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Published online before print June 21, 2002, 10.1148/radiol.2242011412
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(Radiology 2002;224:592-597.)
© RSNA, 2002

Technical Developments

Gastric Motility: Comparison of Assessment with Real-Time MR Imaging or Barostat Measurement—Initial Experience1

Ingrid M. de Zwart, MD, Banafsche Mearadji, MD, Hildo J. Lamb, PhD, Paul H. C. Eilers, PhD, Ad A. M. Masclee, MD, Albert de Roos, MD and Patrik Kunz, PhD

1 From the Departments of Radiology (I.M.d.Z., H.J.L., A.d.R., P.K.), Gastroenterology and Hepatology (B.M., A.A.M.M.), and Medical Statistics (P.H.C.E.), Leiden University Medical Center, Albinusdreef 2, NL-2333 ZA Leiden, the Netherlands. Received August 20, 2001; revision requested October 9; revision received December 14; accepted January 29, 2002. Address correspondence to I.M.d.Z.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 
Measurements of gastric volume and motility with magnetic resonance (MR) imaging were compared with simultaneously performed measurements with a barostat in six healthy volunteers. Three-dimensional volume and two-dimensional dynamic MR images and barostat measurements were obtained at rest. Alterations in gastric volume and motility were induced by means of infusion of glucagon and erythromycin, respectively. There is strong evidence to have the opinion that MR imaging is as accurate as barostat measurement in determining changes in gastric volume, and it yields additional information about gastric contractions.

© RSNA, 2002

Index terms: Stomach, function, 72.91 • Stomach, motility • Stomach, MR, 72.121419, 72.12143


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
Materials and Methods
Results
Discussion
 REFERENCES
 
Assessment of gastric motility is important for the diagnosis of motility disorders, such as functional dyspepsia and diabetic gastroparesis (1–3). Currently, barostat measurement is the reference standard for the assessment of proximal gastric motility. An important disadvantage is the invasive nature of the barostat measurement technique: It requires oral intubation and intragastric positioning of a polyethylene bag that is inflated with air and used to measure intragastric bag volume (3). Correct positioning of the bag is checked with fluoroscopy. The barostat measures variables of compliance and perception of the gastric wall, which is the ability of the subject to feel changes in distention of the gastric wall (3,4). Moreover, the barostat measures tonic and phasic changes in bag volume or pressure with set pressure and set volume, respectively (5). A noninvasive alternative for barostat measurement may be real-time magnetic resonance (MR) imaging of gastric motility.

In recent years, MR imaging has been used to investigate gastric motility and emptying (6–9). Feinle et al validated MR imaging for gastric emptying by comparing it with scintigraphy (10). To our knowledge, however, real-time MR imaging of gastric motility has not been compared with simultaneous barostat recording.

Therefore, the purpose of the present study was to compare simultaneous MR imaging and barostat recording to evaluate MR imaging as a potential method to measure gastric motility and volume and to evaluate phasic volume waves measured with barostat recording.


   Materials and Methods
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 
Subjects
Six healthy volunteers (three women and three men; age range, 22–58 years; mean age, 35 years; body mass index, 23.0 kg/m2 ± 1.2) participated in the study. None had a history of gastrointestinal symptoms, had previously undergone abdominal surgery, or were using medication. Informed consent was obtained from each individual after the nature of the procedure was fully explained. The ethics committee of the university hospital approved the protocol of the study.

Gastric Barostat Measurement
An electronic barostat (Visceral Stimulator; Synectics Medical, Stockholm, Sweden) was used to distend the stomach. A polyethylene bag (1,000-mL maximum capacity) was connected to the end of a multilumen tube (16 F). The pressure and inflation channels were each elongated with a 3-m-long catheter (16 F) to allow placement of the barostat outside the MR investigation room. These catheters were connected to the barostat. The barostat keeps the pressure in the intragastric bag at a preselected level. When the stomach relaxes, the system injects air into the bag; when the stomach contracts, the system aspirates air (5). Thus, the barostat measures gastric motor activity as changes occur in intragastric volume at a constant intragastric pressure (11). Maximal air flow was 20 mL/sec.

Intragastric pressure (in millimeters of mercury), gastric volume (in milliliters), and gastric compliance (in milliliters per millimeter of mercury) were constantly monitored and recorded on a personal computer (Polygram for Windows, SVS module; Synectics Medical) connected to the barostat.

MR Imaging
The subjects underwent 1.5-T MR imaging (ACS-NT; Philips Medical Systems, Best, the Netherlands) with the body coil. The protocol consisted of two acquisitions: three-dimensional volume MR imaging (20 sections with a transverse orientation; turbo field-echo sequence, repetition time msec/echo time msec of 10/3.5; field of view, 450 mm; rectangular field of view, 55%; symmetric reduction, 50%; flip angle, 25°; matrix, 256 x 256; section thickness, 10 mm) was performed to determine the momentary gastric volume. To assess the dynamic activity of the stomach, two-dimensional dynamic MR imaging (coronal section orientation; turbo field-echo sequence, 10/3.6; 300–900 images per acquisition; temporal resolution, 1 second; field of view, 450 mm; rectangular field of view, 55%; symmetric reduction, 50%; flip angle, 25°; matrix, 256 x 128; section thickness, 10 mm) was performed. These MR imaging techniques were used and published previously (6,7).

Study Design
The experiment started at 8:30 AM after an overnight fast of at least 10 hours. The barostat catheter with bag was introduced through the mouth and positioned in the fundus of the stomach. Correct positioning was checked with fluoroscopy. To unfold the bag, air (300 mL) was manually inflated with controlled pressure (<20 mm Hg), and the catheter was pulled back carefully until its passage was restricted by the lower esophageal sphincter. Then the tube was introduced 2 cm further. Thereafter, the bag was deflated and connected to the barostat. A cannula was placed in the antecubital vein of one forearm for infusion of glucagon and erythromycin. Glucagon and erythromycin were used to relax and to contract the stomach, respectively. Glucagon and erythromycin were chosen because their effects on gastric motility and gastric volume have been investigated thoroughly with the barostat measurement procedure (12–14).

Subjects underwent MR imaging in a semisupine position (30°), with the lower extremities 30 cm above the table level in the MR imager, while barostat recordings were made simultaneously.

First, minimal distending pressure, which is the pressure needed to overcome the intraabdominal pressure, was determined. This pressure is defined as the first pressure level that provides an intragastric bag volume of more than 30 mL. The pressure was determined by increasing the intrabag pressure in 1–mm Hg steps every minute.

The barostat was set to maintain a pressure that was 3 mm Hg higher than the minimal distending pressure. During the first 20 minutes, the basal volume of the proximal stomach was measured. Infusion of intravenous glucagon (bolus of 4.8 µg per kilogram of body weight in 5 minutes); thereafter, continuous infusion of 9.6 µg/kg/h was started for 10 minutes. Intragastric volume was continuously measured for another 35 minutes. Then, infusion of erythromycin (1.5 mg/kg in 10 minutes) was started. Thereafter, intragastric volume was measured for an additional 15 minutes. Then the experiment was ended.

During the barostat recordings, three-dimensional volume MR images and two-dimensional dynamic MR images were acquired (Fig 1). Total duration of the experiment was 80 minutes.



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  		Figure 1. Schematic shows the study protocol for MR imaging motility measurement (cross-hatched boxes), MR imaging volume measurement (gray boxes), barostat isobaric measurement (black rectangle), and infusion of glucagon or erythromycin (white boxes).

 
Reproducibility of Barostat Measurements with Short and Long Catheters
Since the barostat is not compatible with MR imaging, longer catheters were used between the patient and the device to place the barostat outside the MR imaging investigation room. In the same six volunteers, reproducibility of the barostat measurements was studied and demonstrated by measuring minimal distending pressure and gastric volume with either the short or long catheter in one experiment performed under the same fasting conditions (data not shown).

Data Analysis
Gastric volumes measured with the barostat are given as average values over 1-minute periods with the personal computer software. Cyclic variations in bag volume, so-called volume waves, are defined as changes in volume of greater than 30 mL that revert in less than 2 minutes to a volume within 50% of the previous level (3,15,16). With fixed pressure in the barostat bag, these volume waves represent phasic contractions.

On all volume MR images, the stomach was outlined manually by one observer (I.M.d.Z.). Gastric volumes were obtained by adding the calculated surfaces of all outlined areas and multiplying by the section thickness by using additional software (MASS; Leiden University, Leiden, the Netherlands). To obtain gastric motility parameters, gastric diameters were calculated at 10 equally distributed points perpendicular to the stomach axis. On the basis of this diameter calculation, peristaltic contractions were detected, and their frequency (in contractions per minute) was calculated (6,7). The 10 diameters obtained at each time point were summated to obtain volume wave curves (in arbitrary units), which were then graphically fitted to the barostat volume waves.

Statistical Analysis
Barostat measurements and MR imaging results are expressed as mean ± standard error of the mean. Barostat data were analyzed for statistical significance with multiple analysis of variance, or MANOVA. When the results indicated a probability of less than .05 for the null hypothesis, Student-Newman-Keuls analyses were performed to determine which values within the experiments differed significantly. The significance level of differences was set at P < .05.

Statistical analysis of the combined study concentrated on linear regression of MR imaging volume and barostat volume, which were sampled at 1-second intervals. The slope of the regression line gives the ratio of changes in volumes as recorded with both techniques. To correct for the delay that was caused by the long catheter, the barostat signal was shifted by 5 seconds. Mean MR imaging results were compared with the mean barostat results with analysis of variance, or ANOVA, after correction for the delay.


   Results
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 
Experiments with Short and Long Barostat Catheters
When the longer catheter was used, a delay of 5 seconds to reach maximum bag volume was found. The mean minimal distending pressure with the short catheter was 5.5 mm Hg ± 0.6 and with the long catheter was 5.8 mm Hg ± 0.8; this difference was not significant (P > .1). The mean intragastric volume in 30 minutes did not differ significantly between the long catheter (174.6 mL ± 35.1) and the short catheter (186.2 mL ± 38.8) (P = .7).

Gastric Volume
Under fasting conditions, mean gastric volume with the barostat was 225 mL ± 51 and with MR imaging was 331 mL ± 56. After glucagon infusion, the mean volume increased significantly to 561 mL ± 58 (250% ± 25, P < .001) with the barostat and to 720 mL ± 65 (218% ± 17, P < .001) with MR imaging. After erythromycin infusion, mean volume decreased to 149 mL ± 61 (66% ± 7 [not significant]) with the barostat and to 206 mL ± 66 (62% ± 6, P < .05) with MR imaging. The difference between volumes with the barostat and those with MR imaging was statistically significant (P < .05) (Table 1). Although different, mean intragastric volumes measured with the barostat and with MR imaging correlated significantly (P < .05). The effects of glucagon and erythromycin on gastric volume are shown in Figure 2.


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  		TABLE 1. Gastric Volume at Basal Fasting Condition and after Infusion of Glucagon and Erythromycin

 


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  		Figure 2. Semicoronal T1-weighted turbo field-echo MR images (3.5/10, flip angle of 25°) of the stomach under fasting conditions. A, Nonenhanced image. B, MR image obtained at 2 minutes after glucagon infusion. Relaxation of the stomach wall induced by glucagon resulted in a significant increase in stomach volume, which is clearly detectable. C, MR image obtained at 2 minutes after erythromycin infusion. Contraction of the stomach wall induced by erythromycin resulted in a significant decrease in stomach volume, which is clearly detectable.

 
Volume Waves and Contractions
Under basal conditions, the barostat detected 1.9 volume waves per minute ± 0.1. The frequency of volume waves measured with the barostat decreased significantly compared with basal conditions to 0.5 volume waves per minute ± 0.1 (P < .01) after glucagon infusion (Fig 3) and did not change after erythromycin infusion (1.7 volume waves per minute ± 0.2 [not significant]) (Fig 4). MR imaging was able to depict individual peristaltic contractions, whereas the barostat measured only volume waves. Two-dimensional dynamic MR images showed that where the barostat measured one volume wave, MR imaging was able to depict more than one contraction present in the stomach at that time. The frequency of individual peristaltic contractions compared with basal conditions measured with MR imaging decreased significantly from 2.6 contractions per minute ± 0.2 under fasting conditions to 1.4 contractions per minute ± 0.2 (P < .01) after glucagon infusion but did not change after erythromycin infusion (2.7 contractions per minute ± 0.2 [not significant ]) (Table 2). An example of a progressing gastric contraction is shown in Figure 5.



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  		Figure 3. After administration of glucagon, graph depicts dynamic alterations in intragastric volume (in milliliters) over time (seconds) as assessed with MR imaging (solid line) and the barostat (dashed line). Gastric volume increased and the number of volume waves decreased as measured with both MR imaging and the barostat.

 


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  		Figure 4. After administration of erythromycin, graph depicts dynamic alterations in intragastric volume (in milliliters) over time (seconds) as assessed with MR imaging (solid line) and the barostat (dashed line). Gastric volume decreased as measured with both MR imaging and the barostat.

 

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  		TABLE 2. Number of Volume Waves and Gastric Contractions at Basal Fasting Condition and after Infusion of Glucagon and Erythromycin

 


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  		Figure 5. Nonenhanced semicoronal T1-weighted turbo field-echo MR images (3.5/10, flip angle of 25°) of the stomach under fasting conditions depict peristaltic contraction (arrow) at (A) 0, (B) 2, and (C) 4, and (D) 6 seconds.

 
Changes in the volume wave pattern induced by glucagon and erythromycin measured with the barostat correlated significantly with those measured on MR images. The correlation coefficients of each dynamic measurement varied between 0.648 and 0.973. In all cases, the estimated slopes of the regression lines were significant (P < .01) according to standard tests for independent observations.


   Discussion
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
REFERENCES
 
Motor function of the proximal stomach is best characterized by means of adaptive relaxation (11,15,17), which consists of the ability to distend, for instance after meal ingestion, with only minimal changes in intragastric pressure. The proximal stomach not only has a storage function but also is involved in gastric emptying. Under fasting conditions, the proximal stomach exerts a sustained tonic contraction, which is maintained by cholinergic input. However, in addition to tonic contractions, phasic variations in bag volume are also seen, so-called phasic volume waves. These phasic volume waves have been described previously (5,11,15), but it is not known whether they represent isolated phasic or peristaltic contractions of the stomach.

The barostat has been used for measurements of proximal gastric motility (5) under physiologic and pathologic conditions (1–3). The barostat measures not only motor characteristics such as compliance but also enables evaluation of visceroperception (3,4) and of tonic and phasic changes in bag volume or pressure with set pressure and set volume, respectively (5). Findings in previous studies with the barostat technique show that visceroperception is increased in patients with functional dyspepsia. Postprandial relaxation was decreased in a subset of patients with symptoms of early satiety. On the basis of these observations, new concepts about the pathogenesis of dyspepsia have been introduced (1,18,19). These concepts rely on data obtained with barostat recordings.

Findings in the present study showed that MR imaging is a valid and noninvasive alternative to the barostat method for the assessment of proximal gastric motility and changes in gastric volume. In addition, MR images show that phasic volume waves assessed with the barostat are the result of superimposed individual peristaltic contractions of the stomach. Detection of individual peristaltic contractions is also a valuable feature of MR imaging. Thus, MR imaging allows the study of gastric physiology in a more detailed way than does the barostat method.

In the present study, MR imaging measurements were of the volume of the entire stomach, whereas barostat measurements were of the volume of only the proximal stomach. Moreover, with the barostat method, only air inside the intragastric barostat bag is measured, and any residual intragastric volume, such as air, is not able to be forced outside by the bag. This residual volume, however, is included in the MR imaging volume measurements. With MR imaging, we were not able to depict the intragastric barostat bag owing to the thin material that was used for the bag. This explains why the intragastric volume measured with MR imaging was larger than that measured with the barostat. This explanation was also suggested in a recent study by Bouras et al, who compared single photon emission computed tomography (SPECT) and barostat measurements of gastric responses to a meal (20). In their study, SPECT depicted the entire stomach and, therefore, allowed measurement of a larger gastric volume than can be measured with the barostat. MR imaging depicted the entire stomach, which is another valuable feature of MR imaging because the barostat was designed for study of only the proximal stomach.

Little is known about the effect of the barostat bag on proximal gastric motility. Findings in the present study do not allow exclusion of the fact that the barostat bag may interfere with gastric motility. Future studies to compare findings at simultaneous MR imaging and barostat recording with those at only MR imaging may reveal possible effects of the bag on gastric motility.

A certain degree of gastric distention (eg, with a contrast material–labeled meal) is needed to be able to analyze gastric motility with MR imaging. A meal instead of a barostat bag will provide the stomach with a physiologic stimulus and will enable further exploration of the pathophysiology of postprandial symptoms in patients with dyspepsia.

In conclusion, there is strong evidence to have the opinion that MR imaging provides accurate measurement of changes in gastric motility and of gastric volume; this evidence suggests that the noninvasive MR imaging method is valid. Real-time MR imaging provides the additional advantage of visualization and measurement of the entire stomach and of peristaltic contractions; these findings are not possible with the barostat. Although the MR imaging examination is more expensive than the barostat examination, it lacks invasiveness and patient discomfort. Real-time MR imaging of gastric motility and volume provides a noninvasive tool to assess gastric motor physiology and to evaluate patients with, for example, functional dyspepsia or diabetic gastroparesis.


   FOOTNOTES
 
Author contributions: Guarantor of integrity of entire study, P.K.; study concepts, I.M.d.Z.; study design, P.K.; literature research, I.M.d.Z.; clinical studies, B.M., P.K.; data acquisition, P.K., H.J.L.; data analysis/interpretation, I.M.d.Z.; statistical analysis, P.H.C.E.; manuscript preparation, I.M.d.Z.; manuscript definition of intellectual content, I.M.d.Z., B.M.; manuscript editing, revision/review, and final version approval, A.A.M.M., A.d.R., H.J.L.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 

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