Surg Endosc (2008) 22:2571–2575
DOI 10.1007/s00464-008-0080-0
A study of intragastric and intravesicular pressure changes during
rest, coughing, weight lifting, retching, and vomiting
Atif Iqbal Æ Mumnoon Haider Æ Rudolf J. Stadlhuber Æ
Anouki Karu Æ Sue Corkill Æ Charles J. Filipi
Received: 17 February 2008 / Accepted: 23 June 2008 / Published online: 23 September 2008
Ó Springer Science+Business Media, LLC 2008
Abstract
Background In patients undergoing a variety of proce-
dures, surgical success is in part dependent on maintaining
normal intra-abdominal pressure in the immediate postop-
erative period. Our objective was to quantify intragastric
and intravesicular pressures during activities, through the
use of manometry catheters.
Methods Ten healthy volunteers had a manometry catheter
placed transnasally, and a urinary Foley catheter placed.
Baseline intragastric and intravesicular pressures were
recorded and the catheters were then transduced continu-
ously. Pressures were recorded with activity: coughing,
lifting weights, retching (dry heaving), and vomiting.
Results All pressure changes were significant from base-
line except for weight lifting. The highest intragastric
pressure was 290 mmHg, seen during vomiting. Compari-
son of intragastric and intravesicular pressures showed no
significant difference. There was significantly higher intra-
gastric pressure with vomiting and retching as compared
A. Iqbal
Department of Surgery, University of Missouri Columbia,
One Hospital Drive, Columbia, MO 65212, USA
M. Haider
Department of Medicine, Grand Rapids Medical Education
and Research Center, Grand Rapids, MI 49503, USA
R. J. Stadlhuber
A. Karu
S. Corkill
C. J. Filipi (&)
Esophageal Center, Division of General Surgery,
Department of Surgery, Creighton University Medical Center,
601 North 30th Street, #3700, Omaha, NE 68131, USA
e-mail: cjfilipi@creighton.edu
R. J. Stadlhuber
e-mail: stubu-r@gmx.at
with coughing, whereas coughing applied more pressure
than weight lifting.
Conclusions This is the first report of intragastric pres-
sures during vomiting and retching (dry heaving). We
conclude that vomiting and retching (dry heaving) can
render significant forces on any tissue apposition within the
stomach or the peritoneal cavity.
Keywords Intragastric pressure
Intravesicular pressure

Manometry
Vomiting
The measurement and understanding of intra-abdominal
pressure in the surgical patient is gaining clinical relevance.
For patients with hernias (abdominal, inguinal, and hiatal)
surgical success is dependent, in part, upon controlling intra-
abdominal pressures in the immediate postoperative period.
This is also true for patients who undergo fundoplication
procedures (both open and laparoscopic) because early
postoperative vomiting is known to cause fundoplication
disruption and intrathoracic migration [1]. We are currently
investigating transoral gastroplasty alternatives and it would
be useful to quantify the pressure that a gastroplasty would
encounter during activities such as lifting, retching, and
vomiting. The measurement of intra-abdominal pressure has
become an integral part of the care of the critically injured
patient, as excessive intra-abdominal pressures lead to
abdominal compartment syndrome with disastrous conse-
quences such as renal failure, hypotension, respiratory
compromise, and decreased splanchnic circulation [2].
A literature review of intra-abdominal pressure during
everyday activities reveals a paucity of information.
Determination of such pressures would establish a baseline
force that needs to be withstood by abdominal closures,
hernia repairs, prosthetic mesh, fundoplications, and a
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transoral gastrotomy closure [a natural orifice transluminal
endosopic surgery (NOTES) procedure]. The data would
be especially relevant after minimally invasive surgery, as
patients often resume normal activities within several days.
Fusco et al. showed a close approximation between intra-
abdominal and vesicular pressures by simultaneously mea-
suring both during laparoscopy [3]. Other authors have
shown the validity of measuring intra-abdominal pressure
through the vesicular route [4, 5]. Still others have established
an association between intragastric and intravesicular pres-
sures in inactive reclined patients [5, 6]. We recorded both
intragastric and intravesicular pressures to obtain baseline
pressures and to compare them during various activities.
The objective of our study was to quantify and compare
the intragastric and intravesicular pressures during rest,
coughing, bench pressing using specified weights, induced
retching, and vomiting. The measurement of intragastric
pressure (equivalent to intraperitoneal pressure) can be
effectively achieved through the use of a manometry cath-
eter. However, to our knowledge there has been no
measurement of these pressures within the normal stomach
at rest and during the activities as mentioned. In addition, we
simultaneously measured the intravesicular pressure in an
attempt to validate the intragastric pressure recordings and to
correlate them. We also compared the values obtained from
our study to suture pull out and breakage force values and
abdominal tensile strength values available in the literature.
Materials and methods
The study was approved by the Institutional Review Board
(IRB #04-13468) and all volunteers signed an informed
consent. Ten healthy volunteers who fulfilled our study
criteria (Table 1) were included in the study. Vital signs
were recorded both before and after the test procedure. A
Table 1 Inclusion and exclusion criteria used for this study
Inclusion criteria for study
1. Volunteers who were in good general physical health and were able
to safely bench press C100 lbs.
Exclusion criteria for study
1. Age \19 years and [65 years
2. Pregnant women
3. History of major abdominal surgery
4. Esophageal or gastric motility disease such as gastroesophageal
reflux or achalasia
5. History of stroke, hypertension or berry aneurysm
6. History of inguinal, hiatal or other abdominal hernias
7. History of repeated vomiting and/or retching (e.g., patients
suffering from anorexia nervosa or bulimia)
8. Anemia or excessive body fluid loss (e.g., diarrhea)
9. Urethral/vesicular pathology
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Surg Endosc (2008) 22:2571–2575
manometry catheter was inserted through the nose into the
stomach. Medtronic (Medtronic USA Inc., Shoreview, MN)
software and hardware was used for manometric determi-
nations. The catheter was withdrawn to determine the lower
border of the high-pressure zone, then advanced 5 cm into
the stomach and secured to the nose at that level. Calibra-
tion was performed in the supine position using the
Dentsleeve Water Perfused System (Dentsleeve Intl. Ltd.,
Mississauga, Ontario, Canada) with the Medtronics Poly-
gram 98 system. A Foley catheter was then inserted into the
urinary bladder. After draining the urine, 50 cc sterile saline
was injected into the bladder and the catheter subsequently
clamped and connected to the manometry system, where the
pressures obtained were recorded. Baseline intragastric and
intravesicular pressures were recorded and the catheters
were then transduced continuously.
The subjects then completed the following activities.
Each subject coughed ten times as hard as possible and
pressures were recorded. The subject then bench-pressed a
weighted bar (26, 44, 70, 88, and 114 lbs) while in the supine
position. The volunteer then drank 250 ml of water, fol-
lowed by 30 ml of Ipecac syrup, and another 240 ml of
water. The pressures were continuously recorded while the
subject was in the right lateral decubitus position to prevent
aspiration. If the subject did not vomit within 30 min, an
additional 15 ml of Ipecac syrup was given. Episodes of
vomiting were distinguished from retching (dry heaving)
and were noted on the recording. After vomiting ceased, the
pressures were recorded to ensure a return to baseline levels
and the catheters were removed. Volunteers were sent home
only after complete cessation of nausea and vomiting and the
absence of any abnormality on examination by a physician.
The data was recorded in an Excel spreadsheet and
analyzed utilizing SPSS (version 11). Significance was
established at p \ 0.05.
Results
Ten volunteers with a mean age of 26 years (range 23–
34 years), mean weight of 184 lbs (range 126–220 lbs) and
mean body mass index (BMI) of 25 kg/m2 (range 17–
29 kg/m2) were studied. No adverse events were encoun-
tered during or after the study. Pressures obtained during
coughing, vomiting, retching (dry heaving), and weight
lifting are shown in Table 2, and a comparison of the
pressure changes seen with different weights is shown in
Table 3. The highest intragastric pressure was seen with
vomiting (290 mmHg) while weight lifting (up to 114 lbs)
increased the pressure by no more than 52 mmHg. There
was significantly higher intragastric pressure with vomiting
and retching as compared with coughing, whereas cough-
ing applied significantly more pressure than weight lifting.
Surg Endosc (2008) 22:2571–2575 2573

Table 2 Intragastric and intrabladder mean and maximum pressures recorded during various straining activities
Intragastric pressure (mmHg) Intrabladder pressure (mmHg)
Mean Maximum Mean Maximum

Coughing (n = 100) 35 233 37 226

Vomiting (n = 40) 82 290 81 255
Retching (n = 46) 69 281 70 250
Weight lifting 2 52 5 121
p value \0.0001 \0.0001 \0.0001 \0.0001
The p values represent the differences between the pressures generated between different activities. The mean pressure changes were neither
significantly different from baseline nor from each other during lifting different weights

Table 3 Mean, minimum, and maximum intragastric and intrabladder pressures recorded during the lifting of specified weights
Weight lifting (n = 50 each) Intragastric pressure (mmHg) Intrabladder pressure (mmHg)
Mean Minimum Maximum Mean Minimum Maximum

26 lbs 12 0 13 22 0 121
44 lbs 19 0 43 15 0 19
70 lbs 10 0 14 16 0 39
88 lbs 3 0 32 4 0 31
114 lbs 5 0 52 6 0 53
p valuea 0.2 – 0.02 0.2 – 0.001
a
The p values represent the differences between the pressures generated during lifting of different weights. The mean pressure changes were
neither significantly different from baseline nor from each other during lifting different weights

All pressure changes were significantly different from
baseline except for weight lifting, which was associated
with a significant change in the mean intravesicular pres-
sure but not the mean gastric pressure, as shown in Fig. 1.
Pressures generated during weight lifting were significantly
lower than those seen with coughing, vomiting or retching
(p \ 0.001). The maximal pressure changes recorded dur-
ing weight lifting were, however, significantly different
from baseline for both the stomach and the bladder.
Subgroup analysis revealed that the mean intravesicular
pressure changed significantly from baseline with 114 lb
weights. Although the mean pressures during lifting of
different weights were not significantly different from each
other, the maximum pressures were. It is unclear why the
weights and intravesicular pressures in Table 3 do not
progress as expected. There are individual patients with
Table 4 A comparison of mean and maximum intragastric and in-
trabladder pressures recorded during the various straining activities
Intragastric Intrabladder p
pressure pressure value

Coughing
Mean 35 mmHg 37 mmHg 0.7
Maximum 233 mmHg 226 mmHg 0.4
Vomiting
Mean 82 mmHg 81 mmHg 0.8
Maximum 290 mmHg 255 mmHg 0.3
Retching
Mean 69 mmHg 70 mmHg 0.9
Maximum 281 mmHg 250 mmHg 0.9
Weight
Fig. 1 Comparison of intragastric and intravesicular pressures during lifting
various straining activities. All changes were significant from baseline Mean 2 mmHg 5 mmHg 0.5
(p \ 0.0001) except for weight lifting. Intragastric and intrabladder Maximum 52 mmHg 121 mmHg 0.9
pressures did not significantly differ

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outlier values and, if these are excluded, the results are as
expected, i.e., increasing intravesicular pressure with
increasing weights.
Comparison of intragastric and intravesicular pressures,
at rest and during various activities, showed no significant
difference (Table 4). This was also true when comparing
pressures during lifting of different weights (Table 3).
Discussion
This is the first report of intragastric pressure during
abdominal compartment stressors, especially vomiting and
weight lifting. Our results demonstrate that vomiting and
retching (dry heaving) can render significant forces on
early tissue repair or any tissue apposition means within the
stomach or within the peritoneal cavity. Coughing pres-
sures were not as high but this stressor may be disruptive as
it is often repetitive and can be chronic. Weight lifting in
the supine position did not produce high intragastric pres-
sure, and in fact there was an inverse relationship between
weight and measured pressure. The pressures within the
bladder verified the results found within the gastric lumen,
and the literature demonstrates that intravesicular pressure
accurately reflects intraperitoneal pressure [4, 5] and
that intravesicular pressure is similar to intragastric pres-
sure [6, 7].
In the clinical setting, intra-abdominal pressure results
in changes in patient management such as the decision to
operate on patients with abdominal compartment syn-
drome. Seventy-one percent of the decisions made by
trauma surgeons to operate in such cases were directly
influenced by the measured intra-abdominal pressure [8].
Thus the role of accurate intra-abdominal pressure mea-
surements in the surgeon’s management algorithm is
significant. To do the same in the critically ill surgical
patient cannot be overstressed.
Historically, intra-abdominal pressures have been mea-
sured directly via a cannula inserted into the abdominal
cavity [9] or by an intraperitoneal catheter [10, 11]. Mea-
surement of intravesicular pressure is an effective, easy,
and noninvasive technique that has been shown to correlate
well with intra-abdominal pressures in both animals and
humans [3–5]. However, intragastric pressure has not been
studied in this respect. Few studies have shown a good
correlation between intravesicular and intragastric pres-
sures in patients [5, 6] but none have quantified both during
activities. There was no significant difference between in-
travesicular and intragastric pressures in our study. This
offers an alternative means of measuring intra-abdominal
pressure when vesicular pressure measurement is not
obtainable, for instance in a patient who requires continu-
ous bladder irrigation.
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Surg Endosc (2008) 22:2571–2575
The role of intra-abdominal pressure in hernia formation
is well known. Previous studies show that the maximal
tensile strength of the cadaveric abdomen is 1600 N/m
[12], which is 4,600 times the maximal pressure generated
in our study. Although, the effect of repetitive stressors is
not known, the intra-abdominal pressures generated in our
study alone do not appear to be responsible for hernia
formation. Further studies are needed to elucidate the effect
of repetitive stressors, the synergistic effects of multiple
coexistent factors, especially in the immediate postopera-
tive period, and the role of abdominal wall muscular
vectors.
Interestingly, prosthetic biomaterials and meshes used
for hernia repair that do reduce the recurrence rates [13–15]
have been postulated to restrict normal abdominal wall
mobility as they are stronger and stiffer than necessary
[16]. Thus, newer-generation mesh products have been
developed with lower tensile strength (N/cm) and more
compliance than previous mesh products [17, 18]. Our
study provides data regarding intra-abdominal pressure
during various activities that the newer mesh products need
to protect against. The data presented may be used to
evaluate the new mesh products requirements.
Previous studies have shown that diaphragm stress fac-
tors do alter hiatal hernia recurrence [1] and results of other
intra-abdominal procedures such as gastroplasty for obesity
[19]. Complications of gastroplasty include staple-line
disruption (12%) which could be the result of intragastric
stressors such as coughing, vomiting or sudden vigorous
lifting. Vertical banded gastroplasty has resulted in weight
loss [20] but any transoral procedure must succeed in
preserving the gastroplasty against the measured pressures
reported in this study.
In our study, the maximum intragastric pressure was
generated by vomiting and was 290 mmHg. Using Lapla-
ce’s law, and making some assumptions about the shape
and distensibility of the fundus of the stomach, we calcu-
lated that the maximum tension produced by vomiting
(290 mmHg) is equivalent to a force of 0.35 N/m. Ikeda
et al. observed that the pull-out force of stitches in a full-
thickness, porcine gastric resection model was 20.3 N [21].
The maximal pressure generated in the stomach in our
study is therefore 1/50 (0.35/20.3 = 0.02) of the suture
pull-out force, as determined by Ikeda et al. Thus, one can
assume a 50-fold margin of safety when comparing the
intragastric pressure generated from postoperative vomit-
ing with the force necessary to cause gastric suture pull-
out. However, this assumption is based on data derived in a
porcine model. Further studies in humans are needed to
elucidate this relationship.
Intra-abdominal pressure with rapid weight lifting show a
direct correlation to the amount of the weight lifted and the
rapidity with which it is lifted [22]. In our study, the weights
Surg Endosc (2008) 22:2571–2575
were lifted slowly and the differing results also may be
attributable to utilization of chest wall musculature (pecto-
ralis) during bench pressing. Cobb et al. in a similar study
evaluated the intravesicular pressures during activities such
as standing, sitting, bending, coughing, jumping, and weight
lifting [23]. The relationship between weight lifting and
intra-abdominal pressure seen in our study was also reported
by Cobb et al., with a maximal pressure of 34 mmHg seen
during bench pressing. However, further studies are needed
to delineate this relationship and to possibly modify the
postoperative weight lifting restrictions.
The common postoperative lifting restriction, although
logical, has little evidence to support it. Based on our data,
patients at high risk of diaphragm stressors, such as those
with chronic obstructive pulmonary disease and coughing,
could potentially benefit from prophylactic cough sup-
pression or antiemetics as the case may be. The
relationship between weight lifting and incisional hernias
or failure of gastric surgery is controversial and needs
further study.
Conclusion
The results emphasize that postoperative control of
coughing, retching (dry heaving), and vomiting may be
essential for the successful outcome of many foregut
operations. From this data, we can conclude that vomiting
and retching (dry heaving) can create significant forces on
any tissue apposition device or procedure within the
stomach.
Acknowledgments The authors would like to thank Sue Corkell,
R.N., our volunteers, and all the staff at the Esophageal Center at
Creighton University School of Medicine for their help in obtaining
and quantifying the data presented.
Grant support: Ethicon Endo-Surgery, 4545 Creek Road, Cincin-
nati, Ohio 45242-7000, USA.
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