Professional Documents
Culture Documents
Authors: Kevin J. Donohoe, MD (Beth Israel Deaconess Medical Center, Boston, MA); Alan H. Maurer, MD (Temple
University Hospital, Philadelphia, PA); Harvey A. Ziessman, MD (Georgetown University Hospital, Washington, DC);
Jean-Luc C. Urbain, MD (Temple University Hospital, Philadelphia, PA); Henry D. Royal, MD (Mallinckrodt Institute
of Radiology, St. Louis, MO); and J. Martin-Comin, MD (Hospital U. de Bellvitge, Barcelona, Spain)
The Society of Nuclear Medicine (SNM) has written and approved these guidelines as an educational tool designed to promote the cost-
effective use of high-quality nuclear medicine procedures or in the conduct of research and to assist practitioners in providing appropriate
care for patients. The guidelines should not be deemed inclusive of all proper procedures nor exclusive of other procedures reasonably di-
rected to obtaining the same results. They are neither inflexible rules nor requirements of practice and are not intended nor should they be
used to establish a legal standard of care. For these reasons, SNM cautions against the use of these guidelines in litigation in which the clini-
cal decisions of a practitioner are called into question.
The ultimate judgment about the propriety of any specific procedure or course of action must be made by the physician when considering the
circumstances presented. Thus, an approach that differs from the guidelines is not necessarily below the standard of care. A conscientious
practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in his or her reasonable judgment,
such course of action is indicated by the condition of the patient, limitations on available resources, or advances in knowledge or technology
subsequent to publication of the guidelines.
All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources,
and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achiev-
ing this objective.
Advances in medicine occur at a rapid rate. The date of a guideline should always be considered in determining its current applicability.
2 z GASTRIC EMPTYING AND MOTILITY
protein content. Recent literature cites the 2. Data points must be corrected for radioactive
need to obtain images for up to 4 h, suggest- decay.
ing that retention of >10% of the meal in the 3. A time–activity curve obtained from the geo-
stomach at 4 h is abnormal. Anterior and pos- metric mean or attenuation corrected counts of
terior views allow calculation of a geometric ROI activity should then be displayed.
mean (the geometric mean is the square root 4. Measurements of gastric emptying may be de-
of the product of counts in the anterior and rived and reported in several ways. Normal
posterior regions of interest [ROIs]), which values should be available for the specific
more consistently represents the amount of analysis protocol being used. The value re-
tracer in ROI independent of anterior– ported as the half-emptying time should be
posterior movement between the fundus and accompanied by a brief description of what
antrum. The geometric mean can be calculated the value represents or how the value was ob-
using sequential anterior and posterior images tained. Values may be obtained by:
from a single-head camera or, preferably, si- a. Determination of the time it takes to reach
multaneously with a 2-head camera. Alterna- half the peak counts.
tively, the study can be acquired in the left an- b. Least squares fit of the emptying data is
terior oblique (LAO) view with a single-head used to derive a half-emptying time to
camera. In this case, no mathematical attenua- reach 50% of the peak counts.
tion correction is required. c. The percentage retained at specific times
4. Continuous data collection with a framing rate after meal ingestion (e.g., at 2, 3, or 4 h).
of 30–60 sec is recommended. If data are col- 5. In addition to rate of emptying, the percentage
lected only every 15 min, emptying half-time of emptying at the end of the study, and the
is not as accurately determined and lag phase percentage retained at specific time points after
information may be unavailable. Intermittent meal ingestion, other information may be ob-
data acquisition may be more suitable than tained from gastric motility studies, including:
continuous data acquisition for imaging pa- a. Regional motility (e.g., antral contraction
tients in an upright position. frequency and amplitude)
5. Images may be obtained standing, sitting, or b. Response to medical interventions
supine, but position should not change during c. Effect of varying meal composition on
the study. Normal values must be established emptying
in the position used (must have separate nor- H. Interpretation Criteria
mal values for upright, supine). 1. Normal values for the specific meal and envi-
6. Follow-up studies should always be done un- ronment used should be established before re-
der the same conditions as the first study (i.e., sults can be reported.
same meal, collimator, analysis program, etc.) 2. Display of images in a cine format should be
F. Interventions done to better demonstrate gastric anatomy
Metoclopramide or other prokinetic drugs can be and findings such as esophageal reflux, over-
used diagnostically in conjunction with gastric lap of small bowel with gastric ROI, and pos-
emptying studies to evaluate the effectiveness of a sible movement of gastric contents outside the
particular therapy. drawn ROI.
G. Processing 3. The emptying curve generated from the ROI
1. An ROI is drawn around the tracer activity in should be interpreted in light of the manner in
the stomach in anterior and posterior views which images were collected. For example, if
(and/or LAO view, if acquired). Cine display only anterior imaging was done, a “plateau
may be helpful to confirm the stomach outline phase” may represent gastric emptying at the
and to determine the extent of patient motion same time posterior-to-anterior movement of
so that the ROI may be appropriately adjusted. tracer is occurring within the stomach.
Alternatively, if continuous imaging is used, 4. A careful history addressing possible prior
the stomach contour may be identified with surgical procedures and current medications
initial images combined with images from should be obtained before the study and con-
later in the study, after the radiolabeled meal sidered during interpretation of findings.
has had an opportunity to distribute itself I. Reporting
within the stomach. Using initial or later im- 1. The meal, imaging protocol, and techniques
ages exclusively may under-represent the ex- for data analysis should be outlined in the re-
tent of the fundus and antrum. port.
4 z GASTRIC EMPTYING AND MOTILITY