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1303902 case study-1.qxd

CHRONIC DYSPEPSIA IN A
MIDDLE-AGED WOMAN WITH
NORMAL GASTRIC EMPTYING
Introduction

When common gastrointestinal diseases are eliminated as a cause of nausea and vomiting, gas-tric neuromuscular disorders, including gastric dysrhythmias, should be considered as potentialcauses of these symptoms.(1) Gastric dysrhythmias are abnormal myoelectrical activities of thestomach that disrupt normal gastric peristaltic contractions, resulting in inadequate contractionswhich can alter the gastric emptying rate.(2) An Electrogastrogram (EGG) is a non-invasive test of myoelectrical activity of the stomach.
Cutaneous electrodes placed on the patient's upper abdomen measure the electrical events thatproduce normal stomach neuromuscular activities and dysrhythmias associated with nauseaand delayed gastric emptying. In humans, the normal frequency is 3 cycles per minute (cpm).(3)Bradygastria is an abnormally slow frequency (1.0-2.5 cpm), while tachygastria is an abnormallyrapid frequency (3.75-10.0 cpm). This test is typically recorded for 15 minutes in the fasting state Kenneth L. Koch, MD
and then for 30 minutes after an appropriate test meal or water load.* Water load is oftenpreferred as a provocative test because comparable results can be achieved in less time (30 Professor of Internal Medicine
minutes versus 2 hours) and the effects of secretin, cholecystokinin and other hormonal responses Chief, Section on
are limited due to the lack of calories in the test meal. Water load also avoids stimulating Gastroenterology
colonic neuromuscular activity, while still provoking symptoms such as bloating and nausea. Wake Forest University School
of Medicine

The utility of EGG as an aid in diagnosing and treating gastric dysrhythmias is demonstrated in Bowman Gray Campus
Winston-Salem, NC
* Visipace proprietary EGGSAS software compares patient results with control values that were established using a Former Professor of Medicine,
Division of Gastroenterology

Patient History
The Milton S. Hershey Medical
Center

A 56-year old woman presented with chronic early satiety and nausea. An acute episode of The Pennsylvania State
severe epigastric pain, nausea and vomiting led to hospitalization. No specific cause of the acutesymptoms was found. Symptoms persisted for months and the patient could not eat regular food.
University
A gastroenterological consultation was obtained and physical examination was within normal Hershey, PA
limits. No abdominal tenderness, masses or organomegaly were found.
Co-founder, International
Evaluation Procedures
Electrogastrography Society
(IEGGS)

An upper GI series, abdominal CT scan and upper endoscopy were all normal, although the Chairman and Co-founder,
pylorus was difficult to traverse. A nuclear solid-phase gastric emptying time (GET) test was normal 3CPM Company, Inc.
at 62% emptied in two 2 hours (in this practice region normal is >60%). Colonoscopy wasnormal as were the results of a CT scan of the head.
Member
American College of

Visipace
Gastroenterology
Electrogastrogram
American Gastroenterology
Analyzer Results
Association
American Motility Society
American Physiological
tachygastria before and after waterload. The patient ingested 400 mlin five minutes during the water Figure 1. EGG Signal Pre-intervention. Rhythm shows abnormallyrapid activity, indicating a possible tachygastria. load test (normal is ~600 ml). TheRunning Spectral Analysis (RSA)showed some peaks at 3 cpm and some smaller peaks in the tachygastria range. The EGGSummary Sheet showed an increase in 3 cpm activity 10 minutes after ingestion of water and anincrease in percentage of power in the tachygastria range, indicating a diagnosis of tachygastria.
Intervention
The patient was started on Reglan but was unable to tolerate the drug. Erythromycin anddomperidone were tried but did not decrease her symptoms. Patient was then given tegaserod,6 mg BID, for three months and symptoms showed marked improvement.
Post-Intervention
EGG Results

Following three months of tegaserodtreatment, another test was performedusing the Visipace ElectrogastrogramAnalyzer. The follow-up test recordedstrong 3 cpm waves at baseline and inresponse to water load. Furthermore, the patient was able to consume 600ml during water load. The RSAshowed consistent 3 cpm peaksbefore and after water load. Finally,the percentage distribution in the EGGSummary Report showed increased 3cpm percentages after water load andresolution of the tachygastria.
Conclusion
Figure 2. Resolution of EGG Signal Post-intervention. Rhythm in (B) shows resolution of tachygastria seen in (A) and restoration of more probable tachygastria. Prokinetic drugtherapy with tegaserod eradicated thesymptoms, corrected the tachygastria and restored regular 3 cpm activity. This is an example oferadication of a gastric dysrhythmia by a prokinetic (anti-arrhythmic) drug and resolution of upperGI symptoms.
References1. Koch KL. Unexplained nausea and vomiting. Current Treatment Options in Gastroenterology 2000; 3:303-313.
2. Koch KL, Stern RM. Functional disorders of the stomach. Semin Gastrointest Dis 1996; 7:185-195.
3. Hinder RA, Kelly KA. Human gastric pacesetter potential. Site of origin, spread and response to gastric transactionand proximal gastric vagotomy. Am J Surg 1978;133:29-33.

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Death by medicine, part i 11/26/03

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