1. Normalization of Delayed GastricNormalization of Delayed Gastric
Emptying after Treatment forEmptying after Treatment for
Bulimia NervosaBulimia Nervosa
Janet L. Guss, BT Walsh, HR Kissileff, EJanet L. Guss, BT Walsh, HR Kissileff, E
Zimmerli, R Sysko & MJ DevlinZimmerli, R Sysko & MJ Devlin
Obesity Research CenterObesity Research Center
Columbia UniversityColumbia University

2. Patients with Bulimia Nervosa (BN) have aPatients with Bulimia Nervosa (BN) have a
disturbance in the development of satiety:disturbance in the development of satiety:
Episodes of uncontrolled hyperphagiaEpisodes of uncontrolled hyperphagia
Rates of eating do not decline as meal progressesRates of eating do not decline as meal progresses
More food required to increase ratings of fullnessMore food required to increase ratings of fullness
Blunted post-prandial cholecystokinin (CCK) releaseBlunted post-prandial cholecystokinin (CCK) release

3. Gastric Emptying may be delayed in BN:Gastric Emptying may be delayed in BN:
Authors Delayed Emptying?Authors Delayed Emptying? CommentsComments
Shih et al, 1987Shih et al, 1987 Yes (12/20) other 8/20 acceleratedYes (12/20) other 8/20 accelerated
Robinson et al, 1988Robinson et al, 1988 No (1/10)No (1/10)
Cuellar et al, 1988Cuellar et al, 1988 Yes (2/5)Yes (2/5) only pts with GI symptomsonly pts with GI symptoms
Hutson & Wald, 1990Hutson & Wald, 1990 NoNo
Geliebter et al, 1992Geliebter et al, 1992 Yes /NoYes /No only @ 5 & 15 minonly @ 5 & 15 min
Inui et al, 1995Inui et al, 1995 YesYes small number of subjectssmall number of subjects
Devlin et al, 1997Devlin et al, 1997 Yes/NoYes/No delayed in 1 of 3 conditionsdelayed in 1 of 3 conditions

4. HypothesisHypothesis
Satiety disturbances in patients with BN maySatiety disturbances in patients with BN may
be perpetuated by delayed gastric emptyingbe perpetuated by delayed gastric emptying
Delayed emptying may blunt nutrient-Delayed emptying may blunt nutrient-
triggered release of gut peptides, such astriggered release of gut peptides, such as
CCK, that normally bring about satiationCCK, that normally bring about satiation

5. PurposePurpose
Confirm previous reports of delayed gastricConfirm previous reports of delayed gastric
emptying among patients with BNemptying among patients with BN
Determine whether disturbance normalizesDetermine whether disturbance normalizes
after cessation of binge & purge behaviorsafter cessation of binge & purge behaviors

6. ProcedureProcedure
Subjects:Subjects:
16 patients meeting DSM-IV criteria for BN16 patients meeting DSM-IV criteria for BN
16 demographically-matched controls16 demographically-matched controls
9 of the 16 patients retested, if they abstained from9 of the 16 patients retested, if they abstained from
bulimic behaviors for at least 4 weeksbulimic behaviors for at least 4 weeks
Procedure:Procedure:
Emptying ofEmptying of 99m99m
TcDTPA-labeled Ensure Plus (600g, 950TcDTPA-labeled Ensure Plus (600g, 950
kcal) monitored via gamma scintigraphykcal) monitored via gamma scintigraphy
Counts collected at 2-min intervals for 90 minutesCounts collected at 2-min intervals for 90 minutes
Counts determined within defined region of interestCounts determined within defined region of interest
(ROI) and converted to percentage of maximum counts(ROI) and converted to percentage of maximum counts

7. Experimental TimelineExperimental Timeline
PositionPosition
SSubjectubject
StartStart
GammaGamma
CameraCamera
600 g600 g
EnsureEnsure
PlusPlus
Stop GammaStop Gamma
CameraCamera
Radioactive counts acquired every 2 min for 90 min
PositionPosition
SubjectSubject

8. Subject Characteristics:Subject Characteristics: (Mean(Mean  SE)SE)
ControlsControls PatientsPatients
nn 1616 1616
Age (yrs)Age (yrs) 26.826.8 ±± 1.01.0 24.224.2 ±± 1.11.1
Weight (kg)Weight (kg) 62.262.2 ±± 1.51.5 59.459.4 ±± 1.91.9
Height (m)Height (m) 1.71.7 ±± 0.020.02 1.61.6 ±± 0.020.02
BMI (kg/m2)BMI (kg/m2) 21.721.7 ±± 0.40.4 22.122.1 ±± 0.70.7

9. Clinical Characteristics (MeanClinical Characteristics (Mean  SE)SE)
ControlsControls PatientsPatients DifferenceDifference
RestraintRestraint 6.56.5  5.75.7 13.713.7  4.74.7 p<.005p<.005
DisinhibitionDisinhibition 3.03.0  1.11.1 13.313.3  2.02.0 p<.001p<.001
HungerHunger 3.53.5  2.02.0 10.010.0  3.33.3 p<.001p<.001
Duration (yrs)Duration (yrs) ---- 11.311.3  7.57.5
Binges/wkBinges/wk ---- 18.218.2  27.727.7
Vomiting/wkVomiting/wk ---- 20.420.4  17.717.7

10. Data AnalysisData Analysis
Patients versus Controls: t-testsPatients versus Controls: t-tests
Amount emptied (g) over 90 minutesAmount emptied (g) over 90 minutes
Rate (g/min)Rate (g/min)
Patients, Pre versus Post Treatment: paired t-testsPatients, Pre versus Post Treatment: paired t-tests
Amount emptied over 90 minutesAmount emptied over 90 minutes
Rate (g/min)Rate (g/min)

11. Gastric Emptying: Patients vs ControlsGastric Emptying: Patients vs Controls
Time (min)
0 10 20 30 40 50 60 70 80 90
PercentofInitialRemaining
40
50
60
70
80
90
100
Bulimia Nervosa
Controls

12. Gastric Emptying: Pre vs Post Treatment
Time (min)
0 10 20 30 40 50 60 70 80 90
PercentageofInitialRemaining
40
50
60
70
80
90
100
Pretreatment
Post-treatment

13. Amount Emptied over 90 MinutesAmount Emptied over 90 Minutes
Bulimic Control Pre-Tx Post-Tx
AmountEmptied(g)
0
50
100
150
200
250
300
350
Patients
v p < 0.001
P < 0.001P < 0.001 P < 0.01P < 0.01

14. Bulimic Control Pre-Tx Post-Tx
EmptyingRate(g/min)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Patients
Gastric Emptying Rate (g/min)Gastric Emptying Rate (g/min)
P < 0.01P < 0.01
P < 0.05P < 0.05

15. SummarySummary
Patients with BN exhibited reducedPatients with BN exhibited reduced
gastric emptying which improvedgastric emptying which improved
significantly after termination ofsignificantly after termination of
binge/purge activitybinge/purge activity

16. ConclusionsConclusions
Normalization of gastricNormalization of gastric
emptying mayemptying may mediatemediate,,
oror be mediated bybe mediated by, a, a
return to normalizedreturn to normalized
eating patterns in BNeating patterns in BN
Future studies will testFuture studies will test
whether pharmacologicalwhether pharmacological
acceleration of gastricacceleration of gastric
emptying diminishes theemptying diminishes the
frequency and size of bingefrequency and size of binge
episodes among BN patientsepisodes among BN patients