Slowed Rate of Gastric Emptying of Solid Food in Man By High Caloric Parenteral Nutrition
Ian L. MacGregor, MD, FACP, FRACP,” Tucson, Arizona Zealous D. Wiley, MD, San Francisco, California Michael E. Lavigne, MD, San Francisco, California Lawrence W. Way, MD, FACS, San Francisco, California
Total parenteral nutrition (hyperalimentation) through a central venous catheter is able to supply 2,000 to 5,000 calories/day plus sufficient nitrogen to maintain positive nitrogen balance. Parenteral nutrition can also be used to supplement the nutritional intake of patients who are eating but are unable to fully satisfy their needs. We have found that some patients on parenteral nutrition who are also receiving oral food experience fullness, nausea, or anorexia even in the absence of intestinal obstruction or abdominal inflammatory lesions. Acute hyperglycemia in the range commonly encountered in patients on total parenteral nutrition is known to slow the rate of gastric emptying of liquid meals [I]. Therefore, we questioned whether the relative intolerance to oral food by patients on parenteral nutrition might be a manifestation of delayed gastric emptying. Accordingly, we studied the rate of gastric emptying of solid food in patients while off and while on parenteral nutrition. Methods Five male patients participated in the study. All were inpatients at the Surgical Service of the Veterans Administration Hospital, San Francisco, and all gave informed consent as detailed by the Committee on Human Research, University of California, San Francisco (protocol no. 801705). Two patients both aged 65 years had cancer of the colon, one patient aged 48 had a pancreatic pseudocyst, one patient aged 79 had esophageal cancer, and the final patient aged 67 had prostatic and esophageal cancer. None
From the Veterans Administration Hospital and University of California, San Francisco, California. This study was supported by the Medical Research Service of the Veterans Administration, San Francisco, California. ’ Present address and address for reprints: Ian L. MacGregor, MD, Castroenterology Section, Veterans AdministrationHospital, South Sixth Avenue, Tucson, Arizona 85723.
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of these patients had mechanical obstruction to the gastrointestinal tract nor any clinically detectable motility disorder. In each case parenteral nutrition had been prescribed to improve protein-calorie malnutrition resulting from the primary disease. The rate of gastric emptying of solid food was measured as previously described [2]. Briefly, a live chicken was given an intravenous injection of 1 mCi of gg-%echnetium sulfur colloid. After 30 minutes the chicken was killed and the liver was removed, diced to 1 cm cubes, and cooked to a rubbery consistency in a microwave oven. The pieces of chicken liver were then heated with a 7.5 ounce can of commercial beef stew and the meal was consumed by the patient along with 200 ml of water. Mid-prandial time was taken as zero time. As soon as the meal was eaten the patient stood in front of a gamma camera fitted with a diverging collimator, and the total radiation emission from the abdomen was measured. The abdomen, apart from the stomach, was then shielded with a lead sheet, and the radiation emission from the intragastric contents was recorded. This sequence was repeated at regular intervals of about 15 minutes. The rate of gastric emptying was determined from the decreasing ratio of radiation emission from intragastric contents to total abdominal radiation. The placement of the lead shield to exclude all but the stomach was aided by the radiation pattern displayed on an oscilloscope and checked by scintiphotographs. No difficulty in shield placement was experienced. Because of food intolerance, several patients could not complete the entire meal. When this occurred, the weight of the meal that the patient had eaten was recorded and the same amount was given to that patient in the second part of the study. Thus, although the patients ate different amounts, each patient ate the same quantity while off and on parenteral nutrition. The two studies were done about 1 week apart, which allowed time for establishment of full pare&era1 nutrition if the first study was done before it was instituted, or for gradual discontinuance of parenteral nutrition if the first study was performed while the patient was on parenteral nutrition. The American Journal of Surgery
Slowed Gastric Emptying by Parenteral Nutrition
Figure 1, left. Effect of parenteral nutrition ( PtU) on the rate of gastric emptying of solid food. a
a
l,, t t t t t t IO
Olf
PN
On
PN
20
30
40
The parenteral nutrition solution, which contained 30 per cent dextrose and 4.25 per cent amino acids, plus electrolytes, vitamins, and minerals, was given at a flow rate of 100 to 125 ml/hr. The patient’s serum glucose concentration was measured immediately before each study. The difference in serum glucose when off and on parenteral nutrition was compared with the rate of gastric emptying while on parenteral nutrition expressed as a per cent of the gastric emptying rate while off total parenteral nutrition. Results were examined by linear regression analysis. Results
The pattern of gastric emptying in all patients was linear as previously described [z]. In all patients the rate of gastric emptying was slower while on total parenteral nutrition (Figure 1). The mean emptying rate (f standard error of the mean) while off parenteral nutrition (55 f 17 per cent/hr) was greater than while on parenteral nutrition (26 f 10 per cent/hr) (p
Ian L. MacGregor, MD, FACP, FRACP,” Tucson, Arizona Zealous D. Wiley, MD, San Francisco, California Michael E. Lavigne, MD, San Francisco, California Lawrence W. Way, MD, FACS, San Francisco, California
Total parenteral nutrition (hyperalimentation) through a central venous catheter is able to supply 2,000 to 5,000 calories/day plus sufficient nitrogen to maintain positive nitrogen balance. Parenteral nutrition can also be used to supplement the nutritional intake of patients who are eating but are unable to fully satisfy their needs. We have found that some patients on parenteral nutrition who are also receiving oral food experience fullness, nausea, or anorexia even in the absence of intestinal obstruction or abdominal inflammatory lesions. Acute hyperglycemia in the range commonly encountered in patients on total parenteral nutrition is known to slow the rate of gastric emptying of liquid meals [I]. Therefore, we questioned whether the relative intolerance to oral food by patients on parenteral nutrition might be a manifestation of delayed gastric emptying. Accordingly, we studied the rate of gastric emptying of solid food in patients while off and while on parenteral nutrition. Methods Five male patients participated in the study. All were inpatients at the Surgical Service of the Veterans Administration Hospital, San Francisco, and all gave informed consent as detailed by the Committee on Human Research, University of California, San Francisco (protocol no. 801705). Two patients both aged 65 years had cancer of the colon, one patient aged 48 had a pancreatic pseudocyst, one patient aged 79 had esophageal cancer, and the final patient aged 67 had prostatic and esophageal cancer. None
From the Veterans Administration Hospital and University of California, San Francisco, California. This study was supported by the Medical Research Service of the Veterans Administration, San Francisco, California. ’ Present address and address for reprints: Ian L. MacGregor, MD, Castroenterology Section, Veterans AdministrationHospital, South Sixth Avenue, Tucson, Arizona 85723.
652
of these patients had mechanical obstruction to the gastrointestinal tract nor any clinically detectable motility disorder. In each case parenteral nutrition had been prescribed to improve protein-calorie malnutrition resulting from the primary disease. The rate of gastric emptying of solid food was measured as previously described [2]. Briefly, a live chicken was given an intravenous injection of 1 mCi of gg-%echnetium sulfur colloid. After 30 minutes the chicken was killed and the liver was removed, diced to 1 cm cubes, and cooked to a rubbery consistency in a microwave oven. The pieces of chicken liver were then heated with a 7.5 ounce can of commercial beef stew and the meal was consumed by the patient along with 200 ml of water. Mid-prandial time was taken as zero time. As soon as the meal was eaten the patient stood in front of a gamma camera fitted with a diverging collimator, and the total radiation emission from the abdomen was measured. The abdomen, apart from the stomach, was then shielded with a lead sheet, and the radiation emission from the intragastric contents was recorded. This sequence was repeated at regular intervals of about 15 minutes. The rate of gastric emptying was determined from the decreasing ratio of radiation emission from intragastric contents to total abdominal radiation. The placement of the lead shield to exclude all but the stomach was aided by the radiation pattern displayed on an oscilloscope and checked by scintiphotographs. No difficulty in shield placement was experienced. Because of food intolerance, several patients could not complete the entire meal. When this occurred, the weight of the meal that the patient had eaten was recorded and the same amount was given to that patient in the second part of the study. Thus, although the patients ate different amounts, each patient ate the same quantity while off and on parenteral nutrition. The two studies were done about 1 week apart, which allowed time for establishment of full pare&era1 nutrition if the first study was done before it was instituted, or for gradual discontinuance of parenteral nutrition if the first study was performed while the patient was on parenteral nutrition. The American Journal of Surgery
Slowed Gastric Emptying by Parenteral Nutrition
Figure 1, left. Effect of parenteral nutrition ( PtU) on the rate of gastric emptying of solid food. a
a
l,, t t t t t t IO
Olf
PN
On
PN
20
30
40
The parenteral nutrition solution, which contained 30 per cent dextrose and 4.25 per cent amino acids, plus electrolytes, vitamins, and minerals, was given at a flow rate of 100 to 125 ml/hr. The patient’s serum glucose concentration was measured immediately before each study. The difference in serum glucose when off and on parenteral nutrition was compared with the rate of gastric emptying while on parenteral nutrition expressed as a per cent of the gastric emptying rate while off total parenteral nutrition. Results were examined by linear regression analysis. Results
The pattern of gastric emptying in all patients was linear as previously described [z]. In all patients the rate of gastric emptying was slower while on total parenteral nutrition (Figure 1). The mean emptying rate (f standard error of the mean) while off parenteral nutrition (55 f 17 per cent/hr) was greater than while on parenteral nutrition (26 f 10 per cent/hr) (p
