14.1 ml)., Conclusion: With the appropriate instrument settings, orientation determined color Doppler can be used for stroke volume quantification of gastric emptying and duodenogastric reflux episodes.

Background: Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years., Methods: The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS., Results: Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic., Conclusions: So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

The aim of the study was estimation of the relation between the gallbladder (GB) motility function and the presence and quantity of enterogastric reflux (EGR). We investigated 172 patients with: physiological GB function (filling and emptying)(FGB), impaired GB function (prolonged filling and ejection fraction < 45%) and afunctional gallbladder (AGB)(without visualization). The study was performed during 90 min (1 f/min) after i.v. application of 185 MB 99mTc-dietil IDA. After 30 min. test meal was given while at the end stomach was marked. According to the parameters from time activity curves over stomach and hepatobiliary system, the index of ERG was calculated, while GB filling and ejection fraction were estimated from the GB time/activity curve. We can conclude that EGR occurs more frequently in the patients with afunctional GB in comparison to those with functional and decreased motor function. Also, EGR quantity is in correlation with the impairment of the GB function.

Background: Late duodenal phase III is characterized by retroperistalsis. The physiologic function of this phenomenon is unknown. Our aim was to study the relationship between duodenal motility and the transport of duodenal contents from the biliary tract and the duodenum by using a double-isotope technique., Methods: Manometric analysis of the direction of interdigestive duodenal pressure waves was performed in 12 volunteers. Duodenal marker was infused directly into the proximal duodenum, and bile marker was infused intravenously for 2 h. Radionuclide activity was examined for regions corresponding to the stomach, gallbladder, and duodenum., Results: In phase II, antegrade pressure waves dominated with propulsion of both markers to the jejunum. Retroperistalsis occurred in 90% of the activity fronts and was always (100%) followed by retropulsion of duodenal marker to the stomach. A clear-cut reflux of bile marker was seen in only 17% of the activity fronts. The incidence rate of duodenogastric reflux was highest in phase III (P=0.008) compared with phase II with an infrequent (P=0.002) admixture of bile. Bile marker contents increased abruptly in the gallbladder during phase III., Conclusions: Late phase III acts as a retroperistaltic pump, retropelling duodenal contents to the stomach. In this physiologic duodenogastric reflux. bile is avoided by deviation to the gallbladder, probably by a phase lll-associated occlusion of the sphincter Oddi.

Objective: Visualization of enterogastric reflux (EGR) may be present during hepatobiliary imaging. Reflux of bile may damage the gastric mucosa, altering its function, and cause such symptoms as epigastric pain, heartburn, nausea, intermittent vomiting and abdominal fullness. These symptoms also are associated with gallbladder disease. The aim of this study was to quantitate the EGR index (EGRI) and to determine if a difference exists in normal and abnormal responses using standard cholecystokinin (CCK)-augmented hepatobiliary imaging., Methods: This study used 129 patients. LAO dynamic data on a 128 x 128 matrix at a rate of 1 frame/min were obtained. After the gallbladder ejection fraction (GBEF) was determined, the EGRI (%) was calculated by relating the counts in the gastric ROI to the counts in the hepatobiliary ROI at a specified time. The results were compared with the patient's final clinical diagnosis., Results: Normal responders (GBEF > or = 35%) had a higher EGRI than abnormal responders with a P = 0.001 EGR observed in 75 patients (58.1%). Significant reflux (EGRI > or = 14.2% at 15 min) was observed in 29 additional patients (22.5%). Patients with EGRI > or = 24.5% showed a strong association with the pathophysiologic syndrome of gastritis, alkaline reflux, gastric ulcer and gastro esophageal reflux disease. There was no EGR observed in the remaining 25 patients (19.4%)., Conclusion: This simple addition to the CCK-augmented hepatobiliary imaging may both detect and quantitate abnormal EGR as the cause of the patient's symptoms in the presence of a normal GBEF result, and/or those patients with risk factors for gastritis.

Background: Duodenogastric reflux is believed to cause damage to gastric mucosa. Most reports on this disorder concern adult patients., Patients and Methods: 1120 children with abdominal pain were studied; endoscopic features of duodenogastric reflux were found in 92 patients. To confirm the diagnosis of duodenogastric reflux, cholescintigraphy (Tc99-HEPIDA) was performed. Children with confirmed duodenogastric reflux by scintigraphy were given a prokinetic drug (cisapride)., Results: Endoscopic features of duodenogastric reflux were found in 92 children; the diagnosis was confirmed by scintigraphy in 59 patients. There was no significant difference in the severity of inflammation in gastric mucosa compared with the control group, whereas significantly fewer of these patients were infected with Helicobacter pylori. There was no correlation between regions of isotope accumulation and inflammatory lesions in the stomach. The prokinetic drug (cisapride) helped eliminate or greatly reduce duodenogastric reflux in children., Conclusions: When endoscopic features of duodenogastric reflux are found the final diagnosis should be based on an examination that does not itself influence the motility of the gastrointestinal tract: cholescintigraphy seems to be a useful method. However, because the use of milk as a test meal affects the scintigraphic image, there was no correlation between the area of isotope accumulation and the localisation of inflammatory lesions in the stomach. Duodenogastric reflux seems to be less important as a cause of inflammatory lesions than other factors (such as genetic predisposition, stress, etc). Prokinetic drugs have a beneficial influence on treatment results in children with inflammatory lesions of gastric mucosa with duodenogastric reflux.

The aim of the study is assessment of the relationship between enterogastric reflux and the presence of Helicobacter pylori infection as factors that cause gastritis, peptic ulcer and adenocarcinoma ventriculi. The study was performed in 52 patients with different digestive disorders, using gamma camera, during 90 min (1 frame/min) after intravenous injection of 185 MBq 99mTc-dietil IDA in the cubital vein. According to time/activity curves from the region of hepatobiliary system and stomach, index of enterogastric reflux (EGR) was assessed. There was no correlation between the presence of Helicobacter pylori and EGR (r = 0.181, df = 52, p > 0.05). However, Helicobacter pylori was present more frequently in the patients with positive EGR (p < 0.01), but there were no significant differences (p > 0.05) in reflux value in patients with either positive or negative findings of Helicobacter pylori.

To elucidate the necessity of pyloroplasty for the gastric tube through the posterior mediastinum in esophageal surgery, gastric emptying and duodenogastric reflux (DGR) were evaluated in 16 cases undergoing an anterior pylorectomy (group P) and in 16 cases treated by the finger bougie method (group F). First, the obstruction and reflux symptoms were examined based on a patient questionnaire using a brief scoring system. The median value of the symptom score showed the patients in P to have more symptoms than those in F; however, the difference was not significant (8.0 vs 6.0). Secondly, the swallowed Tc O4- (85MBq) was counted using a gamma camera at three sites on the sternal bone in the upright position based on a gastric transit scintigram. Both the descending time of the RI peak and the clearance rates were similar between the two groups. Thirdly, intragastric 24-h pH monitoring was carried out. Antimony pH sensors were anchored 5 and 15cm below the esophagogastrostomy. We could not find any difference between the two groups in both the %time pH > 4 and %time pH > 7. These findings thus revealed no big difference between groups P and F. The finger bougie method to drain the vagotomized posterior mediastinal stomach was found to achieve results similar to conventional pyloroplasty, while it was also simpler and safer.

The authors comment the data from research on 70 patients with post cholecystectomy syndrome, using cholescintigraphy HIDA 99mTc to evaluate the relation ship between symptomatology (see classific.) and duodenogastric reflux entity. Cholescintigraphy seems to be a valid clinical means, especially for a correct indication to endoscopy.

The aim of the study is evaluation of the clinical validity of the chosen and modified own model of the nuclear medicine method for the detection and quantification of enterogastric reflux (EGR), as well as evaluation of its clinical validity. The study was performed in 172 patients: with gastric and duodenal ulcer, after Billroth I and Billroth II gastrectomy, with gastroesophageal reflux, after cholecystectomy, with chronic cholecystitis and chronic duodenal disease. Acquisition was performed with gamma camera, during 90 minutes after intravenous application of 185 MBq 99m-Tc-Dietil IDA. Test meal was given in 30th minute, while gastric region was marked at the end of the study. On the basis of the radioactivity changes in the regions of the stomach and hepatobiliary system, presence of enterogastric reflux is determined and its index calculated. In all the groups of patients, values are significantly different from physiological. The most frequent occurrence and the largest quantity of reflux is present in patients after Billroth II gastrectomy with significantly different values from other groups of patients. The obtained results approve clinical value of the chosen and modified scintigraphy of EGR as a non-invasive and physiological method, which provides data about its presence and quantity.

Duodenogastric reflux (DGR) has been implicated in several disease processes. The present study was carried out to document the incidence and evaluate the clinical significance of DGR after choledochoduodenostomy (CDD). A total of 13 patients who had undergone cholecystectomy with a standard side-to-side CDD for choledocholithiasis or chronic pancreatitis were studied by symptom evaluation, scintigraphy, endoscopy, and gastric mucosal histology at least 6 months after surgery. The scintigraphic findings were then compared with those of 10 patients who had undergone cholecystectomy alone. Only two patients (15%) had mild dyspeptic symptoms. The incidence of DGR after CDD was 69% compared to 20% in the cholecystectomy alone group (P < 0.05). In the majority of patients the DGR was only mild to moderate and the severity correlated well with the degree of endoscopic gastritis, but not with the clinical symptoms or histological findings. These results indicate that while CDD is associated with a high incidence of DGR, its occurrence does not produce significant clinical symptoms.

Single photon emission tomographic (SPET) myocardial perfusion imaging was performed on 76 patients using 99Tcm-sestamibi (99Tcm-MIBI). Retrospective analysis of the data showed good cardiac uptake and adequate hepatobiliary clearance. However, duodeno-gastric reflux of the activity excreted from the liver and gallbladder was seen in 34% of the studies. This reflux was considered to be severe in 16% of the studies, resulting in interference with the myocardial uptake and requiring three studies to be repeated. In an attempt to minimize interference from duodeno-gastric reflux, a further 86 patients (18 using 99Tcm-MIBI and 68 using 99Tcm-tetrofosmin) were imaged after lying on their right side for 20 min prior to imaging. Good cardiac uptake with adequate hepatobiliary clearance was again achieved. The incidence of duodeno-gastric reflux was significantly lower (P < 0.001), occurring in 22% of studies, while severe reflux occurred in 6% of studies with no studies being repeated. There was no significant difference in the incidence of reflux between the two agents. Duodeno-gastric reflux of 99Tcm-MIBI and 99Tcm-tetrofosmin is common and can result in significant interference with myocardial uptake. It is concluded that having patients lie on their right side for 20 min prior to imaging is a simple and effective method for significantly reducing the likelihood of such interference.

Morphine intervention in cholescintigraphy decreases imaging time to diagnose acute cholecystitis. Not infrequently we observe duodenogastric reflux during scintigraphy with and without morphine intervention. To evaluate occurrence of duodenogastric reflux related to morphine, we reviewed 55 patients who underwent cholescintigraphy with (32) and without (23) morphine intervention. Morphine was injected when there was bowel activity with non-visualization of the gallbladder at 60 min. Duodenogastric reflux was identified by the appearance of activity in the area just below or immediately adjacent to the tip of the left hepatic lobe laterally. Among 32 patients with morphine intervention, 19 had acute cholecystitis and 13 chronic cholecystitis. Eleven of 19 (58%) with acute cholecystitis had duodenogastric reflux and 6 of 13 (46%) had duodenogastric reflux in chronic cholecystitis. The total of duodenogastric reflux in the group with morphine injection was 53%. Two patients' duodenogastric reflux occurred before morphine injection and was more apparent after morphine was given. In the without morphine group, 3 had acute cholecystitis and 20 had chronic cholecystitis; 2 (one acute and one chronic cholecystitis) of these 23 (9%) had duodenogastric reflux. Our results indicate: (1) occurrence of DG reflux in morphine augmented cholescintigraphy is not significantly different in cholecystitis from that in chronic cholecystitis; (2) duodenogastric reflux in morphine augmentation occurs significantly more often than without morphine intervention (p < 0.001). We conclude that cholescintigraphy with morphine enhances duodenogastric reflux. The degree of duodenogastric reflux in the acute cholecystitis patients has been more severe than in the chronic cholecystitis patients.

The gastroduodenal reflux is considered, to be one of the important factors in the pathogenesis of gastritis and gastric ulcers. Endoscopic features suggesting bile reflux are not fully objective and may be a reason for false diagnosis of gastroduodenal reflux. The following study was established to verify the endoscopically diagnosed bile reflux by a scintigraphical test. In 30 of the 350 patients we showed bile reflux endoscopically, but 21 of them had duodenogastric reflux confirmed by cholescintigraphy. The autors maintain that cholescintigraphy seems to be a very useful method in the proper diagnosis of bile reflux.

The role of cholecystectomy and transduodenal sphincteroplasty on duodenogastric reflux (DGR) is still controversial. PURPOSE--To assess the effect of cholecystectomy alone, transduodenal sphincteroplasty alone and cholecystectomy combined with transduodenal sphincteroplasty on bile reflux into the stomach. METHODS--40 dogs were divided into four groups: control group (C) (n = 12), cholecystectomy group (Co) (n = 10), transduodenal sphincteroplasty group (Es) (n = 10) and cholecystectomy plus transduodenal sphincteroplasty group (Co+Es) (n = 8). A quantitative index of DGR was obtained in each case by determining the percentage of the intravenously injected 99m Technetium-DISIDA that was recovered in the gastric juice. RESULTS--The DGR was significantly higher in Co+Es group (mean: 2.26 +/- 2.69%) than in the C group (mean: 0.23 +/- 0.26%), and the Co group (mean: 1.52 +/- 1.77%) and the Es group (mean: 1.23 +/- 1.23%) (p < 0.05). The DGR did not differ significantly between C, Co and Es groups (p > 0.05). CONCLUSION--The results shows that only cholecystectomy plus sphincteroplasty increases duodenogastric reflux.

A review is presented of the design of radiolabelled test meals for the evaluation of gastrointestinal function, including oesophageal transit, gastro-oesophageal reflux, gastric emptying, enterogastric reflux and transit through the whole bowel. Descriptions of different systems are presented, together with validations of the procedures used. Published methods for assessment of oesophageal transit show a marked degree of consistency, whereas gastric emptying studies employ a wide range of both liquid and solid test meals. Recommendations are made concerning the optimal system for investigation of each part of the gastrointestinal tract, but whichever system is adopted, it is important to employ some validation procedures, and to establish normal ranges in the population under study.

Background: Our objective was to develop a simple, noninvasive method for evaluating duodenogastric reflux, along with antral motility and gastric emptying of a liquid meal., Methods: Antral motility and gastric emptying were measured by ordinary ultrasonography after a meal of 400 ml consommé. Duodenogastric reflux was evaluated by means of color Doppler. In a preliminary in vitro study we demonstrated that the test meal (consommé) contained oil particles suitable as a marker for color Doppler. We then investigated duodenogastric reflux, antral motility, and gastric emptying of a liquid meal in 43 asymptomatic healthy volunteers and in 24 patients with gastric ulcer., Results: This approach was feasible in 65 (97.0%) of the 67 subjects studied. Duodenogastric reflux was demonstrated in 26 (61.9%) of the 42 healthy volunteers and in 20 (87.0%) of the 23 patients with gastric ulcer. The frequency of the duodenogastric reflux and the reflux index were significantly increased in patients with gastric ulcer as compared with asymptomatic healthy volunteers. Gastric emptying and the motility index of antral contractions were significantly decreased in patients with gastric ulcer as compared with asymptomatic healthy volunteers., Conclusions: Ultrasonography with color Doppler is useful for evaluating abnormalities of gastroduodenal motility and can be used to understand the pathogenesis of such disorders.

Duodenogastric reflux, the reflux of duodenal bile into stomach, when suspected clinically requires an objective evaluation for proper management. In this study hepatobiliary scintigraphy in 91 patients of different clinical conditions was evaluated for presence of duodenogastric reflux. Upper gastrointestinal endoscopy was also performed in 44 of these patients. On scintigraphy duodenogastric reflux was present in 26 (29%) of 91 patients. Upper gastrointestinal endoscopy revealed presence of refluxed bile in the stomach in 12 (27%) of 44 patients. In the same groups of patients scintigraphy detected reflux in 18 (41%) of 44 patients. This shows that hepatobiliary scintigraphy is superior to upper gastrointestinal endoscopy in detection of duodenogastric reflux and also has the advantage of being non-invasive and physiological.

Background: Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship., Study Design: We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice., Results: All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001)., Conclusions: Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

Duodenogastric (D-G) reflux is commonly associated with peptic ulcer disease and chronic gastritis. To determine D-G reflux in association with each disease entity, we studied 43 chronic gastritis patients and 21 peptic ulcer patients with cholescintigraphy. Scoring (0 to 3+) was judged by the amount of Tc-99m diethylacetanitanilido-IDA (EHIDA) in the stomach. In the chronic gastritis group, 5, 16, 10, and 12 patients scored 3+, 2+, 1+, and 0, respectively. In the peptic ulcer disease group 6, 2, and 13 patients scored 2+, 1+, and 0, respectively. Thirty-nine of the 64 patients (60.9%) were positive for D-G reflux. D-G reflux occurred in 31 of 43 (72.09%) of chronic gastritis patients and in 8 of 21 (38.1%) patients with peptic ulcer disease. D-G reflux was significantly higher in the chronic gastritis group (P = 0.0009). Chronic gastritis patients were more likely to have more marked D-G reflux than peptic ulcer disease (P = 0.048). The authors conclude that cholescintigraphy is noninvasive and objectively demonstrates D-G reflux in chronic gastritis and peptic ulcer disease and that chronic gastritis is more closely associated with D-G reflux than peptic ulcer disease.

Background: We quantified duodenogastric reflux with 6-hour continuous intravenous infusion of technetium 99m-labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequent quantification in gastric juice., Methods: For this purpose, 50 patients were studied who had undergone surgery on the stomach with different surgical techniques: bilateral vagotomy plus Heineke-Mikulicz pyloroplasty, bilateral truncal vagotomy plus anterior pylorectomy, proximal gastric vagotomy, antrectomy and Billroth I reconstruction, and antrectomy and Billroth II reconstruction, comparing them with 10 healthy subjects used as a control group. We also studied the existing correlation between the rates of reflux determined by 99mTc-HIDA and those of total bile acids in gastric juice., Results and Conclusions: Patients who underwent gastric surgery had significantly greater quantities of duodenogastric reflux (p < 0.001) than had the control group. When the groups undergoing gastric surgery were compared, the patients who underwent resection showed higher reflux rates (p < 0.001) than did the patients who did not undergo resection. We found no differences among the groups of patients who did or did not undergo resection. We also found a highly significant correlation (p < 0.001) between the concentrations of 99mTc-HIDA and bile acids in gastric juice.

Twenty-nine patients with enterogastric reflux syndrome after anti-ulcer gastric surgery underwent a revisional Roux-en-Y gastrectomy. The diagnosis of enterogastric reflux syndrome was based on symptomatology and endoscopy in the first eight patients. The latter 21 patients had, in addition, a 99mTc-HIDA scintigraphy for the documentation and measurement of reflux. An enterogastric reflux index > 20 per cent is considered to justify symptoms due to reflux. Three of the first eight patients continued postoperatively to experience the same symptoms as before. These symptoms were eventually attributed to other than enterogastric reflux syndromes. The latter 21 patients were relieved from their preoperative symptoms and classified as Visick I and II (18 patients) and Visick III (3 patients). The authors conclude that enterogastric reflux syndrome must be documented on scintigraphy before the patient is subjected to revisional anti-reflux surgery in order for failures due to misdiagnosis to be avoided.

Background: The endoscopic observation of a bile lake in the stomach, antral gastritis, or ulcerations and the histologic finding of foveolar hyperplasia or chronic gastritis have been implicated as indicators of excessive duodenogastric reflux. The accuracy of these criteria was evaluated in 135 patients with nonspecific symptoms in the foregut suggestive of duodenogastric reflux and no evidence for alcohol- or drug-induced gastric mucosal injury., Methods: The presence of excessive duodenogastric reflux was objectively determined by means of both gastric pH monitoring and cholescintigraphy with cholecystokinin stimulation., Results: Endoscopy showed antral gastritis in 67 patients, gastric ulcers in 19, and a bile lake in the stomach in 39 (total of 135 patients). Of 90 patients who underwent biopsy, histologic findings showed foveolar hyperplasia in 26, chronic gastritis in 19, and active gastritis in 28 patients. The latter condition was associated with Helicobacter pylori in 20 patients. When gastric pH monitoring, cholescintigraphy, or both were used as "gold standard," the sensitivity, specificity, accuracy, and positive predictive value of endoscopic and histologic criteria to diagnose the presence of excessive duodenogastric reflux were poor except in the rare case of active gastritis but no Helicobacter pylori., Conclusions: The presence of duodenogastric reflux disease cannot be accurately diagnosed with endoscopic or histologic criteria. The diagnosis should be made with objective techniques, particularly when surgical therapy is considered.

Duodenogastric reflux (DGR) as seen on hepatobiliary scintigraphy has been reported as a useful secondary sign for the diagnosis of acute cholecystitis. We evaluated the association of reflux with cases of acute cholecystitis as compared to those with chronic cholecystitis or other conditions. Thirty-six of 198 patients referred for hepatobiliary imaging showed DGR (18%). Among 26 patients with acute cholecystitis, 6 (23%) had DGR as compared to 9/40 (23%) cases with chronic cholecystitis, 3/12 cases with acute pancreatitis, 4/13 cases with previous cholecystectomy, and 3/8 cases with duodenal ulcer. No statistically significant differences were found between the prevalence of DGR in cases with acute cholecystitis and those with chronic cholecystitis or other nonacute cholecystitis diagnostic categories. Although acute cholecystitis is a condition frequently associated with DGR, such reflux is a nonspecific finding and should not be considered as a secondary sign of acute cholecystitis when interpreting hepatobiliary scans.

Anastomotic leakage, pulmonary aspiration and reflux-esophagitis might be induced or aggravated by the increased duodenogastric reflux observed in the thoracic stomach. In this study, the effect of respiration on the reflux-promoting pressure gradient in the intrathoracally located stomach was assessed. In nine patients pressure recording was done in the duodenum and the abdominal and thoracic part of the stomach. Intrapleural pressure was determined by recording mouth pressure during inspiratory occlusion. In addition, the course of injected contrast was examined fluoroscopically. The mean end-expiratory pressure gradient in the thoracic part of the stomach was 0.8 cm H2O, increasing up to 6.0 cm H2O and 21.3 cm H2O during normal and forced inspiration, respectively. Fluoroscopic examination showed reflux of contrast that coincided with the downward movement of the diaphragm. From this study, we conclude that reflux into the thoracic stomach is promoted by intraluminal pressure fluctuations induced by voluntary breathing. Performing a pyloroplasty or -myotomy after intrathoracic esophagogastrostomy destroys the integrity of the pyloric sphincter as a barrier to reflux, thus promoting duodenogastric reflux.

There is no consensus or a uniform technique for measuring gastric emptying and numerous modalities have been reported. We report here the results obtained using a modification of the published techniques for the simultaneous measurement of duodenogastric reflux and gastric emptying utilizing simultaneously the recently developed radiopharmaceutical 97Ru-DISIDA, intravenously, and the oral administration of 99Tcm-sulphur colloid incorporated in a 'solid' test meal.

For the recognition and characterisation of oesophageal motor disorders, manometry represents the most reliable tool but yields no information on bolus transport. The transport can be quantitated by radionuclide techniques. The patient is positioned supine beneath a gamma-camera and instructed to swallow a radiolabelled bolus in a single gulp. Using a marker over the cricoid and the activity in the stomach as landmarks, regions of interest are drawn representing the upper, middle and lower third of the oesophagus and the gastric fundus. Activity-time curves enable one to recognise the clearance patterns in these regions. In combination, manometric and radionuclide transit studies recognise a higher number of motor disorders than either procedure alone. Radionuclide methods also are the most reliable and sensitive to quantitate gastric emptying. Procedure, meal size and composition as well as patient position must be standardised and correction techniques applied. The emptying of solid and liquid meal constituents can be evaluated concomitantly. Solids start to empty only after a lag phase of varying extent. With semi-solid meals, which are emptied at the same rate as solid meals of identical composition in the postlag phase, the recording time can be considerably shorter. Besides gastric emptying, the amplitude, frequency and propagation velocity of antral contractions can be recorded using serial images of short frame time and specially devised analytic techniques.

Pathologic gastroesophageal acid reflux appears to be involved in the pathogenicity of Barrett's esophagus. The possible pathogenic role of duodenogastric reflux, however, has been suggested by several studies. The aim of this prospective study was to assess the prevalence of acid or duodenogastric reflux in patients with Barrett's esophagus. Nine patients with histologically proven Barrett's esophagus (mean length: 7.7cm; range: 2-13 cm) were studied by esophageal manometry and 24 hour pHmetry. Duodenogastric reflux was measured in the interdigestive period by aspiration and during the postprandial period using an isotopic method. The results of these different investigations were compared with healthy volunteers (n = 20 to 27). Three patients had complicated Barrett's esophagus (Barrett's ulcer: n = 2, high-grade dysplasia: n = 1). The results of the different investigations showed that a) all patients had abnormal acid exposure and an esophageal motor dysfunction (decrease in lower esophageal sphincter pressure, amplitude and duration of contractions and increase in percentage of peristaltic dysfunction); b) none of the patients had any pathologic duodenogastric reflux neither in the interdigestive nor in the postprandial period. These results a) confirm the high prevalence of acid reflux in patients with Barrett's esophagus, b) show that bile or pancreatic secretions are not involved in the pathogenicity of Barrett's esophagus.