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.