WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:22.250 --> 00:24.690 the United States Army Medical Department Continuing 00:24.690 --> 00:25.940 education program. 00:27.330 --> 00:30.010 The following program was recorded at the fifth annual 00:30.010 --> 00:32.580 William Beaumont gastrointestinal symposium 00:32.810 --> 00:35.550 17 through 19 March 1976 00:35.560 --> 00:38.240 held at William Beaumont Army Medical Center in el 00:38.240 --> 00:39.300 paso texas. 00:41.370 --> 00:44.070 Gastric functions in peptic ulcer disease 00:45.030 --> 00:46.740 with Andre Dubois M.D. 00:47.760 --> 00:48.850 Uniformed services, 00:48.850 --> 00:51.640 University of Health Sciences and National Naval Medical 00:51.640 --> 00:53.470 Center Bethesda Maryland. 00:54.620 --> 00:57.110 I'm particularly pleased to present our 00:57.110 --> 00:58.800 results of this symposium. 00:59.780 --> 01:00.510 Indeed, 01:00.520 --> 01:03.350 William Beaumont was probably one of the first to have 01:03.350 --> 01:06.340 some insight into the fact that the two 01:06.340 --> 01:08.580 major functions of the stomach are 01:08.590 --> 01:10.760 secretion and controlled 01:10.770 --> 01:11.620 emptying. 01:12.860 --> 01:14.260 Since his time. 01:14.270 --> 01:17.040 Many studies have evaluated gastric secretion in 01:17.040 --> 01:19.610 various diseases and in particular 01:19.620 --> 01:21.800 injured in an ulcer disease. 01:22.840 --> 01:23.740 However, 01:23.890 --> 01:26.600 few attempts have been made to define the role of 01:26.600 --> 01:27.490 gastric emptying. 01:29.530 --> 01:32.260 We have developed a technique which permits simultaneous 01:32.260 --> 01:34.960 determination of the rates of gastric emptying and 01:34.960 --> 01:37.190 gastric secretion of water and 01:37.200 --> 01:39.740 ions in an intact stomach, 01:39.750 --> 01:42.530 both in the fasting state and in 01:42.530 --> 01:44.680 response to a physiologic stimulus. 01:44.690 --> 01:46.320 A liquid meal. 01:48.060 --> 01:50.870 We have examined the stomach functions in 01:50.870 --> 01:53.610 normal subjects and in patients with active 01:53.620 --> 01:54.860 duodenal ulcer. 01:54.870 --> 01:57.370 But before presenting the results that we have 01:57.370 --> 01:58.100 obtained, 01:58.110 --> 02:00.520 I would like to briefly describe the 02:00.520 --> 02:03.320 principle of the technique that was used. 02:04.570 --> 02:06.190 Could I have the first slide please, 02:09.380 --> 02:11.610 for a subject in the steady state. 02:11.620 --> 02:14.320 By definition the amount of a 02:14.320 --> 02:16.700 particular substance which is emptied from the 02:16.700 --> 02:19.370 stomach is exactly equal to the net 02:19.370 --> 02:21.800 amount that is secreted into the 02:21.800 --> 02:22.460 stomach. 02:23.510 --> 02:26.250 Thus any subject with gastric hyper 02:26.250 --> 02:29.190 secretion empties larger amount of fluid 02:29.190 --> 02:30.440 into his duodenum. 02:31.300 --> 02:34.010 Any subject with gastric hypo secretion 02:34.020 --> 02:36.970 empty smaller volume of fluid into his duodenum. 02:38.470 --> 02:41.070 Thus gastric secretary rates 02:41.080 --> 02:43.920 intra gastric volume and rates of gastric 02:43.920 --> 02:46.230 emptying were determined using a die 02:46.230 --> 02:49.040 delusion which is stigmatized in the 02:49.040 --> 02:50.260 next slide. 02:53.890 --> 02:56.790 As indicated in a a sample 02:56.790 --> 02:59.200 of the mixed gastric contents is aspirated, 03:00.000 --> 03:02.940 A strong in B10 seconds later 03:03.630 --> 03:06.630 a non amount of thinner red solution is added 03:06.640 --> 03:09.270 to the stomach as 03:09.270 --> 03:10.540 indicated in c. 03:11.690 --> 03:14.580 The Gastric Contents are mixed for the subsequent 50 03:14.580 --> 03:17.490 seconds that is 10-60 seconds after 03:17.500 --> 03:18.010 a. 03:19.530 --> 03:20.670 As shown in D. 03:21.210 --> 03:23.710 A second sample of the gastric contents is 03:23.710 --> 03:26.420 aspirated by 03:26.420 --> 03:28.810 measuring the concentration of thinner red in the gastric 03:28.810 --> 03:31.810 contents before and after the 03:31.810 --> 03:33.960 addition of a non amount of thinner red 03:33.960 --> 03:34.840 solution. 03:34.850 --> 03:37.670 It is possible to calculate the volume of 03:37.670 --> 03:40.480 water and the amount of thinner red present in the 03:40.480 --> 03:41.090 stomach. 03:42.910 --> 03:45.550 Since this maneuver is repeated at 10 minute 03:45.560 --> 03:47.800 intervals and since China red is not 03:47.800 --> 03:48.640 absorbed, 03:48.650 --> 03:49.650 absorbed. 03:49.660 --> 03:52.270 Secreted or degraded by the stomach, 03:52.280 --> 03:55.240 one can determine the amount of thinner red 03:55.250 --> 03:57.970 leaving the stomach during the given 10 minute 03:57.980 --> 03:58.660 interval. 04:00.270 --> 04:01.670 Could I have the next slide please 04:04.950 --> 04:07.860 by dividing the amount of thinner red indicated by 04:07.860 --> 04:08.590 PSP. 04:08.590 --> 04:10.910 On this slide emptied per unit 04:10.920 --> 04:13.650 time by the amount of fine already 04:13.660 --> 04:15.840 present in the stomach. 04:15.850 --> 04:18.480 One can calculate the fractional rate of 04:18.480 --> 04:21.270 emptying for finer red which is 04:21.270 --> 04:22.660 illustrated here by G. 04:22.670 --> 04:23.120 E. 04:23.130 --> 04:26.040 In red fractional rate of 04:26.040 --> 04:28.240 emptying is the fraction of the gastric 04:28.240 --> 04:31.200 contents which leaves the stomach per unit 04:31.200 --> 04:31.760 time. 04:33.840 --> 04:36.150 Since the gastric contents are homogeneous li 04:36.150 --> 04:39.140 mixed fractional rate of emptying for any other 04:39.140 --> 04:41.520 substance present in the gastric contents 04:41.530 --> 04:42.930 such as water, 04:42.940 --> 04:44.150 hydrogen ion, 04:44.160 --> 04:47.090 sodium etcetera will be 04:47.090 --> 04:49.450 the same as the fractional rate of emptying for 04:49.450 --> 04:51.830 PSP finna red indicated by G. 04:51.840 --> 04:52.310 E. 04:54.060 --> 04:56.530 Thus knowing the amount of any given 04:56.530 --> 04:58.220 substance present in the stomach. 04:58.220 --> 04:58.800 For example, 04:58.800 --> 05:01.610 water indicated by the blue circle 05:01.620 --> 05:02.670 W. 05:02.680 --> 05:03.370 And G. 05:03.380 --> 05:03.940 E. 05:03.950 --> 05:06.730 The fractional rate of emptying determined from final read 05:06.730 --> 05:07.560 data, 05:07.570 --> 05:10.510 one can calculate the net rate at which 05:10.510 --> 05:12.840 water is being secreted into the stomach, 05:12.850 --> 05:14.970 and that rate is illustrated here by G. 05:14.970 --> 05:15.550 W. 05:15.560 --> 05:16.260 In blue. 05:19.020 --> 05:21.470 We perform those measurements in six normal 05:21.470 --> 05:24.380 subjects and 11 patients with active 05:24.390 --> 05:25.470 duodenal ulcer. 05:27.230 --> 05:28.580 Could I have the next slide please? 05:30.350 --> 05:33.290 Fasting steady state value for the rate of water. 05:33.290 --> 05:36.060 See creation expressed in milliliters per minute 05:36.070 --> 05:38.530 intra gastric volume expressed in milli 05:38.530 --> 05:40.890 liter and fractional rate of emptying, 05:40.890 --> 05:43.740 expressed in percent of the gastric contents per 05:43.740 --> 05:44.410 minute. 05:44.420 --> 05:47.270 Where are shown on this slide for normal 05:47.270 --> 05:49.810 subjects and duodenal ulcer patients 05:51.240 --> 05:53.230 In normal subjects in white. 05:53.240 --> 05:56.110 The rate of water secretion indicated 05:56.110 --> 05:58.980 by the arrow pointing toward the circle is 05:58.980 --> 06:01.160 0.9 ml per minute. 06:01.890 --> 06:04.560 Intra gastric volume is 24 present 06:04.560 --> 06:06.560 minus five mL milliliters 06:06.600 --> 06:09.140 fractional rate of emptying 06:09.150 --> 06:12.140 indicated by the arrow pointing away from 06:12.140 --> 06:14.560 the circle is 4% per 06:14.560 --> 06:15.230 minute. 06:15.240 --> 06:18.060 The vertical lines represent one 06:18.060 --> 06:19.410 standard error of the mean. 06:21.040 --> 06:24.010 In general patients in red rate 06:24.010 --> 06:26.760 of water secretion is 2.2 ml 06:26.770 --> 06:29.220 significantly higher than in normal 06:29.230 --> 06:32.060 intra gastric volume was 20 present 06:32.060 --> 06:33.210 -5. 06:33.220 --> 06:35.940 Not significantly different from normal 06:35.950 --> 06:38.660 and fractional rate of emptying was 14% 06:38.670 --> 06:40.980 against significantly higher than in 06:40.980 --> 06:41.860 normals. 06:43.170 --> 06:43.790 Thus, 06:43.800 --> 06:46.590 the fact that fasting intra gastric volume 06:46.600 --> 06:49.440 is not increased in the ordinary cell patients 06:49.450 --> 06:52.380 results from the fact that the increase 06:52.390 --> 06:55.090 of water secretion is matched by a 06:55.090 --> 06:57.610 concomitant increase in fractional rate of 06:57.610 --> 06:58.130 empty. 07:01.890 --> 07:04.830 The next slide illustrates 07:04.840 --> 07:07.420 the rate of hydrogen ions creation on the 07:07.420 --> 07:09.880 vertical axis axis over 07:09.880 --> 07:12.450 time and the original axis 07:13.890 --> 07:16.440 during fasting assets. 07:16.440 --> 07:19.150 A creation as Secretary rate has 07:19.150 --> 07:21.720 increased fivefold in journalism 07:21.730 --> 07:24.690 patients in red as compared to normal 07:24.690 --> 07:26.100 subjects in white. 07:27.860 --> 07:30.040 This observation is in agreement with Dr. 07:30.040 --> 07:32.400 Hirsch of its data presented two days ago. 07:34.290 --> 07:36.870 In addition after administration of a 07:36.880 --> 07:39.490 250 millimeter watermill 07:39.500 --> 07:41.410 indicated by the blue bars. 07:41.420 --> 07:44.020 The pattern of the asset Secretary 07:44.020 --> 07:46.870 response is markedly different in the two 07:46.870 --> 07:47.680 groups 07:49.590 --> 07:50.470 enormous. 07:50.780 --> 07:53.360 The white solid line Acid 07:53.360 --> 07:56.020 secretion increases slowly to reach a peak 07:56.030 --> 07:58.860 between 20 and 30 minutes and to 07:58.860 --> 08:00.500 subsequently decrease. 08:01.850 --> 08:03.960 In contrast in Duodenal ulcer 08:03.960 --> 08:06.580 patients indicated by the red 08:06.580 --> 08:09.140 dashed line assets secretary 08:09.140 --> 08:12.030 response is immediate but lasts only 20 08:12.030 --> 08:12.640 minutes. 08:14.370 --> 08:17.060 This Secretary response is significant for all 08:17.060 --> 08:19.830 duodenal ulcer patients and the large standard 08:19.840 --> 08:22.630 error is related to the fact that 08:22.640 --> 08:25.500 individual variation occurs and 08:25.510 --> 08:27.180 throughout the studies 08:29.440 --> 08:32.350 Thus also rates of acid secretion 08:32.360 --> 08:34.800 are not significantly different from 08:34.810 --> 08:37.640 20 to 50 minutes in the 08:37.640 --> 08:40.440 two groups during a loser 08:40.440 --> 08:43.300 patients differ markedly from normals in terms of 08:43.310 --> 08:46.260 fasting secretary rates as 08:46.260 --> 08:48.840 well as early and late response to the middle. 08:50.140 --> 08:51.500 Could I have the next slide please? 08:54.170 --> 08:56.820 The rates of what the secretion are presented here on the 08:56.820 --> 08:59.780 vertical axis over time and the original 08:59.780 --> 09:02.710 axis has previously shown 09:02.720 --> 09:05.220 fasting rate of water secretion is 09:05.230 --> 09:08.010 increased in the ordinary patients as 09:08.010 --> 09:10.130 indicated by the red broken line. 09:11.210 --> 09:12.120 However, 09:12.130 --> 09:15.110 following the meal indicated again on this slide by the blue 09:15.110 --> 09:15.610 bars, 09:16.240 --> 09:18.890 the two groups do not differ significantly. 09:20.010 --> 09:20.650 Thus, 09:20.660 --> 09:23.430 in contrast to the asset secretary response to the 09:23.430 --> 09:23.960 middle. 09:23.970 --> 09:26.670 What a Secretary response 09:27.720 --> 09:30.290 is not different in journalists er patients when 09:30.290 --> 09:31.620 compared to normals, 09:33.550 --> 09:36.280 the combination of markedly increased acid 09:36.280 --> 09:39.130 output and normal or slightly elevated 09:39.130 --> 09:42.060 water secretion results in the production of a 09:42.060 --> 09:43.850 more acidic gastric juice, 09:43.860 --> 09:46.790 both during fasting and immediately after the 09:46.790 --> 09:47.280 meal. 09:49.160 --> 09:50.490 Could I have the next slide please. 09:53.110 --> 09:55.670 Intra gastric volume is presented here on the vertical 09:55.670 --> 09:56.960 axis over time 09:58.310 --> 09:59.480 during fasting. 09:59.680 --> 10:02.350 As seen previously Intra gastric 10:02.350 --> 10:04.730 volume is similar in the two groups. 10:05.740 --> 10:06.660 However, 10:06.670 --> 10:08.190 after administration of the meal, 10:08.190 --> 10:10.100 indicated again by the blue bars, 10:10.110 --> 10:12.940 two distinct patterns of response emerge 10:14.230 --> 10:15.500 In normal subjects. 10:15.510 --> 10:18.240 The wide solid line volume remains 10:18.240 --> 10:20.340 stable during the initial 10 minutes 10:20.350 --> 10:23.130 subsequently decreases and 10:23.130 --> 10:25.830 returns to fasting value by 35 minutes, 10:27.520 --> 10:29.230 Enduring elusive patients, 10:29.240 --> 10:31.980 the red broken line intra gastric 10:31.980 --> 10:34.600 volume decreases rapidly immediately 10:34.600 --> 10:37.310 following the meal and returns to fasting volume by 10:37.310 --> 10:38.680 15 minutes. 10:40.200 --> 10:42.850 Thus the kinetics of intra gastric volume 10:42.850 --> 10:45.710 Following a liquid meal is profoundly altered in 10:45.710 --> 10:47.210 duodenal ulcer patients, 10:47.220 --> 10:50.190 resulting in a marked shortening of the time during 10:50.190 --> 10:53.090 which the meal is present in the stomach and buffers 10:53.100 --> 10:54.340 its contents. 10:56.240 --> 10:58.140 Since we have seen in the previous slide, 10:58.140 --> 11:01.120 that the pattern of water secretion of what a 11:01.120 --> 11:04.060 secretary response to the meal is not altered. 11:04.140 --> 11:07.000 This difference must result from abnormal 11:07.010 --> 11:09.800 emptying rate which is shown in the next slide. 11:13.360 --> 11:16.290 The fraction of meat remaining in the stomach is flooded here over 11:16.290 --> 11:16.900 time. 11:18.060 --> 11:20.060 At the end of the administration of the mill, 11:20.070 --> 11:22.270 only 40% remaining. 11:22.270 --> 11:25.230 The remaining the stomach and ordinary serve patients as 11:25.230 --> 11:27.400 indicated in red as compared to 11:27.400 --> 11:29.940 50% in normal subjects in 11:29.940 --> 11:30.480 white. 11:31.640 --> 11:34.210 This difference is even more dramatic from 11:34.210 --> 11:35.740 5 to 10 minutes, 11:35.750 --> 11:38.580 as indicated by the slope of the decline 11:38.610 --> 11:40.610 of the intra gastric contents. 11:41.990 --> 11:44.740 This initial emptying is much faster in 11:45.330 --> 11:47.510 patients than in normal subjects. 11:49.550 --> 11:52.070 The slope of the decline of the intra gastric meal 11:52.080 --> 11:55.030 presented on this slide is a graphic representation of the 11:55.030 --> 11:56.400 fractional rate of emptying, 11:56.410 --> 11:58.390 which is shown in the next slide, 12:01.090 --> 12:03.760 fractional rate of emptying is presented here on the 12:03.760 --> 12:06.680 vertical axis over time as 12:06.680 --> 12:09.180 seen before fasting fractional rate of 12:09.180 --> 12:11.980 emptying is significantly increased in the ordinary 12:11.980 --> 12:12.920 serve patients. 12:14.080 --> 12:15.080 In addition, 12:15.090 --> 12:17.430 as could be expected from the previous slide, 12:17.440 --> 12:20.310 it is also significantly increased during the 1st 12:20.320 --> 12:23.310 20 minutes following administration of the meal. 12:23.320 --> 12:26.120 And this difference is particularly dramatic 12:26.120 --> 12:27.690 from 5 to 10 minutes. 12:29.190 --> 12:30.030 Subsequently, 12:30.330 --> 12:33.020 no significant difference is observed between the two 12:33.020 --> 12:33.670 groups. 12:35.500 --> 12:38.390 This fact is related to the situation 12:38.400 --> 12:41.070 in which normal the studded line in 12:41.070 --> 12:43.950 white in normal 12:43.950 --> 12:44.420 story, 12:44.650 --> 12:45.950 the solid light in wine. 12:46.740 --> 12:49.420 The fractional rate of emptying remains elevated 12:49.420 --> 12:52.250 from 10 to 15 minutes after the meal 12:52.260 --> 12:54.960 while it has returned to fasting value by 12:54.970 --> 12:56.330 20 minutes in Jordan. 12:56.330 --> 12:57.530 11 patients. 12:58.890 --> 12:59.480 Thus, 12:59.490 --> 13:02.390 those patients display an increased fractionally rate of 13:02.390 --> 13:05.330 emptying both during fasting and immediately after 13:05.330 --> 13:05.970 the meal, 13:05.980 --> 13:08.820 but the response to the middle fades away very rapidly. 13:10.040 --> 13:13.030 This combination of increased gastric emptying 13:13.040 --> 13:15.670 and increased acid secretion 13:15.680 --> 13:18.680 results in journalism of patients having 13:18.690 --> 13:21.630 a larger amount of a more acidic jews emptied 13:21.630 --> 13:22.730 into the duodenum, 13:22.740 --> 13:25.010 which is demonstrated in the next slide. 13:29.550 --> 13:32.180 The rate of hydrogen ion emptying plotted here on the 13:32.180 --> 13:34.010 vertical axis against time, 13:34.020 --> 13:36.560 is increased in patients. 13:36.570 --> 13:39.200 And this increase is particularly dramatic during 13:39.200 --> 13:41.830 fasting and during the 10 minutes following the 13:41.830 --> 13:42.420 meal. 13:43.840 --> 13:46.680 It is only during the 40 subsequent minutes 13:46.690 --> 13:49.480 that normal subjects are able to attain similar 13:49.480 --> 13:50.670 levels of accident. 13:50.670 --> 13:53.470 Thing This effect of the 13:53.470 --> 13:56.320 meal is short lasting in normal subjects and by 50 13:56.320 --> 13:59.170 minutes rate of acid emptying has returned to 13:59.170 --> 14:02.070 fasting value against significantly lower 14:02.070 --> 14:03.840 than in the ordinary serve patients 14:04.940 --> 14:06.380 could I have the last slide please. 14:08.910 --> 14:09.870 In conclusion, 14:09.880 --> 14:12.030 major differences were found between 14:12.590 --> 14:14.390 patients and normal subjects 14:15.790 --> 14:16.820 during fasting, 14:16.830 --> 14:19.500 Both fractional rate of emptying and rate of acid 14:19.500 --> 14:21.110 secretion are increased, 14:21.120 --> 14:23.980 which results in a dramatic rise of the rate at 14:23.980 --> 14:25.930 which acid enters the duodenum. 14:27.700 --> 14:30.610 Middle stimulation provokes a premature increase in 14:30.610 --> 14:33.350 emptying and acid secretion and a more 14:33.350 --> 14:35.560 rapid return to fasting level. 14:35.570 --> 14:36.230 Slide up, 14:36.230 --> 14:36.850 please. 14:37.950 --> 14:40.720 In addition the increased emptying rate 14:40.720 --> 14:43.460 following meal stimulation decreases the buffering 14:43.460 --> 14:44.550 effect of the meal. 14:45.760 --> 14:48.320 It also prolongs the time during which Jordan al 14:48.320 --> 14:50.890 mucosa is exposed to the potential damaging 14:50.890 --> 14:53.310 effect of a more acidic jews. 14:53.320 --> 14:55.090 And we believe that this difference. 14:55.100 --> 14:57.330 These differences are relevant to the 14:57.330 --> 14:58.980 pathogenesis of the disease. 14:58.990 --> 14:59.760 Thank you. 15:01.170 --> 15:03.960 This program has been produced through the mobile facilities of the 15:03.960 --> 15:06.830 Television Branch Health Sciences Media Division, 15:07.090 --> 15:08.720 the Academy of Health Sciences of the U. 15:08.720 --> 15:08.910 S. 15:08.910 --> 15:09.330 Army, 15:09.450 --> 15:10.890 Fort Sam Houston texas.