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Dyspeptic Symptoms and Delayed Gastric Emptying of Solids in Patients WithInactive Crohn's DiseaseAna Carolina M. Nóbrega, Bruno Roberto D. Ferreira, Graciela J. Oliveira, Miguel Souza,Armênio A. Santos, Luiz E. Troncon, Lúcia Libanês B. Braga, Marcellus H. Souza

Background: Patients with Crohn's disease (CD) have been shown to present dyspepticsymptoms more frequently than the general population. Some of these symptoms could berelated to some degree of motility disorder. There is evidence that impaired gastric emptyingmay occur in a subset of patients with CD without active gastroduodenal disease or gastrointe-stinal obstruction. Aims: To investigate whether gastric emptying of solids in patients withinactive CD is delayed and to determine the relationships between gastric emptying anddyspeptic symptoms in this condition. Methods: Twenty six patients (12 men, 14 women;mean age 43 years, range 26-67) with inactive Crohn's disease, as defined by a Crohn'sDisease Activity Index (CDAI) < 150, underwent a gastric emptying test by breath test using13C octanoic acid coupled to a solid meal. At the same time, they answered a validatedquestionnaire (The Porto Alegre Dyspeptic Symptoms Questionnaire - PADYQ) to assessdyspeptic symptoms. Patients with scores > 6 were considered to have dyspepsia. The controlgroup was composed by 16 healthy volunteers age and sex matched (7 men, 9 women;mean age 42 years, range 19-73 years). Results: Patients with CD had both t 1/2 (192.0 ±7.7 min) and t lag (127.7 ± 4.5 min) significantly longer (p<0.05) than controls (t 1/2 169.4± 8.8 min; t lag 110.6 ± 6.9 min). CD patients with dyspepsia had significantly (p<0.05)delayed gastric emptying (t 1/2 : 203.2 ± 9.9 min) when compared to patients withoutdyspeptic symptoms (t 1/2: 176.6 ± 11.1 min). When the pattern of individual symptomswas analyzed, only vomiting was significantly associated with delayed gastric emptying(p<0.05). Moreover, scores for vomiting were significantly correlated with the degree ofgastric emptying delay. There was no difference between the subgroups of patients in respectto gender, CDAI scores, disease location and clinical behavior (obstructive/obstructive) orprevious gastrointestinal surgery. Conclusion: Patients with inactive Crohn's disease haddelayed gastric emptying for solids when compared with healthy individuals. Delayed empty-ing seems to be associated with the presence of dyspeptic symptoms in these patients. Aclosest association was found between delayed gastric emptying and vomiting, even withoutany evidence of gastrointestinal obstruction. Financial support: CNPq- Brazil, CAPES- Brazil.

Tu1376

Investigation of Small Intestinal Fungal Overgrowth (SIFO) and/or SmallIntestinal Bacterial Overgrowth (SIBO) in Chronic, UnexplainedGastrointestinal SymptomsCarolyn Jacobs, Jessica Valestin, Ashok Attaluri, Gideon K. Zamba, Satish S. Rao

Introduction: Unexplained gastrointestinal symptoms are common and many of thesepatients are labeled as having a functional gastrointestinal disorder. Without clear etiology,patients undergo repeated tests that pose a large health care burden and affect their qualityof life. Although SIBO is well recognized, whether SIFO or mixed infection with SIBOcontributes to persistent gastrointestinal symptoms is unknown. Aim: To investigate presenceof SIFO or SIBO in this patient population. Methods: Patients with chronic gastrointestinalcomplaints and negative GI evaluations (endoscopy, blood tests, CAT scan) and no priorgastric or small intestinal surgery were evaluated. All patients underwent distal duodenalaspirate and culture for aerobic, anerobic and fungal organisms using aseptic techniqueusing a Liguory nasobiliary catheter. Identification of fungal organisms in culture was consid-ered positive for SIFO;bacterial concentrations ≥10 3 cfu/mL was defined as positive forSIBO and presence of both as mixed SIFO/SIBO. Symptoms were recorded on validatedscale and its severity scored on a Likert scale (0-3). Results: 124 (M/F=38/86; ages 17-82)subjects were evaluated; 77/124 (62%) had a positive culture for overgrowth. Among these,23/124 (19%) had SIFO, 23/124 (19%) had mixed SIFO/SIBO and 31/124 (25%) had SIBO.All patients with SIFO grew candida. 36 subjects with SIBO had aerobic flora (enterococcussp, streptococcus sp, etc), and 3 had anaerobic flora (bacteroides sp). Prevalence of symptomsand its severity are detailed in table. Nausea was more prevalent and severe in SIFO whereasabdominal pain and gas were more common in SIBO. Symptoms do not predict presence/absence of infection. Conclusion: SIFO and mixed SIFO/SIBO overgrowth is common andoccurs in three of five individuals with chronic, persistent GI symptoms in tertiary carepractice. Duodenal aspirate/culture can facilitate diagnosis. Our findings reveal that SIFO,either alone or together with SIBO, may be one more important and hitherto unrecognizedpiece of the puzzle that could explain chronic refractory gastrointestinal symptoms.

Tu1377

Comparison of Continuous Breath Test (CBT) Versus Gastric Scintigraphy(GS) for Gastric Emptying Rate (GER) Measurement in Healthy and DyspepticSubjectsRam Dickman, Tatyna Zilper, Adam Steinmetz, Lea Pakanaev, Yishai Ron, HannaBernstine, David Groshar, Yaron Niv, Haim Shirin

Background: Gastric emptying rate (GER) measurement by gastric scintigraphy (GS) isconsidered the gold standard. GS imposes a low but measurable radiation exposure. GERmeasurement by continuous breath test (CBT) may offer an alternative to GS. However,

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there is still little information about normative data of the CBT method. Aims: To determinenormative data for GS and CBT and to compare an automated, real-time, non-radioactive,CBT method versus GS for GER measurement in healthy controls and dyspeptic patients.Methods: A standard meal of 250 Kcal, double labeled both with 1 mCi of Tc-99m colloidand 100μg of non-radioactive C-13 octanoic acid was administered to 22 patients withdyspepsia and to 20 healthy controls. Simultaneous, 4 hours GER measurement by sequentialGS and CBT was performed on all subjects. The CBT (BreathID, Exalenz Bioscience, Israel),automatically and continuously collects and analyzes breath samples with real time displays.Gastric emptying halftime (T1/2), one and two hour retention percents obtained by GS andCBT were compared by linear regression analysis. Consequently, we were able to determinethe normative data of CBT for gastric emptying halftime (T1/2) and for one and two hourretention. GS and CBT were compared by kappa test of agreement for normal/abnormalresults. Results: Mean age, M/F ratio and mean BMI (kg/m2) were: 51.5 ± 15.12 yrs, 20/22 and 25, respectively. The upper limit of normal gastric emptying half-time (T1/2) was100 minutes by GS and of 175 minutes by CBT, respectively. Linear correlations (r values)for CBT and GS were 0.63, 0.62 and 0.41 for T1/2, one and two hours of gastric retention,respectively. The kappa test for agreement of CBT and GS (normal/abnormal) T1/2 was0.73. Conclusion: The novel CBT may be suitable as an alternative method for on-line GERevaluation, in a simple, office based and non-radioactive setting. A larger study will beneeded to show that the CBT can be used as a standard of care to replace GS.

Tu1378

Effect of Peppermint Oil on Intragastric Pressure During Fasting andIntragastric Infusion of a Liquid Meal in HealthAthanasios A. Papathanasopoulos, Alessandra Rotondo, Pieter Janssen, Emidio Scarpellini,Pieter Vanden Berghe, Werend Boesmans, Rita Vos, Jan F. Tack

Background and aims: Animal studies have shown that menthol reduces intestinal segmenta-tion/motility and dampens enteric nervous activity In Vitro, relaxing effects that are probablymediated by transient receptor potential (TRP) channels. Peppermint oil (PO), with mentholas a major constituent, is widely used as a spasmolytic agent in irritable bowel syndrome.Recent data have implicated tone of the proximal stomach, through its effects on intragastricpressure (IGP), in the modulation of satiation during meal ingestion. We set out to investigatethe effect of single-dose PO on IGP and satiation in health. Methods: In ten fasted healthyvolunteers (HVs; mean age ± SEM: 32.5 ± 3.2, BMI: 23.1 ± 0.8, 4 female) a manometryand an infusion catheter were positioned in the proximal stomach. Baseline intragastricpressure was determined over 20 min before administering an enteric-release PO capsule(182 mg) or placebo, in a randomized controlled crossover design. Sixty min post-medicationa nutrient drink was intragastrically infused at 60 ml min-1. HVs scored satiation on a 6-grade Likert scale every min until maximum, when the infusion was stopped. IGP waspresented as a change from baseline (mean ± SEM), and the areas under the IGP and satiationcurves (AUC) were compared with paired t-test. Results: IGP AUC decreased significantlyfrom baseline 40 to 60 min after PO administration, as compared to placebo (-1.9 ± 1.5vs. 2.0 ± 0.6 mmHg min-1, p=0.02, see Figure). In contrast, IGP AUC did not differ betweenPO and placebo during the 20-min period post-medication (p=0.14) and 20 to 40 min post-medication (p=0.10). During intragastric infusion, the maximum infused volume was lower(only significant at the 10% level) after PO as compared to placebo (647.5 ± 52.1 vs. 735.3± 29.2 mL, p=0.06). Accordingly, satiation scores 6 to 8 minutes after the start of theinfusion were significantly higher after PO vs. placebo (3.3 ± 0.3 vs. 2.4 ± 0.3 units min,p=0.01). No significant differences occurred between PO and placebo in infusion-inducedrelaxation (2.7 ± 1.3 vs. 4.2 ± 0.7 mmHg, p=0.23), time-to-nadir-pressure (4.1 ± 0.7 vs.4.5 ± 0.7 min, p=0.69), and IGP recovery slope (0.36 ± 0.10 vs. 0.27 ± 0.06 mmHg min-1, p=0.41). Conclusions: A single dose of PO reduces fasting IGP in health and enhancessatiation during nutrient drink infusion with negligible effects on IGP profiles. Furtherstudies will need to elucidate whether these effects involve members of the TRP channelfamily in the upper g.i. tract.

Tu1379

Needleless Transcutaneous Electroacupuncture (TEA) is as Effective asElectroacupuncture (EA) in Improving Rectal Distention-Induced IntestinalDysmotility in DogsJun Song, Jieyun Yin, Hanaa Sallam, Jiande Chen

Background and aims: Electroacupuncture (EA), electrical stimulation via acupunctureneedles, has been shown to improve gastrointestinal motility and many other diseases. Theaim of this study was to study whether needleless transcutaneous electroacupuncture (TEA),

electrical stimulation via surface electrodes placed at acupoints, was as effective as EA inimproving intestinal dysmotility in dogs. Methods: Six female dogs chronically implantedwith a duodenal cannula, a proximal colon cannula and intestinal serosal electrodes werestudied in six randomized sessions: EA, TEA, sham, atropine+EA, atropine+TEA andatropine+sham. Intestinal myoelectrical activity (IMA), heart rate variability (HRV), smallbowel transit (SBT) and contractions in the fed state were evaluated. Each session wascomposed of 4 periods: 30min baseline after the meal, 30 min during rectal distention (RD,140ml) with EA, TEA or sham, 30 min without RD but with EA or TEA or sham, and 90 minrecovery. EA or TEA was performed at ST-36 (Zusanli) bilaterally. The electrical stimulationparameters were the same for EA and TEA: pulse train of 2s-on 3s-off, 25 Hz and 6 mA.Atropine 0.02mg/kg was administrated intravenously prior to the feeding. The IMA wasrecorded via the serosal electrodes. The HRV signal was derived from the ECG and subjectedto spectral analysis for the assessment of sympathovagal activity. The SBT was measured byinjection of phenol red into the duodenal cannula and observation of its first appearance fromthe colon cannula. Intestinal contractions were evaluated by manometry via an intraluminalcatheter placed through the duodenal cannula. Results: 1) RD at a volume of 140 mlsuppressed intestinal contraction (contractile index: 6.2 ± 0.3 vs. 8.5 ± 0.3 at baseline, P <0.001). Both EA and TEA improved intestinal contractions (7.9 ± 0.2 with EA and 7.8 ±0.3 with TEA vs. 6.2 ± 0.3 with control, P < 0.001). 2) RD reduced the percentage ofnormal intestinal slow waves from 92.0 ± 4.0% to 51.1 ± 3.1 (P < 0.01) that was increasedto 68.7 ± 6.2% with EA and to 61.1 ± 4.1% with TEA (P < 0.05). 3) EA and TEA reducedthe small bowel transit time (SBTT) ( 100.8 ± 15.3 min with EA, 136.7 ± 8.0 min withTEA vs. 190.8 ± 9.3 min in sham, P < 0.01), and this effect was partially blocked byAtropine. 4) The HRV analysis showed increased vagal activity with both EA and TEA (P =0.03 via sham). 5) No significant differences were noted in the ameliorating effects ofacupuncture on intestinal motility between EA and TEA (P > 0.05). Conclusion: EA at ST-36 is able to improve the RD-induced impairment in intestinal motility and the amelioratingeffect is at least partially mediated via the vagal pathway. Needless TEA is as effective as EAvia acupuncture needles. The findings suggest that needleless TEA may be an attractivemethod for treating intestinal motility disorders.

Tu1381

Rumination VariationsEmily Tucker, Jeff Wright, Mark R. Fox

Introduction: Rumination syndrome is the voluntary, albeit subconscious return of gastriccontent to the mouth. It is socially disabling, often leads to repeated, non-diagnostic investi-gations and can have significant morbidity. High Resolution Manometry (HRM) with observa-tions after drinking or a test meal is a simple, objective way of establishing the diagnosis.A variety of behaviours and manometric findings are associated with rumination. This studydescribes how these influence patient presentation and may affect treatment. Methods: Aretrospective review of 20 patients (M=8, F=12, age 21-68) referred for HRM with a finaldiagnosis of rumination was completed. Predominant presenting symptoms included regur-gitation (n=4), vomiting (n=9), or suspicion of rumination (n=7). Recurrent belching wasalso a feature in some (n=7). In addition to the return of gastric content, patients describedtypical dyspeptic symptoms (n=17) and reflux symptoms (n=3). Results: HRM revealednormal motility in 14/20, hypotensive in 4/20 and hypertensive in 2/20. Rumination wasobserved during water swallows in 10, following multiple water swallows in 2 and after atest meal in 8 patients. In patients with dyspepsia, HRM demonstrated classical rumination(“R waves”) in 10/17 (59%), powerful contraction of abdominal muscles forced gastriccontent across the lower oesophageal sphincter (LOS). Five patients ruminated following aswallow while the LOS was relaxed, making it easy for gastric content to pass. One ruminatedwith a closed upper oesophageal sphincter leading to bolus “trapping” and pain, at whichpoint she would induce vomiting. One patient, who had fundoplication as a child, wouldcough to create the abdominal pressure required to overcome the resistance formed by thewrap. Some patients with prominent belching and dyspepsia (4/7) exhibited supra-gastricbelching with rumination. Air was sucked into the oesophagus by creating a negative intra-thoracic pressure and expelled, without passing the LOS. In patients with reflux symptoms(n=3), all ruminated a few seconds following the appearance of transient LOS relaxationwith common cavity (reflux). Unlike classical rumination these events were often highvolume, occur after meals, on exertion and in the supine position. Conclusion: HRM facilitatesdiagnosis and reveals the behaviour associated with rumination. Ingestion of a test drinkand meal increases test sensitivity. Three key “rumination variations” were identified; -Dyspepsia with typical rumination - Dyspepsia with rumination and supra-gastric belching- Reflux related rumination All may benefit from biofeedback therapy; however, the focusmay differ for rumination and supra-gastric belching. Visceral analgesics may ease dyspepsiabut proton pump inhibitors or even anti-reflux surgery may be appropriate for refluxrelated rumination.

Tu1382

Long Term Efficacy of Gastric Electrical Stimulation in Intractable Nausea andVomitingGuillaume Gourcerol, Emmanuel Huet, Nathalie Bertiaux Vandaële, Ulriikka Chaput,Valérie Bridoux, Francis Michot, Anne-Marie Leroi, Philippe R. Ducrotté

Abstract Gastric electrical stimulation (GES) has become a new alternative in the treatmentof medically refractory nausea and vomiting, especially in patients with gastroparesis.Although the efficacy of the technique has been reported in short term studies, there is todate a lack of data on the long term improvement of nausea and vomiting by GES in patientswith delayed or normal gastric emptying rate. Methods From 1998 to 2005, 26 patientswere implanted at our center for severe and chronic nausea and/or vomiting refractory tostandard medical management. Patients were evaluated at baseline, 6 months and beyond5 years after implantation (mean follow-up 83 ± 4 months) using symptomatic scale from0 (worse) to 4 (best) and the GIQLI quality of life scale. Results Out of the 26 patients, 4were lost, 6 were explanted for absence of improvement, and 1 patient died (cause of deathwas unrelated to the stimulator). Out of the 15 patients evaluated over 5 years, the GIQLIscale was 31% improved (p=0.005), as well as nausea, (29%; p=0.04), vomiting (43%; p=

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0.01) , satiety (60%; p=0.01), bloating (31%; p=0.03), regurgitation (25%; p=0.05) andepigastric pain (23%; p=0.04). Over 5 years, 12 patients out of 15 reported a 50 % ofimprovement with a global satisfaction rated at 68 ± 6 %. In intention to treat, 12 patientsout of 22 were improved over (55%) 5 years. Univariate analysis failed to identify factorsassociated with improvement over 5 years, while long term improvement was correlatedwith the severity of symptoms and their improvement at 6 months. Last, patients withdelayed gastric emptying or with normal gastric emptying rate before surgery were improvedover 5 years in a similar manner (respectively 58% versus 50% in intention to treat).Conclusion GES is a safe and effective therapy on the long term in patients with medicallyrefractory nausea and vomiting, with a efficacy over 50% beyond 5 years in intention totreat. Gastric emptying measured before implantation did not influence the response rateover 5 years.

Tu1383

Effect of Peppermint Oil on Gastric Accommodation to a Meal, Complianceand Sensitivity to Balloon Distension in HealthAthanasios A. Papathanasopoulos, Alessandra Rotondo, Rita Vos, Pieter Janssen, EmidioScarpellini, Pieter Vanden Berghe, Werend Boesmans, Jan F. Tack

Background and aims: Animal studies have shown that menthol reduces intestinal segmenta-tion/motility, an effect that is probably mediated by transient receptor potential (TRP)channels. Peppermint oil (PO), with menthol as a major constituent, is widely used as aspasmolytic agent in irritable bowel syndrome. Recent data have implicated tone of theproximal stomach in the modulation of satiation during meal ingestion. We set out toinvestigate the effect of PO on gastric sensorimotor functions in health. Methods: Ten fastedhealthy volunteers (HV, mean age±SEM: 33±2.4, BMI: 23±0.8, 6 female) underwent a gastricbarostat study in a randomized controlled crossover design. Intragastric balloon volume wasrecorded with pressure maintained at intra-abdominal pressure +2 mmHg. HVs consumeda 300-Kcal liquid meal 60 min after ingesting a PO capsule (182 mg) or placebo; on separatevisits, stepwise isobaric distensions were performed before and 60 min post-medication.HVs scored hunger and 9 epigastric symptoms on a visual analogue scale (VAS). Barostatparameters and VAS scores were compared between placebo and PO with t-test. Results:During isobaric distension, no significant differences were demonstrated in fundic compliancebetween placebo and PO pre- (54.4±4.6 vs. 56.7±10.8 mL mmHg-1, p=0.84), and post-medication (54.1±2.3 vs. 55.1±7.9 mL mmHg-1, p=0.97). Accordingly, threshold pressuresdid not differ pre- (11.1±0.8 vs. 12±1.3 mmHg, p=0.51) and post-medication (10.6±0.4vs. 11.7±0.9 mmHg, p=0.20), and discomfort pressures did not differ pre- (18.6±0.5 vs.25.3±5.9 mmHg, p=0.29) and post-medication (17.7±0.9 vs. 18±1 mmHg, p=0.87). Sim-ilarly, threshold volumes were comparable between placebo and PO before (193.1±38.6 vs.175.2±47.6 mL, p=0.63) and post-medication (217.3±37.8 vs. 293.6±80.8, p=0.43), anddiscomfort volumes were similar before (614.6±65.6 vs. 588±64.8 mL, p=0.56) and post-drug (617.3±40.2 vs. 582.8±70.6 mL, p=0.71). We observed no significant differences inballoon volume between placebo and PO at baseline (p=0.87, see Table), post-medication(p=0.97), and post-meal (p=0.84). Accordingly, meal-induced accommodation (delta volumepre- and post-meal) was not significantly different (p=0.78). In contrast, pre-meal cumulativeVAS scores were significantly higher after placebo compared to PO for hunger (p<0.05) andappetite (p=0.01). Furthermore, post-meal cumulative VAS scores were significantly higherafter placebo compared to PO for fullness sensation (p<0.05) and nausea (p<0.05). Conclu-sions: After single-dose administration, PO reduces hunger and decreases meal-related symp-toms in health, without inducing significant effects on sensitivity to gastric distention orgastric accommodation.

Tu1384

Small Intestine Bacterial Overgrowth (SIBO) is Common in Patients WithIdiopathic GastroparesisLubin F. Arevalo, Aaron B. Trimble, Jody Hirsch, Brad M. Dworkin

BACKGROUND : The etiology of small intestine bacterial overgrowth (SIBO) is complex,and associated with immunodeficiency disorders, anatomical abnormalities and motilitydisorders including IBS. The symptomatic spectrum of SIBOmay be similar to those observedin patients with gastroparesis. It is also known that etiologies for gastroparesis could predis-pose to SIBO. The aim of our study was to assess the prevalence of SIBO in a group ofpatients with largely idiopathic gastroparesis. METHODS: We retrospective analyzed 23patients with gastroparesis in whom SIBO study was conducted due to persistent symptoms ofabdominal pain, irregular bowel function and bloating despite prokinetic therapy. Associatedfactors including PPI status, use of narcotic medications and constipation were analyzed.RESULTS: Twenty three patients with gastroparesis underwent SIBO study by Lactulosebreath test .Hydrogen and methane were measured. A test was considered positive if a20ppm rise was seen by 120 minutes time. 19 (82%) patients were female and 4 (18%)

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