GASTRIC FUNCTIONAL TESTS

NORMAL PHYSIOLOGY- OVERVIEW

About 1000ml of gastric juice secreted by stomach per

24hr in a fasting person & 2000-3000ml of juice in a
subject taking a normal diet.
Gastric juice is a mixture of secretions from different cells.
• HCl
• Mucus
• Electrolytes
• enzymes
Parietal cells secrete HCl and intrinsic factor.
Zymogen (chief) cells secrete pepsinogens
Average pH of mixed gastric juice is about 1.5
FUNCTIONS OF THE STOMACH
Major functions of the stomach include:
 Temporary storage and controlled release of ingested
nutrients into the duodenum for absorbtion
 initiation of protein digestion (pepsin and HCl)
 acid production to keep the upper GIT relatively
sterile
production of intrinsic factor for vitamin B12
absorbtion.
Stimulants of gastric juice
Physiologically, vagus nerve impulses & polypeptide
hormone gastrin released in response to food
In disease conditions, alterations of gastric secretion
often occurs.

Analysis of secretions gives limited but specific value

in the diagnosis of disorders of upper GIT.
 Why Gastric functional tests?
To determine whether the patient can secrete any gastric
acid
To determine the amount of acid produced by a patient
with symptoms of PUD(peptic ulcer disease).
To support a hypersecretory state characteristic of
zollinger Ellison syndrome
To determine the completeness of vagotomy.
To aid in the differential diagnosis of gastric ulcer from
duodenal ulcer.
Diagnosis of other gastric disorders, as shown below;-
COMMON DISORDERS
Gastric functional tests are used in diagnosis of ;
Peptic Ulcer Disease- Collective name for chronic
duodenal and gastric ulcers
Chronic duodenal ulcers- Ulcer-round, >3cm in
diameter, in duodenal mucosa
- May be superficial or penetrate the serosa
- 90% occur in the 1st duodenal portion
Chronic gastric ulcers-Ulcers any where in the stomach
mostly in the lesser curvature
-Between 1-2cm in diameter
 Disorders cont’d
Zolinger-Ellison syndrome- Triad of gastric
hyper secretion, severe peptic ulceration, and non
beta cell islet tumor of pancreas(gastrinoma)
- Hypergastrinemia, diarrhea,stearrhea are also
common
-Gastric secreting tumors(gastrinomas)vary from
0.2-20cm.
-Involves elevated fasting gastrin levels of 2-2000
times the normal level
disorders cont’d…
Gastritis- Inflammation of gastric mucosa
-May be ; -erosive/hemorrhagic.
-non erosive.
Gastric cancer- Commonly referred to as
stomach cancer
-Can develop in any part of the stomach and may
spread throughout the stomach and other organs
particularly esophogus,lungs lymphnodes and liver.
disorders cont’d…
Post gastrectomy syndrome- Anatomical
changes affect gastric function.
Early dumping syndrome- abdominal
discomfort soon after meals, nausea.
-Involves rapid passage of hypertonic fluid into
duodenum.
Late dumping syndrome- Meals with high
glucose passing rapidly into duodenum
FUNCTIONAL TESTS
They include:-
Pentagastrin test
Hollander’s Insulin test
Gastrin level estimation
Barium meal test
Urease test
The diagnex blue
The schilling test
Pentagastrin test- method
1. 24hr overnight fast
2. Pass a wide –bore stomach tube into the stomach, check the
positioning of the tube by fluoroscopy.
3. Aspirate the resting juice completely. This may be examined
for volume and general appearance.
4. Collect the basal, spontaneously secreted gastric juice
quantitatively by continuous suction for a period of 30min
5. Inject intramuscularly 6µg pentagastrin/kg body weight
6. Continuously aspirate the stimulated secretion for the next
60 min dividing this collection into 4 separate specimens.
15min/sample.
7. The five specimens are then sent to the lab in separate
containers
Pentagastrin test--interpretation
total basal acid output (BAO) ≤5mmol/h
Maximum acid output(MAO)in 60 min after pentagastrin is
about 20mmol in man & 10mmol in women
Pts with duodenal ulcers have twice the normal outputs
Peak acid output(PAO)=2*highest 2consecutive 15 min
periods is normally less than 45mmol/h in men and
30mmol/h in women
High BAO more than 5mmol/h suggest a duodenal ulcer
NB: pts with gastric ulcers usually have a normal acid
secretion
Pts with ca of stomach may have achlorhyndria(absence of
HCl) or may secrete normally.
Absolute achlorhyndria if none of specimens has a pH less
than 7.Occurs in pernicious anemia, gastric ca.
2-Gastrin level estimation
• Gastrin is secreted by G cells from gastric antrum.
• Radioimmunoassay of plasma or serum gastrin in dx
of zollinger ellison & pernicious anemia---- gastrin.
• Number of cells is increased in duodenal ulcer, G-cell
hyperplasia, but not in gastric ulcer.
• Normal plasma value is 50ng/l of plasma(fasting).it is
analyzed by radio immunoassay.
• It is to many 1000’s in gastrinoma, hypochlorhydria
due to gastric atrophy & in pernicious anemia due to
negative feedback.
3-Hollander’s Insulin test.
 Used postoperatively to investigate the completeness of
vagotomy, usually performed in treatment of peptic
ulcers.
Procedure
• Pass a gastric tube and collect a 1-hr basal secretion.
• Pre conditions are as in pentagastrin test
• inject 0.2units/kg body weight of soluble insulin
intravenously.
This creates hypoglycemia of below 35mg% which in turn
stimulates the parietal cells through the hypothalamus &
vagus nerve to cause increased acid secretion.
• Collect complete samples of gastric juice every 15mins for
2hrs, and of blood for glucose estimation for every 30mins.
Results
• An increase of acid secretion of less than 20mmol/l above
basal activity is taken as indicating that vagotomy has been
complete.
• Early response signifies incomplete vagotomy wherein there
is increased acid concentration in 1st hour of > 20mmol/L
• Delayed response signifies an increase in gastric
concentration in-between 1st &2nd hours and is probably due
to vagal gastrin release.
NOTE;
• The pt. must be closely observed, & iv 50%glucose kept
available, because of the risk of severe hypoglycemia.
• Resustatory machines for emergency should be available.
4-Barium meal test
• Barium sulphate solution is used
(Barium is neurotoxic but in sulphate media, it will
not be absorbed)
• Microcrystalised Barium sulphate is better because it
does not precipitate intestinal obstruction.
• About 300ml solution is given to the patient to drink
and it’s flow down to the stomach is observed under
fluoroscopic guidance.
Films are taken as required. Oblique views are
normally taken.
Cont`d
Indications
1. Gastric ulcer:- shows a niche which is the ulcer crater, a notch
which is due to spasm of circular muscle on the greater
curvature.
2. Chronic duodenal ulcer:- shows absence or deformed duodenal
cap (due to spasm of 1st part of duodenum, Barium will not stay
& so a niche will not be formed)
3. Gastric outlet obstruction:- the cause may be chronic duodenal
ulcer with pyloric stenosis or carcinoma pylorus.

Features:-enormous dilation of stomach, greater curvature below

the level of iliac crest, absence of duodenal cap, evidence of gastric
molted appearance of stomach because of retained food particles.
cont
4. Carcinoma of stomach:- irregular filling defect.
5. Pseudo cyst of pancreas:- widened vertebrogastric
angle.
6. In chronic duodenal ileus (Wilkie’s syndrome):-
shows dilation of stomach,1st &2nd part of
duodenum, proximal portion of 3rd part of
duodenum.
7. Carcinoma of head of pancreas:-=shows a pad sign;
in peri ampullary carcinoma → reverse E sign.
8. Hiatus hernia.
5-Urease test
For Helicobacter pylori
 Is a major cause of PUD.
 H. pylori secretes Urease that converts urea to
ammonia thereby producing an alkaline
environment enabling its survival in the stomach.
PANCREATIC FUNCTIONAL TESTS
Anatomical location.
NORMAL PHYSIOLOGY-OVERVIEW
The pancreas a vital organ in the body which plays both endocrine
and exocrine roles.

Endocrine; production of insulin and glucagon that control the

plasma glucose concentration, somatostatin and pancreatic
polypeptide.

Exocrine; production of alkaline pancreatic fluid and digestive

enzymes.

The pancreas is an organ that is inaccessible to biochemical study.

Both endocrine and exocrine functional tests are performed in the
diagnosis of pancreatic disorders.
Exocrine pancreas
 Ducts empty into the duodenum.
 Secret digestive enzymes;
- Trypsin
- Chymotrypsin
- lipase
- Amylase
- Elastase
Bicarbonate solution.
Normal pancreatic Juice
Colourless and odourless
Has a ph of 8.0 to 8.3
Has specific gravity of 1.007 to
1.042
Total 24 hour scretion Volume
may be as high as 3000mls.
control of exocrine secretion
 Is by gut peptide hormones released in response
to fall in pH or presence food.
 They include:
 Secretin –stimulates the release of alkaline
fluid(bicarbonate soln.)
 Cholecystokinin – stimulates release of
enzyme rich fluid
Endocrine pancreas;
Has about 1 million islet cells.
Four types of cells;
 A- cells secret Glucagon
 B- cells secret insulin
 D- cells secret Somatostatin.
 F- cells secret pancreatic polypeptide
N.B 70% of islet cells are B- cells
Common disorders
Acute Pancreatis; necrosis of pancreatic cells.
Carcinoma of the pancreas; malignant neoplasm of
the pancreatic cells.
Pancreatic malabsorption syndrome; deficiency in
enzyme secretion.
Cystic Fibrosis; recessive genetic disease.
NB. Pancreatic insufficiency cannot clearly be
demonstrated until at least 50% of the acinar cells have
been destroyed. Clinical signs do not appear until the
destruction of 90% of the acinar tissue. so the tests have
inadequate sensitivity for diagnosing chronic
pancreatitis.
Predisposing factors in pancreatic disorders;
Smoking
Excessive consumption of alcohol
Use of Opiates
Obesity
Trauma to the pancreas
Hypercalcaemia, hypertriglyceridemia
Diets high in red meat
Diabetes mellitus (both a risk factor and sign)
Helicobacter pylori infection
PANCREATIC FUNCTION TESTS:
indications
Are aimed at diagnosing the most common diseases of the
pancreas such as; Acute and Chronic pancreatitis, cystic
fibrosis, pancreatic endocrine tumor syndrome.
 Test for efficacy of pancreatic enzyme replacement therapy
Differentiate pancreatigenous malabsorption from other
malabsorptions.

They are categorized into:

1. Exocrine pancreatic function tests and
2. Endocrine pancreatic function tests
EXOCRINE PANCREATIC FUNCTION TESTS
Involve assessing the secretory ability of the exocrine
pancreas (i.e. Secretion of enzymes and bicarbonate )
They are categorized into two:
1. Invasive tests (involves duodenal intubation);
-Secretin test
-Dimethadione test
-Lundh test
2. Non invasive tests ( no intubation involved);
-plasma enzyme tests
-PABA test
-triolein test
INVASIVE TESTS
SECRETIN TEST:
Based on the principles that secretion of pancreatic juice
depends on the functional mass of the pancreatic tissue.
Procedure
Patient fasts overnight.
An orogastric tube (double lumen) inserted into
duodenum
Aspirate duodenal content and analyze
Administer secretin (1-2 U/kg body weight ) I/V
Aspirate all fluid every after 20 minutes and
analyze for bicarbonate, amylase, lipase levels
Secretin test; normal values:
Duodenal fluid Values

Volume 95 -235 mL/Hr

Bicarbonate 74 -121 mEq/L

Amylase 87,000 -267,000 mg

Lipase < 1.5 U/mL

Secretin test cont..
Low levels indicate pancreatic dysfunction e.g. chronic
pancreatitis, cystic fibrosis, advanced pancreatic
cancer.etc
Volume increased in Zollinger Ellison syndrome.
Dimethadione test (DMO)
Pancreas degrades Trimethadione (anticonvulsant),
and secretes its metabolite, DMO.
Trimethadione – administered orally for 3 days
Secretin test is performed.
The duodenal output of DMO measured
Impaired in exocrine insufficiency
 Lundh test
Based on endogenous secretion of secretin and CCK in
addition to pancreatic secretion,

procedure.
 Overnight fast
Basal collection of duodenal fluid by use of a single
lumen Levin 12 tube passed & positioned
fluoroscopically in the duodenum
Give a standard meal which contains 18g cornoil,18g
casilan(casein hydroly) and 10g glucose, in 300ml water
Thirty-minute interval collection of duodenal aspirate
for 2 hours
Analyze for trypsin, amylase, and lipase levels.
Interpretation
 The normal stimulated pancreatic juice has a trypsin
activity of 25-80µmol/ml.min
 In chronic pancreatitis disease or carcinoma, the
activity is usually below 20 units
Abnormal in patients with chronic pancreatitis
Limitations - Need for duodenal intubation
Abnormal - Dis. involving the GI mucosa
NON-INVASIVE TESTS
Plasma Enzymes
 Plasma Trypsin:
- Assessed by immunoassays.
low levels in adult is diagnostic of pancreatic
insufficiency
-In neonates, high levels indicative of cystic fibrosis
Plasma Amylase
 In normal subjects, amylase consist principally of
salivary isoenzymes; the total enzymes activity is
therefore not significantly lowered when the secretary
cell mass is reduce by chronic pancreatic disease, and
measurement of plsma amylase is of limited value in
the diagnosis of chronic conditions. However in acute
pancreatitis, total plasma amylase activity is usually
significantly increased by releaese of enzymes from
damaged cells.
Fecal enzymes
Fecal trypsin levels are extremely variable probably
because of bacterial degradation in the intestinal
lumen
In infants with diarrhea the absence of enzymes
suggest fibro-cystic disease of the pancreas.
Fecal elastase. Elastase is stable in fecal sample. A
commercially available ELISA using two monoclonal
antibodies in fecal samples in vitro.
PABA test
This method avoids the need for intubation.
A synthetic peptide labelled with p-aminobenzoic
acid(PABA) is taken orally and the product of its digestion
by chymotrypsin is absorbed and excreted in urine.
Urinary excretion of PABA is significantly reduced in
chronic pancreatitis.
However abnormal results may also occur if there is renal
impairment, liver disease, or malabsorption even with
normal pancreatic function.
-the effect of these conditions is assessed by repeating the
test with conjugated PABA, which eliminates the need for
digestion before absorption
Triolein test
25 grams of corn oil containing 5 mCi of [14C]triolein
is given orally
4 hours later - metabolite 14C-carbon dioxide
measured in breath
In fat digestion or malabsorption less than 3% of the
[14C] triolein dose per hour measured.
Test repeated after oral pancreatic enzyme
replacement.
In exocrine insufficiency achieve a normal rate of
excretion of 14C–carbon dioxide, whereas patients
with enteric disorders show no improvement
ENDOCRINE PANCREATIC TESTS
 Glucose tolerance test;
-A glucose tolerance test is a medical test in which
glucose is given and blood samples taken afterward to
determine how quickly it is cleared from the blood
-The test is usually used to test for diabetes, insulin
resistance, and sometimes reactive hypoglycemia or rare
disorders of carbohydrate metabolism
Preparation
The patient is instructed not to restrict carbohydrate
intake in the days or weeks before the test.
The test should not be done during an illness
A full adult dose should not be given to a person
weighing less than 43 kg
Usually the OGTT is performed in the morning as
glucose tolerance can exhibit a diurnal rhythm with a
significant decrease in the afternoon
The patient is instructed to fast (water is allowed) for
8–12 hours prior to the tests.
Procedure
1. A zero time (baseline) blood sample is drawn.
2. The patient is then given a measured dose (below) of
glucose solution to drink within a 5 minute time frame.
3. Blood is drawn at intervals for measurement of glucose
(blood sugar), and sometimes insulin levels

Dose of glucose
The WHO recommendation is for a 75g oral dose in all
adults: the dose is adjusted for weight only in children. The
dose should be drunk within 5 minutes.
A variant is often used in pregnancy to screen for gestational
diabetes, with a screening test of 50 grams over one hour.
 Interpretation of OGTT results
Fasting plasma glucose (measured before the OGTT
begins) should be below 6.1 mmol/l (110 mg/dl).
Fasting levels between 6.1 and 7.0 mmol/l (110 and 125
mg/dl) are borderline ("impaired fasting glycaemia"),
and fasting levels repeatedly at or above 7.0 mmol/l (126
mg/dl) are diagnostic of diabetes. The 2 hour OGTT
glucose level should be below 7.8 mmol/l (140 mg/dl).
Levels between this and 11.1 mmol/l (200 mg/dl)
indicate "impaired glucose tolerance".
Glucose levels above 11.1 mmol/l (200 mg/dl) at 2 hours
confirms a diagnosis of diabetes.
 INTERPRETATION OF ORAL GLUCOSE TOLERANCE TEST
RESULTS
Interpretation Fasting Intermediate 2-Hour
glucose glucose glucose
value value value
(mg/dL) (mg/dL) (mg/dL)

Normal <115 and All values and 140

<200

Impaired <140 and Any value and 140–199

glucose ≥200
tolerance
Diabetic ≥140 or (Glucose
<140 tolerance
test not
necessary)

and Any value and ≥200

200

Non diagnostic Any combination of glucose values that does not fit into another
category
Intravenous glucose tolerance test
Eliminates the GI influences on glucose
metabolism that affects the oral GTT
IV bolus of 0.5 g of glucose per kg over 2 to 5
minutes.
Blood samples - every 10 minutes for 1 hour.
The decline in glucose concentration (percentage
of disappearance per minute) is called the K value.
A K value of 1.5 or higher is normal.
Intravenous arginine test
Arginine stimulates the secretion of islet hormones
Diagnosis of hormone-secreting tumors
Overnight fast, and given a 30-minute infusion of 0.5 g of
arginine per kilogram.
Blood samples are taken every 10 minutes
Radioimmunoassays are performed for the specific
hormones in question.
This test is particularly useful for the diagnosis of
glucagon-secreting tumors
Elevations of plasma glucagon to above 400 pg/mL usually
indicate a glucagonoma
Tolbutamide response test
 Useful in detecting hormone-secreting tumors.
 Sulfonylurea stimulates insulin secretion.
 Overnight fasting, basal blood samples are drawn.
 One gram of sodium tolbutamide is given intravenously
 Blood glucose level is monitored for 1 hour.
 Blood samples for radioimmunoassay of insulin or other suspected
hormones, such as somatostatin obtained.
 In normal patients, the blood glucose level falls to 50% of basal values
after 30 minutes.
 Sustained hypoglycemia with hypersecretion of insulin is consistent
with an insulinoma.
 In the case of a somatostatinoma, somatostatin levels are more than
twice as high as the prevailing normal values for the particular
somatostatin radioimmunoassay
REFERENCES
CLINICAL CHEMISTRY & METABOLIC MEDICINE,
Martin A Crook, 7th Edition.

CLLINICAL DIAGNOSIS & MANAGEMENT,

BY LABORATORY METHODS
John Bernard Henry MD, 18th Edition.
A NEW SHORT TEXTBOOK OF CHEMICAL PATHOLOGY
by D.N.BARON 1989 5th Ed.
TIETZ TEXTBOOK OF CLINICAL CHEMISTRY
Carl A Bartis, Edward R Astward, 3rd Edition, 1999, USA.
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