GASTROENTEROLOGY 1999;116:1035–1042
Gastric Wall Tension Determines Perception
of Gastric Distention
ELEONORA DISTRUTTI, FERNANDO AZPIROZ, ALFREDO SOLDEVILLA, and JUAN–R. MALAGELADA
Digestive System Research Unit, Hospital General Vall d’Hebron, Autonomous University of Barcelona, Barcelona, Spain
Background & Aims: The primary mechanism that origi-
nates symptoms in response to gastric distention
remains undefined. The aim of this study was to
determine which factor, whether intragastric volume,
pressure, or wall tension, determines perception of
gastric distention. Methods: Healthy subjects under-
went increasing gastric distentions (2-minute duration
at 5-minute intervals) either at fixed pressure levels
using a conventional barostat (n ⴝ 10) or at fixed
tension levels using a newly developed computerized
tensostat (n ⴝ 12); perception was scored by a 0–6
scale. Distentions were performed during basal condi-
tions (intravenous saline) and during gastric relaxation
by glucagon administration (4.8 ␮g/kg intravenous
bolus plus 9.6 ␮g · kgⴚ1 · hⴚ1 infusion). Results: Iso-
baric distentions with the conventional barostat pro-
duced more intense perception during glucagon (95% ⴞ
40% higher; P F 0.05). However, the factor that
determined higher perception could not be ascer-
tained, because at the same pressure levels both
intragastric volume and wall tension were greater
during glucagon administration (174% ⴞ 56% and
34% ⴞ 8% greater, respectively; P F 0.05 vs. saline
for both). The tensostat evidenced that perception was
selectively related to tension, not to elongation; during
glucagon administration, intragastric volumes were
significantly larger (80% ⴞ 28% larger increase; P F
0.05), but perception of isotonic distentions remained
the same (27% ⴞ 22%; nonsignificant change).
Conclusions: Gastric wall tension, but not intragastric
volume, determines perception of gastric distention, at
least below nociception.
ut stimuli, specifically gastric distentions, may
G induce abdominal symptoms; this simple sensory
phenomenon is presumably involved in various clinical
conditions. However, despite its substantial relevance,
the primary mechanism that originates perception re-
mains unclear.
We have previously shown that gastric tone determines
the sensitivity of the stomach to distention.1 Specifically,
we showed that when the stomach was relaxed, gastric
distention produced the following effects: at constant
distending volumes, both intragastric pressure and wall
tension, as well as perception, were smaller, but at
constant distending pressures applied by a barostat both
intragastric volume and wall tension, as well as percep-
tion, were greater. Hence, we could not define whether
perception is determined by intragastric volume, pres-
sure, or gastric wall tension.
We therefore developed a computerized tensostat,
which applies constant tension levels on the gastric wall
by a feedback regulation of an air pump. Following
basically the same procedure as in previous studies, we
applied distentions of the stomach during fasting, when
gastric tone is high, and during gastric relaxation
induced by glucagon.1 To determine which factor (ten-
sion, pressure, or volume) determines perception, we
produced distentions at fixed tension and at fixed
pressure levels in two separate groups of subjects. We
hypothesized that perception is exclusively determined
by tension receptors; hence, appropriate measures were
adopted to prevent a type II error: the size of the fixed
tension group, expected to have no change in perception
during gastric relaxation, was made larger than the fixed
pressure group, expected to have increased perception.
Other methodological aspects, such as the change in tone
produced by glucagon, the technique to measure percep-
tion, and the reproducibility of the responses to repeat
distentions, have been previously validated in detail.1–5
Materials and Methods
Participants
Twenty-two healthy individuals (13 women and 9 men;
age range, 19–24 years) without gastrointestinal symptoms
gave written informed consent to participate in the study. The
protocol for the study had been previously approved by the
Institutional Review Board of the Hospital General Vall
d’Hebron.
Tensostat
The tensostat is a computerized pump (Tensostat/
Barostat; Sicie, Barcelona, Spain) that can be programmed to
apply fixed tension levels on the gastric wall (Figure 1). The
r 1999 by the American Gastroenterological Association
0016-5085/99/$10.00
1036 DISTRUTTI ET AL.
Figure 1. The gastric tensostat is a computerized air pump that
applies a constant tension level on the gastric wall. Based on
intragastric pressure and volume, the system calculates wall tension
and drives the pump to maintain the preselected tension level.
system consists of a strain gauge and an injection/aspiration air
pump that are independently connected via a double-lumen
polyvinyl tube (12F, Argyle; Sherwood Medical, St. Louis, MO)
to a high-compliance intragastric bag. The bag (1-L capacity,
36-cm maximal perimeter, made of ultrathin polyethylene) is
similar to that previously used with the barostat and validated
in detail.6,7 Air volume in the air pump is monitored by a
potentiometer, and a separate strain gauge measures the
pressure within the air pump. All these components are fed by
an electronic relay. Analogic signals from both strain gauges
and the potentiometer are digitized (80 Hz) by an A/D
converter and fed into a personal computer, which controls the
air pump. First, the intra-abdominal pressure level has to be
measured and entered; the computer program calculates the
transmural pressure in the stomach by substrating the intra-
abdominal pressure from the pressure recorded within the
intragastric bag. Second, on the basis of the volume output
from the potentiometer and the pressure within the pump, the
program calculates on-line the real volume within the bag, by
correcting for air compressibility using Boyle’s law (P · V ⫽ K).
Third, the system assumes that the intragastric air (the
corrected volume) conforms to a spherical shape, and calculates
the corresponding radius. The potential error derived from this
assumption was calculated by specific validation studies (see
below). Fourth, based on the calculated radius and the
transmural gastric pressure (intragastric minus intra-abdomi-
nal pressure), the program calculates the tension exerted on the
gastric wall by applying Laplace’s law: T ⫽ P R/2.8 Expressing
the length of the radius in centimeters and the pressure in
grams per square centimeter (1 g/cm2 ⫽ 0.73558 mm Hg),
tension will be calculated as grams per centimeter, that is, as
the force (grams) acting on a 1-cm wide circumferential strip of
the gastric wall. Fifth, the system can be programmed to apply
a fixed tension level on the gastric wall; when the calculated
tension exceeds by 1 g the programmed tension level, the
system activates the pump to aspirate air, and when the tension
is 1 g below the programmed level, the system activates the air
injection. Changes in tension are applied gradually to prevent
GASTROENTEROLOGY Vol. 116, No. 5
overpressurization of the pump and rebound effects: the
changes are applied in intermediate steps differing by 20, 10,
and 3 g from the final desired tension level; each step is
activated with a 2-second lag time after the recorded tension
has reached the previous level.
The following parameters are continuously displayed on the
computer screen and stored for later analysis: pressure recorded
within the intragastric bag, pressure recorded within the
pump, volume recorded by the potentiometer, corrected intra-
gastric volume, and calculated gastric wall tension (Figure 2).
Only one eighth of the data acquired at 80 Hz is stored, i.e., at
10 Hz. An accessory data analysis program allows automatic
averaging of each parameter within any specific time interval.
The computerized air pump of the system can also operate as
a barostat and as a volumetric pump, automatically providing
all the above measurements and corrections.
Perception Questionnaire
We used a graded questionnaire to measure the type
and intensity of sensations perceived, and anatomic question-
naires to measure the location, extension, and depth of the
sensations. The graded questionnaire included five scales
specifically for scoring: (1) abdominal pressure, (2) fullness, (3)
hunger, (4) nausea, and (5) other type of sensation (to be
specified). Participants were asked to score any perceived
sensation (one or more perceived simultaneously) on the
respective scale(s). Each graphic rating scale combined verbal
descriptors on a visual analog scale graded from 0 to 6.4,9 All
participants received standard instructions, specifying that
score 0 represented no perception at all, score 5 represented
discomfort, and score 6 represented a painful sensation, which
was not intended, and was to be instantaneously reported for
immediate discontinuation of the stimulus. Any sensation had
to be scored on the scale based on its perceived intensity, and
orientative descriptors were provided indicating that score 1
represented vague perception of mild sensation; score 2
Figure 2. Example of gastric distention with the tensostat. Steps of
operation: (1) based on the pressure and volume in the pump,
the system corrects for air compressibility; (2) based on corrected
intragastric volume and transmural pressure, the system calculates
wall tension; and (3) operates the pump to maintain tension within
⫾1 g of the preselected level.
May 1999
represented definite perception of mild sensation; and scores 3
and 4 represented vague and definite perception of moderate
sensation. Participants were also told that, when appropriate,
they could mark half unit scores on the scale so that 12
intensity grades were actually provided. This type of question-
naire has been extensively used in our laboratory.1,3–5,10,11
To record the area of referral of the perceived sensations we
used an anatomic questionnaire that incorporated a diagram of
the abdomen divided in six regions (mid and lateral regions
above and below the umbilicus). Participants were instructed
to mark the location, i.e., abdominal region(s), where the
sensations were perceived. To measure the extension of the
referral area we used six numbered circles that covered 0.5%,
2.5%, 5%, 20%, 50%, and 100% of the abdominal surface in
the diagram depicted in the anatomic questionnaire. Partici-
pants were asked to select the circle that best represented the
extension of the area over which sensations were perceived. To
measure the depth in the abdomen where sensations were
perceived, we used an abdominal wedge diagram depicting
four concentric strata from the abdominal surface to the
innermost abdominal core, corresponding to depth levels of
0%, 33%, 66%, and 100% from the abdominal surface.
Before the study, participants were told that gastric disten-
tions of 2-minute duration and different intensities would be
tested. Participants were also told that unless pain was
perceived, they should remain quiet and relaxed to avoid
motion artifacts in the recordings, until the stimuli had been
discontinued and the investigator asked them to report in the
questionnaires the sensation perceived during the preceding
2-minute period. The questionnaires were fully explained to
the participants.
Procedure
General conditions. Studies were conducted in a quiet,
isolated room, and the testing period did not exceed 3 hours.
Participants were studied after an 8-hour fast, and no drugs,
particularly analgesics, were allowed for at least 48 hours before
the study. The bag of the gastric tensostat/barostat, finely
folded, was introduced through the mouth into the stomach.
To unfold the intragastric bag, the small lumen of the
connecting tube was plugged into the pressure transducer of
the system, and the bag was slowly inflated through the other
lumen of the tube with 300 mL of air under controlled pressure
(⬍20 mm Hg). The bag was then completely deflated and
connected to the air pump. Participants were comfortably
seated on an ergonomic chair, maintaining the trunk erect. This
position was chosen for the air within the intragastric bag to
spontaneously accumulate in the proximal stomach, and hence
distend the walls of the gastric reservoir, i.e., body and fundus.12 An
intravenous (IV) line was established, and saline was continuously
perfused at 50 mL/h using an infusion pump (model pp 50-300;
Lubrationics GmbH, Boeblingen, Germany).
Measurement of intra-abdominal pressure. Gastric
wall tension depends on the transmural distending pressure in
the stomach, i.e., the pressure differential between intraluminal
pressure (recorded within the stomach) and extraluminal
GASTRIC WALL TENSION AND PERCEPTION 1037
(intra-abdominal) pressure. Using the barostat modem of the
system, we first determined the intra-abdominal pressure by
the conventional method, i.e., increasing intragastric pressure
in 1–mm Hg steps every minute until volume variations
induced by respiratory motions were registered (minimal
distending pressure).7,13 The minimal distending pressure was
4.0 ⫾ 0.3 mm Hg.
We then performed an ancillary validation study testing a
simplified procedure to determine the intra-abdominal pres-
sure. Air (5, 10, and 20 mL) was injected for 1 minute each into
the intragastric bag while intrabag pressure was being concomi-
tantly measured and averaged. With small volumes, the pressure
was identical (4.3 ⫾ 0.3 mm Hg both with 5 and 10 mL) and
similar to the minimal distending pressure. However, the pressure
increased with larger volumes (5.2 ⫾ 0.3 with 20 mL; P ⬍ 0.05 vs.
5 and 10 mL and minimal distending pressure).
Distention procedure. After a 10-minute equilibra-
tion period, we produced intermittent gastric distentions of 2
minutes’ duration separated by 5-minute intervals. Sequential
distentions were performed in stepwise increments until the
participants, specifically instructed, reported discomfort, with-
out exceeding 900 mL intragastric volume. At the completion
of each sequence of distentions, gastric tone was recorded as
intragastric volume at constant pressure level (2 mm Hg above
intra-abdominal pressure) using the barostat modem of the
system. After 2 minutes of baseline recording, glucagon
(Glucagon Novo; Laboratorios Novo, Madrid, Spain) was
administered IV in saline solution (4.8 µg/kg bolus followed by
9.6 µg · kg⫺1 · h⫺1 continuous infusion) and gastric tone was
recorded for 10 minutes. Subsequently, during glucagon
administration we retested in each subject the four highest
tolerated distentions of those previously applied during saline.
Experimental Design
Each subject participated in only one experiment. In
each experiment we tested a sequence of either fixed pressure or
fixed tension gastric distentions, first during IV saline (basal
gastric contraction) and afterwards during glucagon administra-
tion (pharmacological gastric relaxation). This experimental
design has been validated by showing the reproducibility of the
responses to two consecutive trials of gastric distention.1
Fixed pressure distention. We compared the effect of
isobaric gastric distentions during IV saline and during gastric
relaxation by glucagon in 10 subjects (1 man and 9 women; age
range, 19–24 years). Using the barostat modem, we set a baseline
intragastric pressure level 2 mm Hg above the minimal distending
pressure, i.e., the intra-abdominal pressure level. Sequential disten-
tions were performed in 2–mm Hg stepwise pressure increments.
Fixed tension distention. We compared the effect of
isotonic gastric distentions during IV saline and during gastric
relaxation by glucagon in 12 subjects (8 men and 4 women; age
range, 20–24 years). Using the tensostat modem, we set a
baseline tension level of 4 g, which provided an intragastric
pressure level 2.2 ⫾ 0.1 mm Hg above the minimal distending
pressure. Sequential distentions were performed in 8-g step-
1038 DISTRUTTI ET AL.
wise tension increments up to a perception score of 3 or more,
and thereafter in 4-g increments.
Data Analysis
For each distending episode, the dependent variable
(volume and tension in the fixed pressure distentions; volume
and pressure in the fixed tension distentions) was measured by
averaging the recordings obtained during the last minute of the
distention using the data analysis program. Gastric relaxation
induced by glucagon was measured as the difference of
intragastric volume averaged over the 2-minute periods start-
ing immediately before and 5 minutes after glucagon adminis-
tration, respectively. To further evaluate the gastric relaxatory
effects of glucagon, we calculated the compliance of the
stomach during each distention (intragastric volume/pressure).
We then averaged in each subject the values corresponding to
the four highest distentions tested during IV saline and the
values corresponding to the same distentions tested during
glucagon administration.
Perception was measured by the score in the graded
questionnaire. When more than one sensation was scored, only
the maximal score, instead of the cumulative score, was used for
comparisons. In each subject, we calculated the relative
frequency (as percent distribution) of the different sensations.
We also calculated the percentage of stimuli referred over each
abdominal region, the average extension of the referral area over
which the stimuli were perceived (percent of abdominal
surface), and the average depth of the sensations. To determine
whether the type of perception was a function of stimulus
intensity, we divided the number of fixed tension gastric
distentions that were perceived during IV saline in a lower half
(i.e., weak stimuli) and a higher half (i.e., strong stimuli). We
then compared the type of symptoms, their location, the
extension of the referral area, and the depth of the sensations
elicited by strong and weak stimuli.
Statistical Analysis
We compared in each subject the responses to the four
highest distending levels that were tested both during IV
saline (basal contraction) and during glucagon administration
(gastric relaxation). Therefore, we compared intragastric vol-
umes, gastric wall tension, and perception scores obtained
during four isobaric distentions and the intragastric volumes,
pressures, and perception scores during four isotonic disten-
tions. Gastric compliance during IV saline and during gluca-
gon administration was calculated using only the data from the
four highest distentions. Statistical comparisons were per-
formed using the cumulative values of the responses to these
stimuli in each subject. In each group (fixed pressure and fixed
tension distentions), we calculated the mean values (⫾SE), or
grand means when appropriate, of the different parameters
measured. Statistical comparisons of paired data (saline vs.
glucagon) were performed by the Wilcoxon signed-rank test.
GASTROENTEROLOGY Vol. 116, No. 5
In Vitro Validation Study
To validate the reliability of the tensostat, we compared
the elongation of latex balloons produced by the tensostat to
that produced by equivalent weights on latex strips. We
carefully prepared latex balloons of spherical shape by tying a
condom over a tube similar to that connected to the intragastric
bag. Using the tensostat we applied stepwise distentions from
2 g (baseline) to 28 g in 4-g steps. At each tension level, we
verified by visual inspection that the balloons conformed to a
spherical shape and, based on the balloon volume, calculated its
circumference (perimeter).
Using a cutter, we prepared 1-cm wide strips of the same
latex material. Strips were fixed by one end, and gradual
weights were applied at the other end hanging freely on the air.
Weights from 2 g (baseline) to 28 g were applied in 4-g steps.
At each distention level, the length of the strip was measured.
Balloon distentions and strip distention were each tested in
four different preparations (n ⫽ 4). In each preparation,
distentions were performed in triplicate. Grand means ⫾ SE
were calculated. Elongation data (circumference of balloons and
length of strips) were referred to baseline length (l0, at 2 g
tension) and were expressed as fractional stretch (l1 ⫺ l0/l0).
Graded tension levels applied both on the balloons and on
the strips produced a linear elongation, which was reproducible
on repeat trials. The elongation produced on latex balloons by
the tensostat was virtually identical to that produced by the
same tension levels on latex strips (the mean values differed by
10%).
Theoretical Validation Study
The tensostat assumes that air conforms to a spherical
shape, which may not be entirely exact under physiological
conditions. To calculate the error in tension calculations caused
by deformation, we compared wall tension produced by a given
intraluminal pressure level for an ideal sphere and for graded
ellipsoidal flattening of the same volume as follows.
For different volumes (300, 600, and 900 mL) we calculated
the radius assuming a spherical shape [V ⫽ (4/3)␲r3] or the
radii of five ellipsoids [V ⫽ (4/3)␲r12 r2] in which one radius
(r1) is 10%, 20%, 30%, 40%, or 50% shorter than the other
(r2), respectively. We then calculated the wall tension at
different pressure levels (5 and 10 mm Hg) using Laplace’s law
for the sphere (see above) and for the five ellipsoids: T ⫽
P/(1/r1 ⫹ 1/r2).8 We finally calculated the percent difference in
tension between each ellipsoid and the ideal sphere.
Ellipsoidal deformation reduces wall tension; the percent
difference is related to the degree of deformation but unrelated
to either pressure or volume. Compared with the ideal sphere,
marked shortening of one radius results in a relatively small
decrease in wall tension (Figure 3).
Results
Gastric Tone and Compliance
In the experiments with the barostat, baseline
intragastric volume during IV saline remained relatively
May 1999
Figure 3. Effect of shape on wall tension: theoretical validation.
Ellipsoidal deformation produces a relatively small decrease in wall
tension compared with the sphere.
small and stable throughout the sequence of distentions
(data not shown), indicating that basal gastric tone was
not modified by either baseline intragastric pressure over
time or by repeated distentions. Likewise, the tensostat
did not distort basal gastric tone; the intragastric volume
during IV saline infusion was 107 ⫾ 63 mL at the
beginning of the sequence of distentions and 110 ⫾ 28
mL at the end. After each distention, the intragastric
volume promptly recovered to the previous level. Gluca-
gon administration produced a marked gastric relaxation,
which was similar in both groups; in 5 minutes, basal
gastric tone changed by 198 ⫾ 24 mL (pooled data for
barostat and tensostat groups; P ⬍ 0.005 after vs. before
glucagon). Intragastric volume remained stable through-
out the glucagon infusion period. In the experiments
with the tensostat, the intragastric volume was 304 ⫾ 36
mL at the beginning and 288 ⫾ 34 mL at the end of the
sequence of the distentions. By relaxing the stomach,
glucagon produced a significant increase in gastric
compliance; compliance increased from 36 ⫾ 2 mL/mm
Hg during IV saline to 76 ⫾ 6 mL/mm Hg during
glucagon administration (pooled data for barostat and
tensostat groups; P ⬍ 0.05).
Fixed Pressure Gastric Distentions
During IV saline, distention of the stomach with
progressively higher intragastric pressures resulted in
progressively larger intragastric volumes, as well as
higher wall tension values and perception scores (Figure
4). This stimulus-response relationship was also patent
during glucagon administration. However, at equivalent
distending pressure levels (isobaric distentions), both the
intragastric volumes and the wall tension levels were
significantly greater when the stomach was relaxed by
glucagon than during IV saline (P ⬍ 0.05) (Figure 4).
Furthermore, at equivalent pressure levels, perception
scores were also larger during glucagon. A combined
tension vs. perception plot pooling together the disten-
tions during saline and glucagon administration showed
GASTRIC WALL TENSION AND PERCEPTION 1039
Figure 4. Gastric distentions with the barostat. At the same pressure
levels, intragastric volume, gastric wall tension, and perception were
larger when the stomach was relaxed by glucagon (䉱) than during IV
saline (䊐). *P ⬍ 0.05 vs. saline.
a linear relationship (R ⫽ 0.96; P ⬍ 0.005) consistent
with the interpretation that tension determines percep-
tion; the relationship of perception with volume (R ⫽
0.82; P ⬍ 0.05) and with pressure (R ⫽ 0.86; P ⬍ 0.05)
was less robust.
The quality of sensations induced by gastric distention
was also analyzed. Participants perceived predominantly
a sensation of abdominal pressure and fullness (49% ⫾
12% and 39% ⫾ 14% of the perceived stimuli, respec-
tively). These sensations were referred to an area located
over the supraumbilical midline (72% ⫾ 9% of the
sensations), covering an extension of 13% ⫾ 3% of the
abdominal surface, and at a depth of 60% ⫾ 5% beneath
the abdominal surface. The quality of the sensations was
not significantly changed by glucagon (76% ⫾ 21% of
the sensations were perceived over an extension equiva-
lent to 22% ⫾ 5% of the abdominal surface, located in
the supraumbilical midline, and at a depth of 65% ⫾ 7%
beneath the abdominal surface).
Fixed Tension Gastric Distentions
During IV saline, distention of the stomach at
progressively higher levels of wall tension produced
increasing intragastric volumes and perception scores
(Figure 5). The threshold for perception was 14 ⫾ 2 g,
and the threshold for discomfort was 37 ⫾ 4 g. As
expected, at equivalent wall tension levels (isotonic
distentions), intragastric volumes were larger when the
stomach was relaxed by glucagon than during IV saline
infusion, and the differences were statistically significant.
However, at the same tension levels, perception was
similar during glucagon administration, despite the
markedly larger volumes (Figure 5). Hence, the same
levels of gastric wall tension produced larger volumes
during gastric relaxation, but perception remained un-
changed.
The quality of the sensations induced by fixed tension
1040 DISTRUTTI ET AL.
Figure 5. Gastric distentions with the tensostat. The same tension
levels produced significantly larger intragastric volumes when the
stomach was relaxed by glucagon (䉱); nevertheless, perception
remained similar than during IV saline (䊐). *P ⬍0.05 vs. saline.
distentions was similar to those induced by fixed pressure
distentions. Distentions were predominantly perceived as
pressure, and fullness (33% ⫾ 11% and 65% ⫾ 11% of
the perceived stimuli, respectively) referred to the supra-
umbilical midline area (61% ⫾ 7% of the sensations)
over an extension 17% ⫾ 5% of the abdominal surface
and at a depth of 62% ⫾ 65% beneath the abdominal
surface. Neither the type of symptoms, the location, nor
extension of the referral area were related to the intensity
of the stimuli. Perception was only slightly deeper in the
higher half than in the lower half of the perceived stimuli
(56% ⫾ 6% vs. 68% ⫾ 6% beneath the abdominal
surface, respectively; P ⬍ 0.05). Glucagon did not
modify the character of the sensations induced by isotonic
distentions (data not shown).
Discussion
Using an original methodological approach, we
have shown that symptoms in response to gastric disten-
tion depend on gastric wall tension, whereas intragastric
volume and expansion seem irrelevant.
By comparing the responses to distention when the
stomach was either contracted or relaxed, we showed that
at similar intragastric pressure levels, perception was
more intense when the intragastric volume was larger.
However, these experiments alone were inconclusive
because gastric wall tension was also greater. Complemen-
tary information to interpret these data was obtained by
comparing the responses to fixed levels of gastric wall
tension; perception was directly related to the tension
level and remained unchanged despite that intragastric
volumes were markedly larger when the stomach was
relaxed. Within our experimental conditions, intragastric
GASTROENTEROLOGY Vol. 116, No. 5
volume or gastric stretch was not involved in perception,
but we cannot ascertain whether the same situation
prevails at higher levels of distention producing nocicep-
tion, or in patients with abnormal sensitivity of the
stomach. Conceivably, both wall tension and intralumi-
nal volume elicit a variety of vagal and sympathetic
reflexes,14–17 but only tension seems to activate afferent
pathways leading to perception.
Various mechanosensitive afferents in or on the gastric
wall, such as muscle tension receptors,18 volume recep-
tors,19 and serosal mechanoreceptors,20,21 may respond to
distortion of their receptor endings with a wide range of
sensitivity and thresholds. However, assigning function
to the receptors on the basis of sensory experiences may be
misleading because the final response may be influenced
at many different levels along the afferent pathway.
The present studies are based on an experimental
model that combines particular physical and physiologi-
cal conditions. By manipulating gastric tone and gastric
wall tension, different equations relating intragastric
pressure, volume, wall tension, and perception could be
established to deduce the factor that determines percep-
tion. The response of the stomach to distention depends
on its muscular contraction, being more distensible, i.e.,
compliant, when relaxed. Gastric tone is a physiological
concept defined as the level of tonic or sustained muscular
contraction.12,16 At any given volume in the stomach,
gastric tone determines the stress or tension of the gastric
wall.12 Tension is a purely physical concept, synonymous
with force. In hollow structures, wall tension depends not
only on the transmural (internal minus external) pressure,
but also on the internal surface, so that, at the same
pressure, tension is proportional to the wall area.8 When
the structure is spherical, a simple relation of wall
tension, pressure, and area, as a function of the radius, can
be established by Laplace’s law.8 We applied these known
physical relations to develop a computerized air pump
that operates as a tensostat. Based on pressure and volume
values, the program calculates the wall tension in the
corresponding sphere and drives the pump to maintain
the desired tension level, regardless of muscular contrac-
tion.
The tensostat principle is based on the assumption that
air within the intragastric bag conforms to a spherical
shape, but some deviations from the ideal situation
should be expected. Without practical space restrictions,
large air volumes, driven by physical forces, tend to
configure a spherical bubble; this was proven by radio-
logic imaging in dogs.22 Uncontrolled observations in
our laboratory have confirmed this phenomenon in
humans, provided that the trunk is erect, allowing air to
May 1999
float in the proximal stomach, but exact morphological
studies have not been performed. Nevertheless, by a
theoretical validation study, we showed that alterations of
geometry of the gaseous mass have a relatively small
impact on the calculations of wall tension; with up to a
40% ellipsoidal deformation, which constitutes a substan-
tial flattening, the error in calculated tension is limited to
about 10%. We have applied the system to study the
stomach, but the same principle also can be applied to
cylindrical segments of the gut such as the small bowel or
the colon. In that case, tension should be calculated based
on Laplace’s law for the cylinder.8
Calculation of wall tension requires an accurate mea-
surement of intra-abdominal pressure. In an ancillary
study, we tested a new method to measure intra-
abdominal pressure by recording intragastric pressure at
very low intragastric volumes. Different low volumes,
which do not actually distend the gastric wall (5 and 10
mL), provide reproducible pressure measurements; higher
volumes (20 mL) introduce an overestimation of intra-
abdominal pressure due to gastric distention. This new
method is much simpler, and it appears more reliable
than the conventional and more complicated method
based on the determination of the minimal distending
pressure.7,13
The use of the depth questionnaire provided an
original ancillary observation related to the referral
pattern of visceral perception. Referred sensations are
explained by the convergence of somatic and visceral
afferent input onto spinal viscerosomatic neurons. How-
ever, the sensations induced by gastric distention were
distinctively perceived as arising from within the abdomi-
nal cavity, rather than from the skin or other somatic
structures of the abdominal wall. The interpretation of
these challenging data remains unclear.
Our study has a practical significance related to gut
sensitivity testing and the limitations of the barostat. At
fixed intraluminal pressure, tension and perception de-
pend on the intraluminal volume. In turn, volume is
determined by the size of the hollow viscera and, as we
have shown, by its muscular tone. Both are subjected to
intra- and interindividual variations. Because perception
depends on wall tension, the tensostat provides a more
reliable standardization of gut distention, regardless of
the capacity and tone of the segment tested. Nevertheless,
data obtained with other distending systems, when
properly analyzed, may also provide similar information.
Recent studies using different approaches also concluded
that perception of gastric distention depends on wall
tension rather than on intraluminal pressure or vol-
ume.23–25 Hence, tension, rather than pressure- or volume-
GASTRIC WALL TENSION AND PERCEPTION 1041
based distention, seems to be the best approach in
designing gastric sensitivity studies.
Our study also bears pathophysiological significance
and helps to explain the mechanism of postprandial
symptoms. For instance, in patients with functional
dyspepsia and impaired gastric accommodation, meal
ingestion would increase wall tension and therefore
contribute to postprandial discomfort, more so when
these patients may also display altered sensitivity and
exaggerated gastric perception.24–26
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Received May 11, 1998. Accepted January 19, 1999.
Address requests for reprints to: Fernando Azpiroz, M.D., Digestive
System Research Unit, Hospital General Vall d’Hebron, 08035
Barcelona, Spain. Fax: (34) 93-428-18-83.
Supported in part by the Spanish Ministry of Education, Dirección
General de Enseñanza Superior del Ministerio de Educación y
Cultura, PM97-0096.
Presented in part at the annual meeting of the American
Gastroenterological Association, San Francisco, California, 1996.
Dr. Distrutti’s present address is: Istituto di Gastroenterologia,
Policlinico Monteluce, 06100 Perugia, Italy.
The authors thank Maite Casaus and Anna Aparici for technical
support and Gloria Santaliestra for secretarial assistance.