the United States Army Medical Department Continuing
education program.
The following program was recorded at the fifth annual
William Beaumont gastrointestinal symposium
17 through 19 March 1976
held at William Beaumont Army Medical Center in el
paso texas.
Gastric functions in peptic ulcer disease
with Andre Dubois M.D.
Uniformed services,
University of Health Sciences and National Naval Medical
Center Bethesda Maryland.
I'm particularly pleased to present our
results of this symposium.
Indeed,
William Beaumont was probably one of the first to have
some insight into the fact that the two
major functions of the stomach are
secretion and controlled
emptying.
Since his time.
Many studies have evaluated gastric secretion in
various diseases and in particular
injured in an ulcer disease.
However,
few attempts have been made to define the role of
gastric emptying.
We have developed a technique which permits simultaneous
determination of the rates of gastric emptying and
gastric secretion of water and
ions in an intact stomach,
both in the fasting state and in
response to a physiologic stimulus.
A liquid meal.
We have examined the stomach functions in
normal subjects and in patients with active
duodenal ulcer.
But before presenting the results that we have
obtained,
I would like to briefly describe the
principle of the technique that was used.
Could I have the first slide please,
for a subject in the steady state.
By definition the amount of a
particular substance which is emptied from the
stomach is exactly equal to the net
amount that is secreted into the
stomach.
Thus any subject with gastric hyper
secretion empties larger amount of fluid
into his duodenum.
Any subject with gastric hypo secretion
empty smaller volume of fluid into his duodenum.
Thus gastric secretary rates
intra gastric volume and rates of gastric
emptying were determined using a die
delusion which is stigmatized in the
next slide.
As indicated in a a sample
of the mixed gastric contents is aspirated,
A strong in B10 seconds later
a non amount of thinner red solution is added
to the stomach as
indicated in c.
The Gastric Contents are mixed for the subsequent 50
seconds that is 10-60 seconds after
a.
As shown in D.
A second sample of the gastric contents is
aspirated by
measuring the concentration of thinner red in the gastric
contents before and after the
addition of a non amount of thinner red
solution.
It is possible to calculate the volume of
water and the amount of thinner red present in the
stomach.
Since this maneuver is repeated at 10 minute
intervals and since China red is not
absorbed,
absorbed.
Secreted or degraded by the stomach,
one can determine the amount of thinner red
leaving the stomach during the given 10 minute
interval.
Could I have the next slide please
by dividing the amount of thinner red indicated by
PSP.
On this slide emptied per unit
time by the amount of fine already
present in the stomach.
One can calculate the fractional rate of
emptying for finer red which is
illustrated here by G.
E.
In red fractional rate of
emptying is the fraction of the gastric
contents which leaves the stomach per unit
time.
Since the gastric contents are homogeneous li
mixed fractional rate of emptying for any other
substance present in the gastric contents
such as water,
hydrogen ion,
sodium etcetera will be
the same as the fractional rate of emptying for
PSP finna red indicated by G.
E.
Thus knowing the amount of any given
substance present in the stomach.
For example,
water indicated by the blue circle
W.
And G.
E.
The fractional rate of emptying determined from final read
data,
one can calculate the net rate at which
water is being secreted into the stomach,
and that rate is illustrated here by G.
W.
In blue.
We perform those measurements in six normal
subjects and 11 patients with active
duodenal ulcer.
Could I have the next slide please?
Fasting steady state value for the rate of water.
See creation expressed in milliliters per minute
intra gastric volume expressed in milli
liter and fractional rate of emptying,
expressed in percent of the gastric contents per
minute.
Where are shown on this slide for normal
subjects and duodenal ulcer patients
In normal subjects in white.
The rate of water secretion indicated
by the arrow pointing toward the circle is
0.9 ml per minute.
Intra gastric volume is 24 present
minus five mL milliliters
fractional rate of emptying
indicated by the arrow pointing away from
the circle is 4% per
minute.
The vertical lines represent one
standard error of the mean.
In general patients in red rate
of water secretion is 2.2 ml
significantly higher than in normal
intra gastric volume was 20 present
-5.
Not significantly different from normal
and fractional rate of emptying was 14%
against significantly higher than in
normals.
Thus,
the fact that fasting intra gastric volume
is not increased in the ordinary cell patients
results from the fact that the increase
of water secretion is matched by a
concomitant increase in fractional rate of
empty.
The next slide illustrates
the rate of hydrogen ions creation on the
vertical axis axis over
time and the original axis
during fasting assets.
A creation as Secretary rate has
increased fivefold in journalism
patients in red as compared to normal
subjects in white.
This observation is in agreement with Dr.
Hirsch of its data presented two days ago.
In addition after administration of a
250 millimeter watermill
indicated by the blue bars.
The pattern of the asset Secretary
response is markedly different in the two
groups
enormous.
The white solid line Acid
secretion increases slowly to reach a peak
between 20 and 30 minutes and to
subsequently decrease.
In contrast in Duodenal ulcer
patients indicated by the red
dashed line assets secretary
response is immediate but lasts only 20
minutes.
This Secretary response is significant for all
duodenal ulcer patients and the large standard
error is related to the fact that
individual variation occurs and
throughout the studies
Thus also rates of acid secretion
are not significantly different from
20 to 50 minutes in the
two groups during a loser
patients differ markedly from normals in terms of
fasting secretary rates as
well as early and late response to the middle.
Could I have the next slide please?
The rates of what the secretion are presented here on the
vertical axis over time and the original
axis has previously shown
fasting rate of water secretion is
increased in the ordinary patients as
indicated by the red broken line.
However,
following the meal indicated again on this slide by the blue
bars,
the two groups do not differ significantly.
Thus,
in contrast to the asset secretary response to the
middle.
What a Secretary response
is not different in journalists er patients when
compared to normals,
the combination of markedly increased acid
output and normal or slightly elevated
water secretion results in the production of a
more acidic gastric juice,
both during fasting and immediately after the
meal.
Could I have the next slide please.
Intra gastric volume is presented here on the vertical
axis over time
during fasting.
As seen previously Intra gastric
volume is similar in the two groups.
However,
after administration of the meal,
indicated again by the blue bars,
two distinct patterns of response emerge
In normal subjects.
The wide solid line volume remains
stable during the initial 10 minutes
subsequently decreases and
returns to fasting value by 35 minutes,
Enduring elusive patients,
the red broken line intra gastric
volume decreases rapidly immediately
following the meal and returns to fasting volume by
15 minutes.
Thus the kinetics of intra gastric volume
Following a liquid meal is profoundly altered in
duodenal ulcer patients,
resulting in a marked shortening of the time during
which the meal is present in the stomach and buffers
its contents.
Since we have seen in the previous slide,
that the pattern of water secretion of what a
secretary response to the meal is not altered.
This difference must result from abnormal
emptying rate which is shown in the next slide.
The fraction of meat remaining in the stomach is flooded here over
time.
At the end of the administration of the mill,
only 40% remaining.
The remaining the stomach and ordinary serve patients as
indicated in red as compared to
50% in normal subjects in
white.
This difference is even more dramatic from
5 to 10 minutes,
as indicated by the slope of the decline
of the intra gastric contents.
This initial emptying is much faster in
patients than in normal subjects.
The slope of the decline of the intra gastric meal
presented on this slide is a graphic representation of the
fractional rate of emptying,
which is shown in the next slide,
fractional rate of emptying is presented here on the
vertical axis over time as
seen before fasting fractional rate of
emptying is significantly increased in the ordinary
serve patients.
In addition,
as could be expected from the previous slide,
it is also significantly increased during the 1st
20 minutes following administration of the meal.
And this difference is particularly dramatic
from 5 to 10 minutes.
Subsequently,
no significant difference is observed between the two
groups.
This fact is related to the situation
in which normal the studded line in
white in normal
story,
the solid light in wine.
The fractional rate of emptying remains elevated
from 10 to 15 minutes after the meal
while it has returned to fasting value by
20 minutes in Jordan.
11 patients.
Thus,
those patients display an increased fractionally rate of
emptying both during fasting and immediately after
the meal,
but the response to the middle fades away very rapidly.
This combination of increased gastric emptying
and increased acid secretion
results in journalism of patients having
a larger amount of a more acidic jews emptied
into the duodenum,
which is demonstrated in the next slide.
The rate of hydrogen ion emptying plotted here on the
vertical axis against time,
is increased in patients.
And this increase is particularly dramatic during
fasting and during the 10 minutes following the
meal.
It is only during the 40 subsequent minutes
that normal subjects are able to attain similar
levels of accident.
Thing This effect of the
meal is short lasting in normal subjects and by 50
minutes rate of acid emptying has returned to
fasting value against significantly lower
than in the ordinary serve patients
could I have the last slide please.
In conclusion,
major differences were found between
patients and normal subjects
during fasting,
Both fractional rate of emptying and rate of acid
secretion are increased,
which results in a dramatic rise of the rate at
which acid enters the duodenum.
Middle stimulation provokes a premature increase in
emptying and acid secretion and a more
rapid return to fasting level.
Slide up,
please.
In addition the increased emptying rate
following meal stimulation decreases the buffering
effect of the meal.
It also prolongs the time during which Jordan al
mucosa is exposed to the potential damaging
effect of a more acidic jews.
And we believe that this difference.
These differences are relevant to the
pathogenesis of the disease.
Thank you.
This program has been produced through the mobile facilities of the
Television Branch Health Sciences Media Division,
the Academy of Health Sciences of the U.
S.
Army,
Fort Sam Houston texas.