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Gastric Emptying

PROCEDURE: GASTRIC EMPTYING STUDY - Adult and Pediatric
SECTION: GASTROINTESTINAL 4.3
ORIGINAL DATE: 4-24-00
DATE REVISED: 8-16-15

7-29-15 Will be adding 2 and 3 hr post ingestion images to the normal pediatric protocol…which already included a 4 hr delayed image. The new GE Processing program will need to be reviewed by Dr. Manske prior to use.

Indications: Evaluate patients with symptoms that suggest an alteration of Gastric Emptying and/or motility

Contraindications: Allergy to eggs (standard meal would need to be replaced.) Review case with Radiologist.

Exam time length: 4 ½ hours- study should be done in the morning because the gastric emptying time varies with the time of day.

Patient Preparation: 
General: Overnight fast or 6 hours, No barium studies within 2 days prior to scan

Referring physician should determine what medications are to be discontinued prior to GE study.(Medications not limited to those listed below).

  • Proton Pump Inhibitors, Usually stopped 12 hrs prior to test:
    • Aciphex=Rabeprazole
    • Nexium=Esomeprazole
    • Omeprazole=Omeprazole
    • Prevacid=Iansoprazole
    • Prevacid SoluTab=Iansoprazole
    • Prilosec=Omeprazole
    • Protonix=Pantoprazole
  • Prokinetic agents (enhance GE): Usually stopped 2 days prior to test: Metoclopramide (Reglan), Tegaserod (Zelnorm), Erythromycin, Domperidone (Motilium). 
  • Opiate analgesic (delay GE): Usually stopped 2 days prior to test: Demoral, Codeine, Morphine, Oxycontin, Percodan and Percocet. 
  • Anticholinergic antispasmodic agents: Usually stopped 2 days prior to test: Bentyl, Donnatal, Levsin, and Robinul.

Unless directed by physician, normal medications could be taken with a small sip of water up to 2 hrs prior to the exam.

Diabetic patients- Exam should be performed with the pt’s fasting glucose < 275 mg/dL. Patient to take 1/2 of normal insulin dose before they arrive.

Radiopharmaceutical & Dose:

  • 1 mCi , 99mTc Sulfur Colloid in yolk 
  • Place egg in heated pan, inject RpH into yolk. Fry the egg until firm on each side. Place between two pieces of buttered toast. Offer 1 package of Jelly and 300 ml of water with sanwich

Administration Technique: Oral

References:

  1. Dr. Aberger- Meeting data from “Comprehensive Review of Gastroenterology 2004 - “Greater than 10% retention in the stomach at 4-hours is abnormal.”
  2. Abell T, Camilleri M, et al. Consensus Recommendations for Gastric Empty Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Journal of Nuclear Medicine Technology 2008; 36:44-5
  3. Dr. Alan H. Maurer, DVD Teaching Program 2012 Clinical Nuclear Medicine- “Update on the Current Consensus Recommendations on Solid Meal GE Studies”. Release date: August 5, 2012.

WHOLE BODY ACQUISITION PARAMETERS (INFINIA):

Standard 1.5 hr image series: Select corresponding pt/exam and click ‘Acquire Patient’ button.

Accession Number: Selected with correct procedure

Time interval between tracer injection and imaging:

  • Document: Time it takes patient to eat meal (best within 10minutes), what percent of meal patient finishes (best with >50% completed) and most recent blood sugar. 
  • Patient eats radioactive egg sandwich and drinks 300 ml of water.

Detector settings H1/H2: ANT0/POST0, (label images ANT0, POST0,ANT1,POST1…for processing to run properly)

Camera/Collimator: LEAP/LEHR

Camera Mode: H

Start angle: 0

Body part: Abdomen

Patient position: Feet 1st, Supine

Energy: 140 KeV +/- 10%

FE Mode: Normal

Corrections: N/A

Matrix: 256 x 256

Zoom: 1

Mirror: N

Time per view: 120 sec, Acquire serial digital images, anterior and posterior, every 15 minutes

4 Hour Acquisition, if needed: Select patient data, que up ANT240/POST240 images

Screen Caps to make: Clinical Summary Page, Empty curve, if imaged-4hr Delay images

Send to FUJI: Clinical Summary Page, Empty curve, if imaged-4hr Delay images

Send to Dr. PET: N/A

-Recommendations on Solid Meal GE Studies”.  Release date: August 5, 2012.

Adult Gastric Empty

Standard processing of first 1.5 hours of imaging.

  1. Highlight patient name and make sure all data sets are there:
    • ANT/POST 0, 15, 30,45,60,75 and 90 min images
  2. Click ‘All Applications” tab. Click ↓ on Gastrointestinal processing section. Click ‘Gastric Empty’ container. Click ‘start’ button to begin processing.
  3. Program will load all of the ANTERIOR images. Follow instructions to draw a ROI around ANT view of stomach.
    • Click ‘Proceed’ button if satisfied with ROI.
    • Click ‘Redo’ button to redraw ROI.
  4. Program will load all of the POSTERIOR images. Follow instructions to draw a ROI around POST view of stomach.
    • Click ‘Proceed’ button if satisfied with ROI.
    • Click ‘Redo’ button to redraw ROI.
  5. The program will display each corresponding timed image set in the lower RT corner of the processing screen. Please follow the instructions to either Modify, Proceed or Re-do the ROI.
  6. If you are unsure of the true stomach size, please ask the reading Radiologist for assistance.
  7. When finished, take a screen capture of the displayed ‘Clinical Summary’.
  8. Click ‘File’ then ‘Save and Exit’.
  9. Process study and show images/graph to the Nuclear Medicine reader. That radiologist will determine if the patient needs to return for the 4hr image. Anything less than 85% Empty @ 90 min will necessitate a 4hr images per Dr. Hanratty. (Original article-Gastric Empty is 65% or less at the 1.5 hour point, patient returns for 4hr images).

To continue with 4 Hour images:

  1. Highlight patient name and make sure all data sets are there:
    • ANT/POST 0, 15, 30,45,60,75 and 90 min images
    • Gastric_EmptyV3 OT RESULTS SERIES
  2. Click ‘All Applications” tab. Click ↓ on User Applications section. Click ‘Gastgra3’container. Click ‘Start’ button to begin processing. 
  3. When screen stabilizes, take a screen capture of the displayed ‘Empty curve’
  4. Click ‘4hr delay’ Button. Program will load the Ant0/Post0+Ant240/Post240 images.
    Follow instructions to draw a ROI around Ant0 view of stomach.
    • Click ‘Proceed’ button if satisfied with ROI.
    • Click ‘Redo’ button to redraw ROI.
  5. Follow instructions to reposition ROI on Ant240 image, Proceed to continue.
  6. Steps 4 and 5 will be repeated with Post0 and Post240 images.
  7. When finished, take a screen capture of the displayed ‘4hr Delay images’.
  8. Click ‘File’ then ‘Quit’.

Pediatric Gastric Empty

Indications: Evaluate patients with symptoms that suggest an alteration of Gastric Emptying and/or motility

Contraindications: Allergy or unable to tolerate eggs (standard meal would need to be replaced w/ ENSURE-PLUS/ PEDIASURE + water).

Exam time length: 4 ½ hours- study should be done in the morning because the gastric emptying time varies with the time of day.

Patient Preparation (NOTE: Call patient day before exam):

  • General: Overnight fast or 6 hours, No barium studies within 2 days prior to scan
  • Referring physician should determine what medications are to be discontinued prior to GE study.(Medications not limited to those listed below). 
    • Proton Pump Inhibitors, Usually stopped 12 hrs. prior to test:
      • Aciphex=Rabeprazole
      • Nexium=Esomeprazole
      • Omeprazole=Omeprazole
      • Prevacid=Iansoprazole
      • Prevacid SoluTab=Iansoprazole
      • Prilosec=Omeprazole
      • Protonix=Pantoprazole
    • Prokinetic agents (enhance GE): Usually stopped 2 days prior to test: Metoclopramide (Reglan), Tegaserod (Zelnorm), Erythromycin, Domperidone (Motilium).
    • Opiate analgesic (delay GE): Usually stopped 2 days prior to test: Demoral, Codeine, Morphine, Oxycontin, Percodan and Percocet.
    • Anticholinergic antispasmodic agents: Usually stopped 2 days prior to test: Bentyl, Donnatal, Levsin, and Robinul.
  • Unless directed by physician, normal medications could be taken with a small sip of water up to 2 hrs prior to the exam.

  • Diabetic patients- Exam should be performed with the pt’s fasting glucose < 275 mg/dL. Patient to take ½ of normal insulin dose before they arrive. 
    *Questions to patient’s family: What is does patient eat and how much for typical feeding? Is feeding given over certain length of time (Tubes), How is patient fed?, Can he/she lay still for 2 min?

Radiopharmaceutical & Dose

  • 0.2 mCi – 1.1 mCi 99mTc Sulfur Colloid (or Nonabsorbable solid labeled with 99mTc -MAA) in small amount of meal. 
  • If egg, place egg in heated pan, inject RpH into yolk. Fry the egg until fully cooked. Serve with two pieces of buttered toast. Offer 300 ml of water with sandwich.
  • If non-egg, add RpH to small amount of meal and feed up to 5-10 min. Follow with rest of normal feeding. Complete remaining feeding in 60 mins. (Imaging can be started then continue rest of meal)

Administration Technique: Oral or Feeding tube

Standard 1.5hr image series, 2,3 and 4 hr: Select corresponding pt/exam and click ‘Acquire Patient’ button.

Accession Number: Selected with correct procedure

Time interval between tracer injection and imaging: Document: Time it takes patient to eat meal (best within 10-minutes), what percent of meal patient finishes (best with > 50% completed) and most recent blood sugar, if applicable.

Detector settings H1/H2: ANT0/POST0, (label images ANT0, POST0,ANT1,POST1…for processing to run properly)

Camera/Collimator: LEAP/ LEHR

Camera Mode: H

Start angle: 0

Body part: Abdomen

Patient position: Feet 1st, Supine

Energy: 140 KeV +/- 10%

FE Mode: Normal

Corrections: N/A

Matrix: 256 x 256

Zoom: 1

Mirror: N

Time per view: 120 sec, Acquire serial digital images, anterior and posterior, every 15 minutes. Continue with 2, 3, and 4 hr.

Screen Caps to make: Clinical Summary Page, Pediatric ROI/EF page

Send to FUJI: Clinical Summary Page, Pediatric ROI/EF page

Send to Dr. PET: N/A

Processing:

  • Process the first part as normal under the GE gastric empty program. 
  • The second part we use the GastGraph program which we had created. The first table shows the graph with our normals. For our typical patient we would select the second tab to get our 4 hour EF. We do/should not do this for our ped’s patients that follow Dr. Uko’s protocol. Instead we now select the third tab labeled “Pediatric Processing”. This will display our immediate, 1 hour, 2 hour, 3 hour, and 4 hour images. Just follow the instructions drawing and adjusting the ROI’s of the images. This will calculate out the EF’s. This program will not work without all the images, properly labeled. If you missed one of these images, you can rename and delete the results, or process them manually
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