THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 95, No.

1, 2000
© 2000 by Am. Coll. of Gastroenterology ISSN 0002-9270/00/$20.00
Published by Elsevier Science Inc. PII S0002-9270(99)00762-5

Standardization of a Simplified
Scintigraphic Methodology for the Assessment
of Gastric Emptying in a Multicenter Setting
Gervais Tougas, M.D.C.M., F.R.C.P.C., Ying Chen, M.Sc., Geoffrey Coates, M.B.B.S., F.R.C.P.C.,
William Paterson, M.D., F.R.C.P.C., Christian Dallaire, M.D., F.R.C.P.C., Pierre Paré, M.D., F.R.C.P.C.,
Michel Boivin, M.D., F.R.C.P.C., Alain Watier, M.D., F.R.C.P.C., Sandra Daniels, M.Sc., and
Nicholas Diamant, M.D., F.R.C.P.C.
McMaster University, Hamilton, Ontario; Queen’s University, Kingston, Ontario; Université Laval, Québec,
Québec; Université de Montréal, Montréal, Québec; Université de Sherbrooke, Sherbrooke, Québec; Astra
Pharma, Mississauga, Ontario; and University of Toronto, Toronto, Ontario, Canada

OBJECTIVE: Scintigraphy remains the gold standard to study
gastric emptying. The technique is onerous and normal
values vary between centers. Standardized protocols, al-
though desirable, are not presently available. We validated
a simplified scintigraphic protocol in a multicenter setting.
METHODS: In 69 healthy volunteers from seven Canadian
institutions, gastric emptying of a standard meal (99mTc-
labeled beef liver) was assessed by scintigraphy every 10
min for 1 h, then every 20 min for the next 2 h. Gastric
retention was fitted to a power exponential model, Propt ⫽
{-(␬t)␤ } with Propt ⫽ proportion of retention at time t, either
using all 13 time intervals (conventional technique) or using
measurements at 0, 1, 2, and 3 h (simplified technique).
RESULTS: The power exponential model yielded identical
emptying curves and T 1⁄2 values with both techniques.
Gastric emptying was more rapid in men than in women ⬍
35 yr (p ⬍ 0.01) and in younger than in older men (p ⬍
0.005). Gastric emptying was slower in women from Qué-
bec than in women from Ontario (p ⬍ 0.04). Gastric reten-
tion was similar at 1, 2, and 3 h among the seven centers.
Gastric emptying of a beef liver meal was slower than that
of a low fat egg substitute (p ⬍ 0.03).
CONCLUSIONS: A simpler scintigraphic approach, using
four rather than 13 samples, provides results comparable to
those of the conventional technique. This simpler approach
provides an economical, yet accurate, alternative to the
techniques presently used and is applicable to a multicenter
setting. (Am J Gastroenterol 2000;95:78 – 86. © 2000 by
Am. Coll. of Gastroenterology)
INTRODUCTION
Gastroparesis is usually defined as a symptomatic delay in
gastric emptying in the absence of any definable mechanical
obstruction (1). Delayed gastric emptying is one of the
factors implicated in the pathogenesis of several common
GI conditions and symptoms, including gastroesophageal
reflux disease (GERD), and dyspepsia (2, 3). Furthermore,
symptoms usually associated with gastroparesis, such as
nausea, vomiting, early satiety, bloating, and belching, can
also be the result of several other mechanisms and often
correlate poorly with delayed gastric emptying (4). Finally,
it is often difficult to identify gastroparesis on clinical
rounds alone (4). Therefore, it is important to establish
whether or not there is an actual delay in gastric emptying, as
prokinetic drugs may be useful in patients who have a pro-
longed gastric emptying but may be of limited efficacy in those
with normal, or even rapid, gastric emptying.
Gastric scintigraphy is the most commonly used test for
the assessment of gastric emptying and, although several
other methods have been proposed as alternatives, scintig-
raphy remains the gold standard. However, a standardized
approach to the scintigraphic assessment of gastric empty-
ing is still lacking, and techniques can vary substantially
between individual centers. In a Canadian survey of gastric
scintigraphy, a wide variability was found in the actual
technique as well as in the values believed to represent the
normal range (5). Thus, comparisons between gastric emp-
tying studies obtained in different institutions and pooling of
results in the context of clinical trials are difficult. In addi-
tion, as presently conducted, scintigraphy is costly, labor
intensive, and time consuming, both for the patients and for
the personnel involved.
The aims of the present study were 1) to establish a
standardized yet simple scintigraphic protocol for the as-
sessment of gastric emptying in seven academic Canadian
institutions, and 2) to determine what constitutes normal
emptying of a standardized meal. We have also attempted to
simplify data analysis and the requirement for frequent
sampling to make the technique more widely usable. Fi-
nally, we examined whether there are regional differences in
gastric emptying between residents of French- and English-
speaking Canada.
AJG – January, 2000
MATERIALS AND METHODS
Subjects
A total of 69 healthy volunteers (33 male and 36 female;
mean age ⫽ 39 yr, range 20 – 63 yr) were recruited from
seven different Canadian institutions. The centers involved
were Hamilton (McMaster University Medical Centre), To-
ronto (The Toronto Hospital, Western Division), Kingston
(Hotel-Dieu Hospital), Montréal (Hôpital Saint-Luc), Sher-
brooke (Center Hospitalier Universitaire de Sherbrooke),
Québec (Hôtel-Dieu de Québec and Hôpital Saint-François
d’Assise).
All subjects were in good health and without GI, neuro-
logical, endocrine, renal, hepatic, pulmonary, or cardiovas-
cular disease. They had no prior GI surgery, with the ex-
ception of appendectomy. In addition, none of the subjects
had any symptoms suggestive of delayed gastric emptying.
The subjects were currently not taking any medication
and had not been smoking for ⱖ14 days. Female partici-
pants were either postmenopausal or had had a negative
pregnancy test within 3 days of the study.
Signed, informed consent was obtained from each partic-
ipant. The study was approved by the ethical review board
of every institution involved.
Test Meal
The standard meal used in every center consisted of a slice
of beef liver (57 g) mixed into 225 g of Campbell’s chicken
stew (225 g). The caloric value of the meal was 275.5 kcal
(22.8% carbohydrate, 43.7% protein, and 33.5% fat). The
meal was prepared de novo on the morning of the study.
Using a microwave oven, liver and stew were first sepa-
rately thawed but not cooked. Then 18.5 Mbp (0.5 mCi) of
99m
Tc sulfur colloid were drawn up into a tuberculin syringe
and made up to 1 ml using normal saline. Afterward, the
isotope was injected into the slice of liver, using 10 discrete
injections so as to cover as much of the total surface area as
possible. Immediately afterward, the liver was fried in an
electric, Teflon-coated frying pan for approximately 1 min
on each side. It was then removed from the pan, cut into
square pieces of approximately 1 cm2, and then returned to
the frying pan and fried until thoroughly cooked (5 min
more). At that time, the thawed chicken stew was added to
the pan and the entire mixture heated. The meal was then
taken to the scintigraphy room and the fasting volunteer
instructed to consume it within 10 min.
In two centers (Hamilton and Montréal), a low fat meal
using a synthetic egg-substitute was also used to assess
gastric emptying. This meal consisted of a scrambled egg
substitute (120 g EggBeater, equivalent to the volume of
two large eggs), two slices of bread, strawberry jam (30 g),
and drinking water (120 ml). The egg substitute was first
radio-labeled using 1 mCi (37 Mbp) of 99mTc-labeled sulfur
colloid, which was mixed into the liquid egg substitute
preparation. The labeled mixture was then either scrambled
in a nonstick frying pan for 4 –5 min or cooked in a micro-
Simplified Scintigraphy for Gastric Emptying Assessment 79
wave oven for 1–2 min, stirring the mixture once during
cooking. The meal was then ingested within 10 min. The
caloric value of the low fat meal was 255 Kcal; it contained
2% fat, with 72% carbohydrate 24% proteins and 2% fiber).
Scintigraphy
To avoid possible diurnal variations, all studies began be-
tween 09:00 and 10:00, to finish between 12:00 and 13:00.
Anterior and posterior images of the gastric region were
taken within 1 min of the completion of the meal (defined as
time 0, T0). Subsequent images were obtained every 10 min
during the first 1 h and every 20 min afterward until 3 h had
elapsed. For every time point, both 1-min anterior and
posterior images were obtained in the 140 KeV 99Tc peak
with a 20% window. All images were collected with the
volunteers standing and leaning right up against the camera.
Between imaging periods, the subjects were allowed to sit
upright in an adjacent waiting area. This frees the gamma
camera for most of the time.
Analysis of Gastric Emptying
For each image taken, the gastric region was drawn using a
manually operated cursor. The geometric mean was calcu-
lated as the square root of the product of the anterior and
posterior counts corrected for time decay.
Several parameters were individually calculated for every
subject. These include calculation of percent gastric reten-
tion at 13 data collecting times, gastric retention curves
spanning the entire period from the end of the meal (T0) to
180 min later, and estimation of lag phase and T 1⁄2. Gastric
retention curve were generated using a power exponential
model, Propt ⫽ {⫺(␬t)␤}, where Propt is the proportion of
retention at time t.
Lag phase was defined a priori as the period extending
from the end of the meal to the time at which 5% of the
original gastric content has left the stomach, and T 1⁄2 as the
time to emptying of 50% of the original gastric content.
We compared two different approaches to generate gas-
tric retention curves: in the first instance we used the con-
ventional technique, and all data samples from each time
interval (every 10 min in the first 1 h, and every 20 min
thereafter) used to determine lag phase and T 1⁄2. In the
second instance we used a simplified method in which only
the gastric counts at T0 and 60, 120 and 180 min were used
to generate the gastric emptying curve and subsequently
calculate lag phase and T 1⁄2.
Statistics
As most of the measured data were not normally distributed,
results are primarily reported as medians, with 90th and 95th
percentiles, and plots presented as box and whiskers plots.
The central horizontal line of the box represents the median
and the bottom and top edges the 25th and 75th percentiles,
respectively. The whiskers extend from the box upward and
downward to the 10th and 90th percentiles, respectively.
Data that are normally distributed are reported as mean ⫾
2 SD (T 1⁄2 in particular). When appropriate, comparisons by
80 Tougas et al. AJG – Vol. 95, No. 1, 2000

99m
Table 1. Descriptive Statistics of Gastric Emptying of a Tc-Labeled Beef Liver Meal
Healthy Probability
Volunteers 1st 3rd of Normal 90th 95th
(N ⫽ 69) Median Quartile Quartile Skewness Distribution Percentile Percentile
% Gastric Retention
1h 77 70 85 ⫺1.29 ⬍0.0001 92 95
2h 42 ⫾ 36 29 53 ⫺0.12 ⬍0.5 67 70
3h 17 10 27 0.33 ⬍0.06 34 42
* As data for % retention at 2 h are normally distributed, mean ⫾ SD are presented.

groups were performed using repeated analysis of variance
(ANOVA) based on rank, two sample t test, Kruskal-Wallis,
and Wilcoxon rank-sum tests. Differences are considered
significant only at p ⬍ 0.05.
RESULTS
Sample Population: Demographic Characteristics
A total of 69 subjects (range 20 – 63 yr) were studied. There
were 33 men and 36 women. In all, 29 subjects (15 men and
14 women) were ⬍35 yr of age, and 40 subjects (18 men
and 22 women) were ⱖ35 yr.
Each of the seven centers contributed 10 subjects, with
the exception of one center, which recruited nine individu-
als. There were a total of 29 subjects from Ontario and 40
from Québec.
Effect of Gender and Age on Gastric Emptying
Although there are no overall significant differences be-
tween the gastric emptying of men and women, there are
significant differences between men and women ⬍35 yr of
age. Men exhibit a significantly faster gastric emptying than
women ⬍35 yr of age (p ⬍ 0.01, Fig. 3A). This is reflected
in longer mean T 1⁄2 in women than in men ⬍ 35 yr (118 and
91 min, respectively, p ⬍ 0.04). However there are no
differences in gastric emptying between men and women
ⱖ35 yr (p ⬍ 0.4) (Fig. 3B).
As shown in Figure 4A, younger men (⬍35 yr) empty
their stomach more rapidly than men ⬎35 yr (p ⬍ 0.005
overall, p ⬍ 0.02, 0.02 and 0.01 at 1, 2, and 3 h, respec-
tively). Correlation between percent residual and age of men
was significant at 2 and 3 h (p ⬍ 0.02) and nearly significant

Gastric Emptying of a Liver Meal: Descriptive Values

Table 1 shows the median measured percent gastric reten-
tion at 1, 2, and 3 h. The data are not normally distributed
(Fig. 1A, B, and C), particularly at 1 h (the probability of
normal distribution p ⬍ 0.0001); consequently, the median
and 90th or 95th percentile, rather than the mean and SD, are
used to determine normal values.
At 1, 2, and 3 h, the 90th percentile values for percent
gastric retention are 92%, 67%, and 34%, respectively. The
95th percentile values are 95%, 70%, and 42%, respectively,
for the same intervals.
Figure 2 shows the estimated gastric emptying curves
generated by the power exponential model (Propt ⫽
{⫺(␬t)␤}) using median ␬ and ␤ values derived from the
entire database. Both the simplified method, using only four
data points (0, 60, 120, and 180 min), and the conventional
method, which uses a total of 13 data points, provide es-
sentially identical results. The median lag phase and mean T
1⁄2, as determined by the conventional method, were 25 min

(5th and 95th percentile ⫽ 7 and 55 min) and 107 min

(normal range, defined as mean ⫾ 2 SD ⫽ 46 –169 min),
respectively.
The results are almost identical when only four data
samples are used, with the median lag phase being 24 min
(5th and 95th percentiles ⫽ 7 and 54 min) and the mean T
1⁄2 being 107 min (normal range, defined as mean ⫾ 2 SD ⫽

46 ⫺ 169 min). The calculated ␬ and ␤ were 0.0077 and

1.80 with the conventional method and were 0.0077 and Figure 1. Overall distribution of percent gastric retention of a beef
1.85 with the simplified scintigraphic method. All data are liver meal at 1, 2, and 3 h in 69 subjects. The distribution of the
summarized in Table 2 and Table 3. data are markedly skewed at 1 and 3 h, but less so at 2 h.
AJG – January, 2000
Figure 2. Overall estimated percent gastric retention curves gen-
erated using a power exponential model, either with frequent
imaging (dashed line, median ␬ ⫽ 0.0077 and median ␤ ⫽ 1.80),
or only with imaging at 0, 60, 120, and 180 min (solid line, median
␬ ⫽ 0.0077 and median ␤ ⫽ 1.85). The power exponential model
is defined as propt ⫽ {-(kt)␤} (see Materials and Methods).
at 1 h (p ⬍ 0.07). The calculated median lag phase and mean
T 1⁄2 were 21 and 91 min, respectively, in men ⬍35 yr and
29 and 115 min in men ⱖ35 yr (p ⬍ 0.05). There were no
comparable differences between women ⬍35 yr and ⬎35 yr
of age (p ⬍ 0.8 overall) (Fig. 4B).
Interinstitutional and Interprovincial Variability
As can be seen in Figure 5, there were no overall differences
in gastric emptying among participants from the seven dif-
ferent centers (p ⬍ 0.2). However, when grouped according
the province of origin, there were significant differences
between the four centers from Québec (⬎90% French Ca-
nadian origin) and the three centers from Ontario (⬍5% of
French Canadian origin). Overall, gastric emptying was
significantly slower in the centers located in French Canada
Table 2. Calculated Parameters Using Power Exponential Model Based on Four Data Points
Median
(1st to 3rd Quartile)
␬ 0.0077 (0.0065–0.0090)
␤ 1.85 (1.51–2.21)
T50 (min)* 107 (46–169)
Lag phase (min) 24 (18–38)
* As data for T50 were normally distributed, mean ⫾ 2 SD are reported.
Simplified Scintigraphy for Gastric Emptying Assessment 81
than in those located in English Canada (p ⬍ 0.04 overall).
Median lag phase and mean T 1⁄2 were, respectively, 20 and
96 min in Ontario and 27 and 116 min in Québec (p ⬍
0.009). This interprovincial difference is entirely attribut-
able to a significantly slower gastric emptying in women
from Québec (French Canada) compared to gastric empty-
ing in women from Ontario (English Canada, p ⬍ 0.04
overall, p ⬍ 0.02, 0.04 and 0.08 at 60, 120 and 180 min, see
Fig. 6A). There were no interprovincial differences in the
gastric emptying among men (p ⬍ 0.4 overall) (Fig. 6B).
Comparison Between Gastric Emptying of a
99m
Tc-Labeled Beef Liver Meal and a Low Fat
Meal Using 99mTc-Labeled Egg Substitute (Eggbeater)
In two centers (Hamilton and Montréal), we further com-
pared the values obtained using 99mTc-labeled beef liver and
a low fat meal using 99mTc-labeled synthetic egg prepara-
tion (EggBeater). The protocols used were identical in both
studies except for the preparation and nature of the meal.
The demographic characteristics of the participants were
comparable. The two meal have a very similar caloric con-
tent (liver meal ⫽ 275.5 kcal, low fat meal ⫽ 255 kcal). The
beef liver meal has higher fat content and different compo-
sition than the low fat meal (liver meal ⫽ 33.5% fat, 22.8%
carbohydrate, and 43.7% protein; low fat meal ⫽ 2% fat,
72% carbohydrate, 24% protein, plus 2% fiber).
Gastric emptying of a low fat meal was significantly more
rapid than gastric emptying of a beef liver meal which
contains more fat (overall, p ⬍ 0.03; p ⬍ 0.05 and 0.007 at
2 and 3 h, respectively, Fig. 7). Median lag phase and mean
T 1⁄2 were 17 min and 81 min, respectively, when using the
low fat egg substitute meal compared to 18 and 96 min with
the beef liver meal (p ⬍ 0.02).
Although most subjects found the low fat meal easier to
ingest, both meals were well tolerated and could be ingested
easily by everyone within the allotted time. Technical staff
involved generally found preparation of the low fat meal
easier than the preparation of the beef liver meal, which
requires an electric frying pan and freezer facilities to store
the frozen constituents. Cleaning of the cooking utensils was
also mentioned as an inconvenient feature of the liver meal.
DISCUSSION
A precise definition of what constitutes normal gastric emp-
tying remains elusive. A direct relationship is often missing
Probability
of Normal 10th to 90th 5th to 95th
Distribution Skewness Percentile Percentile
⬍0.0001 2.36 0.0056–0.0119 0.0052–0.0156
⬍0.004 1.09 1.29–2.53 1.26–2.89
ⱕ0.5 ⫺0.17 68–151 53–160
⬍0.002 0.90 13–49 7–54
82 Tougas et al. AJG – Vol. 95, No. 1, 2000

Table 3. Calculated Parameters Using Power Exponential Model Based on 13 Data Points
Probability
Median of Normal 10th to 90th 5th to 95th
(1st to 3rd Quartile) Distribution Skewness Percentile Percentile
␬ 0.0077 (0.0064–0.0090) ⬍0.0001 2.58 0.0056–0.0118 0.0051–0.0164
␤ 1.80 (1.48–2.14) ⬍0.0001 1.38 1.29–2.64 1.21–2.91
T50 (min)* 107 (46–169) ⬍0.8 ⫺0.13 71–149 46–158
Lag phase (min) 25 (17–36) ⬍0.0001 1.18 12–49 7–55
* As data for T50 were normally distributed, mean ⫾ SD reported.

between symptoms and evidence of delayed gastric empty-
ing (6) (7). Patients with seemingly delayed gastric empty-
ing are often completely asymptomatic, whereas others,
with ostensibly normal gastric emptying, are very symptom-
atic. The usual symptoms associated with delayed gastric
emptying (nausea, vomiting, bloating, early satiety, exces-
sive belching, and regurgitation) can result from not only
from gastroparesis but from other GI factors as well as from
several metabolic or neurological causes (8). In these con-
ditions, there is often no alteration of gastric emptying. It is
therefore clinically important to have methods capable of
objectively assessing gastric emptying in patients in whom
it may be contributing to symptoms, to better determine the
respective contributions of gastroparesis and other factors to
the symptoms reported.
An objective and reproducible assessment of gastric emp-
tying would also be very useful in clinical trials examining
the effects and clinical utility of prokinetic compounds on
gastric emptying and symptoms. Disorders of gastric emp-
tying being relatively uncommon, therapeutic trials studying
the efficacy of new drugs and approaches in those conditions
usually require the involvement of several centers for pa-
tient recruitment. At the present time, the techniques, meals,
and methods of analysis used for the scintigraphic assess-
ment of gastric emptying vary widely among institutions
(9 –13), and large multicenter trials with standardized tech-
niques are very difficult to conduct because of this lack of
standardization. As the data are generated differently at
different institutions, pooling of results is problematic if not
impossible.
Our study is the first multicenter study to use a standard-
ized methodology in seven different institutions to charac-
terize gastric emptying, in this case of healthy Canadian
adults of both genders. Our results demonstrate that, by
using a standardized methodology, data from different cen-
ters can in fact be pooled. These seven centers collectively
generated a database of 69 healthy volunteers, allowing us
to statistically determine the normal range in a healthy adult
Canadian population of different ages. Furthermore, the
large sample size also provided us with the statistical power
to examine the data set in a number of different ways and to
see if the procedure could actually be simplified and more
easily used in the clinical arena. Simplification has practical
implications. Presently, gastric emptying scintigraphy re-
quires frequent, if not continuous, sampling for 2– 4 h,
thereby monopolizing the use of a gamma camera for almost
the entire period (14, 15). This is something that is increas-
ingly difficult in an era of decreasing resources and acces-
sibility.
In the clinical setting, identification of delayed gastric
emptying is the necessary clinical endpoint. Therefore, our
approach was designed to define normal gastric emptying of
a standardized meal and to identify subjects with delayed
gastric emptying. In this context, the ideal measure is one
that will focus on the demonstration of an abnormal gastric
retention of a meal for a prolonged period. The measure-

Figure 3. Box whiskers plots of the male and female percent gastric retention at 1, 2, and 3 h, in subjects aged ⬍35 yr (A) and in subjects
ⱖ35 yr (B). The central horizontal line of the box represents the median and the bottom and top edges the 25th and 75th percentiles,
respectively. The whiskers extend from the box upward and downward to the 10th and 90th percentiles, respectively. There was a clear
gender effect in younger persons, p ⬍ 0.01, which was not present among older individuals (p ⬍ 0.4).
AJG – January, 2000 Simplified Scintigraphy for Gastric Emptying Assessment 83

Figure 4. Box whiskers plots of the percent gastric retention at 1, 2, and 3 h among groups separated according to age (⬍35 yr vs ⱖ35
yr) and gender. The central horizontal line of the box represents the median and the bottom and top edges the 25th and 75th percentiles,
respectively.The whiskers extend from the box upward and downward to the 10th and 90th percentiles, respectively. A: The significant
difference in percent gastric retention at 1, 2, and 3 h between younger (⬍35 yr) and older men is shown. B: Percent gastric retention at
1, 2, and 3 h between younger and older women. There was a significant overall age effect in men (p ⬍ 0.005) but not in women (p ⬍
0.8).

ment of percent gastric retention after 2, 3, or even 4 h is
probably a more useful index (16, 17). However, measures
such as T 1⁄2 or the lag phase may be more important than
percent gastric retention over time to assess gastric function
in relation to symptoms such as early satiety and fullness, or
in conditions such as functional dyspepsia. In these condi-
tions, it is the initial part of the postprandial period that
seems to be disordered (18).
Several aspects of the data deserve further attention. Gas-
tric emptying data are often described in terms of mean and
SD (5, 12). This approach implies that the data are normally
distributed, which is clearly not the case based on our
analysis (see Fig. 1). A more appropriate approach would be
to use the median and a range defined as either between the
5th and 95th percentiles or between the 10th and 90th
percentiles to define what constitutes normal emptying. If
such an approach is used, delayed gastric emptying would
Figure 5. Box whisker plots of the percent gastric retention at 1, 2,
and 3 h in all seven individual centers. The central horizontal line
of the box represents the median and the bottom and top edges the
25th and 75th percentiles, respectively. The whiskers extend from
the box upward and downward to the 10th and 90th percentiles,
respectively. There was no center effect at 1, 2, or 3 h (p ⬍ 0.2).
be defined by a gastric retention of ⬎34% (90th percentile)
or ⬎42% (95th percentile) of a standard beef liver meal at
3 h. These values are greater than those generally reported.
A more commonly used measure of gastric emptying is
the T50 or T 1⁄2 emptying time, the estimated time required
for the stomach to empty one-half of the original meal (19).
As our data indicate, these calculated values are more nor-
mally distributed, and the mean ⫾ standard deviations is
probably appropriate to define the normal range. However,
in a recent study examining the performance of scinti-
graphic gastric emptying studies in 173 different Canadian
hospitals, abnormal emptying was defined in a number of
ways, with widely different values, based on several differ-
ent criteria to describe the normal range (5). These criteria
sometimes, but not always, included the mean ⫾ 1 or 2 SD.
It ranged from as low as 36 min to as high as 125 min as the
upper limit of normal for T 1⁄2. On the basis of our own data,
generated among seven different centers, these previous
values seem to be underestimations and likely produce a
high incidence of false-positive results. Based on the present
database, T 1⁄2 values ⬍135 min (mean and 2 SD) should be
considered normal with a low fat meal (an egg substitute),
whereas a liver- based meal (with a higher fat content)
would require T 1⁄2 values ⬎169 min for delayed gastric
emptying to be demonstrated. Poitras et al. (20) have pre-
viously reported comparable values using similar meals in
another series of healthy volunteers examined in two of the
institutions included in the present study. In addition, using
a low fat meal indentical to the meal used in the present
study, we have previously reported nearly identical results
in a large international multicenter study involving 11 in-
stitutions in four different countries (21). If T 1⁄2 is used to
assess gastric emptying in that previous study, delayed
gastric emptying would be defined by a T 1⁄2 ⬎141 min, a
figure that is almost identical to that reported in the present
study (135 min).
84 Tougas et al. AJG – Vol. 95, No. 1, 2000

Figure 6. Calculated power exponential model of gastric emptying of a beef liver meal in subject from Ontario (English Canadians, solid
line) and from Québec (French Canadians, dashed line). A: Power exponential curves for women, ␬ ⫽ 0.0084 and ␤ ⫽ 1.72 among women
from Ontario. ␬ ⫽ 0.0069 and ␤ ⫽ 1.95 among women from Québec (p ⬍ 0.04). B: Power exponential curves in men; ␬ ⫽ 0.0078 and
␤ ⫽ 1.70 among men from Ontario. ␬ ⫽ 0.0079 and ␤ ⫽ 1.95 among men from Québec (p ⬍ 0.4).

Performance of gastric scintigraphy and analysis of the
data are cumbersome with the conventional methodology,
because of the necessity to obtain frequent (if not continu-
Figure 7. Box whisker plots of the percent gastric retention at 1, 2,
and 3 h of a beef liver meal (Beef) and a low fat meal (Egg), using
EggBeater. The central horizontal line of the box represents the
median and the bottom and top edges the 25th and 75th percentiles,
respectively. The whiskers extend from the box upward and down-
ward to the 10th and 90th percentiles, respectively. There was a
significant overall difference between the two meals (p ⬍ 0.03),
with the gastric retention of the beef liver meal being greater than
that of the egg substitute meal.
ous) imaging, to get a precise representation of the actual
emptying curve, and a reasonable estimate of parameters
such as T 1⁄2, and lag phase (10, 11, 15). Less frequent
imaging would go a long way in improving the clinical
utility and the applicability of the technique. Using our large
database, we have demonstrated that a much simpler ap-
proach to the analysis of scintigraphic data for the determi-
nation of gastric emptying is feasible and reliable. The
simplified power exponential model makes it possible to
describe describe and predict accurately the emptying be-
havior of the stomach after a standardized meal, using only
four scintigraphic readings rather than the 13 readings pres-
ently necessary. Our simplified approach provides nearly
identical values for the estimation of lag phase, and T 1⁄2 to
those obtained with the much more labor-intensive conven-
tional methods.
The simplified approach only requires hourly scinti-
graphic sampling (T0, then at 60, 120, and 180 min), does
not monopolize use of scintigraphic equipment for the entire
period of the study, and therefore allows the use of the
equipment for other purposes between readings. In an era of
cost constraints and increasing pressure toward a better, if
not optimal, use of equipment, this type of approach cer-
tainly has its appeal.
Gastric emptying has been shown to vary depending on
AJG – January, 2000
the age and gender of the subjects (22, 23). It tends to be
more rapid in younger subjects and in men. In the present
study, we find that in men, gastric emptying is more rapid in
younger (⬍35 yr) than older (ⱖ35 yr) individuals, but this
age effect was not seen in women. Others have previously
reported similar effects of age on gastric emptying, but not
specifically in men (24 –26). However different meals, with
lower fat content, were used. Horowitz et al. (26) further
argued that, although the age-related difference in gastric
emptying is statistically significant, it was unlikely to be
clinically significant. Our present results would tend to
support this assertion, as we found such a large variance and
a substantial overlap in what constitutes normal emptying in
both age groups. Furthermore, Madsen has also questioned
the effect of age on gastric emptying, having found it to be
similar across a wide age range (27).
Men have been shown to empty their stomachs more
rapidly than women (22, 28 –30). The present study supports
this observation, but only in younger men and women.
Interestingly, there were no detectable differences between
men and women ⬎35 yr. The difference in gastric emptying
could be entirely attributed to the difference observed in
subjects ⬍35 yr. This is in keeping with several previous
reports including the study of Knight et al. (31), who have
reported a similar difference in gastric emptying between
young women and young men.
When a beef liver meal is compared with a low fat
alternative such as the egg substitute used in the present
study, we find that the latter is emptied faster and more
completely at 3 h. In addition, the low fat meal was believed
to be more palatable and was actually preferred by most
subjects. Still, both the low fat meal and the beef liver meal
were generally well tolerated. Although the higher fat con-
tent of the beef liver meal is likely to result in a slower
gastric emptying, it is also possible that the different con-
sistency of the beef liver and the low fat meal may also
contribute to the observed difference.
Although there was no difference in gastric emptying
between men from Ontario and Québec, there was a sur-
prising but significant difference between women of the two
provinces, gastric emptying being much slower in Québec
women. The difference cannot be explained on the basis of
age. However, we are unable to confirm whether differences
in body mass index (BMI) could account for the difference
(29). In the present study, premenopausal women were not
studied at a specific time in their menstrual cycle. Therefore,
an involuntary but systematic bias resulting in the subjects
being studied at different times of their cycle in the three
English Canadian and the four French Canadian centers
cannot be completely ruled out. However, on statistical
grounds alone, this is very unlikely. Cultural or dietary
factors could also be involved, but further studies will be
needed to confirm and possibly to explain the reasons be-
hind this surprising observation.
In summary, accurate scintigraphic estimation of the gas-
tric emptying of a solid meal can be obtained with a sim-
Simplified Scintigraphy for Gastric Emptying Assessment 85
plified approach based on a power exponential model using
only four scintigraphic scans over 3 h. The method com-
pares favorably with the more labor intensive conventional
approach. The adoption of standardized methods would
facilitate comparability of results between institutions and
the conduct of multicenter trials. There are, however, sig-
nificant differences between men and women and between
younger and older individuals. There may be ethnic or
cultural factors involved in the differences observed be-
tween individuals originating from French- and English-
speaking Canada, although this original observation remains
to be confirmed.
ACKNOWLEDGMENT
This study was supported in part through an unrestricted
grant from Astra Hässle AB, Sweden.
Reprint requests and correspondence: Gervais Tougas,
M.D.C.M., F.R.C.P.C., Division of Gastroenterology, Digestive
Disease Research Unit, Room 3N5D, McMaster University Med-
ical Centre, 1200 Main Street West, Hamilton, ON, Canada L8N
3Z5.
Received Apr. 20, 1999; accepted Sep. 7, 1999.
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