Journal Title
Title of Journal: Dig Dis Sci
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Abbravation: Digestive Diseases and Sciences
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Publisher
Kluwer Academic Publishers-Plenum Publishers
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Authors: Johannes A Otte Ellie Oostveen Peter B F Mensink Robert H Geelkerken Jeroen J Kolkman
Publish Date: 2007/03/24
Volume: 52, Issue: 8, Pages: 1771-1775
Abstract
Gastric exercise tonometry is a functional diagnostic test in chronic gastrointestinal ischemia As maximal exercise can cause falsepositive tests exercise buildup should be controlled to remain submaximal We evaluated three parameters for monitoring and adjusting exercise levels heart rate HR respiratory quotient RQ and serial lactate measurements in 178 tests in both healthy volunteers and patients suspected of gastrointestinal ischemia Exercise levels above submaximal occurred in 20 of HR 2 of RQ and 5 of lactatemonitored tests P005 for HR vs RQ and lactate Low levels were seen in 5 of HR 10 of RQ and 41 of lactatemonitored tests P001 for lactate vs HR and RQ High levels resulted in 43 falsepositive tonometry results compared to 19 of all tests P0001 low levels did not result in more false negatives 5 vs 6 Although RQ monitoring yielded the greatest proportion of optimal exercise tests serial lactate monitoring is our method of choice combining optimal diagnostic accuracy low cost and simplicityFor diagnosis in patients with suspected chronic gastrointestinal ischemia we have previously shown that gastric exercise tonometry can be used as a functional test providing information about the adequacy of the gastrointestinal mucosal perfusion 1 2 In these studies it was demonstrated that during 10 min of submaximal exercise gastric ischemia occurred only in patients with splanchnic artery stenosis An extreme exercise level may cause falsepositive tests as shown in a study in healthy volunteers where lactate levels exceeding 8 mM resulted in gastric ischemia in 50 3 Furthermore it may be conceivable that exercise of very low intensity can lead to falsenegative results in exercise tonometry used for diagnosing chronic gastrointestinal ischemia In order to prevent falsepositive and falsenegative tonometry tests the exercise intensity should be monitored throughout the test and if necessary adjustments of the workload should be made in order to obtain an optimal exercise testExercise intensity can be monitored by various parameters including arterial plasma lactate concentration decrease in serum arterial base excess BE or bicarbonate concentration which are both directly related to lactate level heart rate HR and respiratory parameters respiratory gas exchange ratio RQ = carbon dioxide output VCO2/oxygen uptake VO2 4In this study we evaluated and compared three consecutive time periods in each of which a different parameter was used for monitoring the exercise intensity and adjusting the workload in order to obtain a submaximal exercise test Initially HR monitoring was used in the second period exercise intensity monitoring and adjustment were guided by monitoring of RQ In the final period exercise intensity was monitored by serial rapid lactate measurementsIn 10 volunteers 5 females 5 males mean age 25 years range 23–28 years and 157 patients 59 males 98 females median age 55 years range 13–82 years 178 tonometry exercise tests were performed The volunteers were tested as part of a more extensive study investigating the effect of two different exercise levels on gastric tonometry 3 All patients were suspected of having symptomatic chronic gastrointestinal ischemia Their clinical presentation was that of unexplained abdominal pain weight loss diarrhea or gastric ulcers Gastric tonometry exercise testing was performed as a diagnostic function test in addition to duplex sonography and selective angiography of the splanchnic vessels Some of the patients in this study have been previously described in a publication by our group investigating the diagnostic potential of gastric exercise tonometry 1The procedure of gastric tonometry exercise testing was described in detail in a previous study 3 In short a standard nasogastric tonometry catheter was inserted and connected to an automated air tonometry device that was set up to measure intragastric partial carbon dioxide pressure PCO2 every 10 min All subjects were studied after a fasting episode of 4 hr Ranitidine 100 mg was given intravenously 90 min prior to exercise testing A radial artery catheter was introduced in the nondominant arm to allow sequential arterial blood samplingThe maximal workload W max was estimated using standard criteria ie age sex and weight 5 The exercise episode was started at 10 of W max and in the first 4–6 min the workload was increased every minute by 10 of W max The workload was intended to remain constant thereafter at a submaximal exercise level Three different approaches for monitoring the exercise intensity and—if necessary—guiding additional adjustments of the workload were evaluated in consecutive periods
Keywords:
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