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Gastro-intestinal ultrasound (GIUS) is a non-invasive and cost-effective tool, widely used as a first-line diagnostic method in patients presenting with abdominal complaints, especially in patients affected by inflammatory bowel disease (IBD), such as Crohn’s disease and ulcerative colitis. In this setting, gastro-intestinal ultrasound has been especially used to evaluate the bowel wall features (thickening, stratification, vascularization) and complications related to IBD (fistulas, abscesses). Nevertheless, gastro-intestinal ultrasound can be also used to detect and evaluate the content of several segments of the gut. In fact, there is a growing interest in utilizing GIUS for suspected functional disorders, where assessing intestinal content may play a significant diagnostic role, as well as directing therapy. In our review, we provided a sonographic description of GIUS appearances of bowel content in various pathological and physiological conditions, offering potential applications in clinical practice and providing insights for further research.

Purpose Fasting guidelines for children recommend restricting clear fluids for one or two hours before a procedure to reduce pulmonary aspiration. Gastric volumes < 1.5 mL·kg −1 do not seem to present an increased risk of pulmonary aspiration. Our aim was to quantify the time to achieve a gastric volume < 1.5 mL·kg −1 after clear fluid ingestion in children. Methods We conducted a prospective observational study in healthy volunteers aged 1–14 yr. Participants followed American Society of Anesthesiologists fasting guidelines prior to data collection. Gastric ultrasound (US) was performed in the right lateral decubitus (RLD) position to determine the antral cross-sectional area (CSA). Following baseline measurements, participants consumed 250 mL of a clear fluid. We then performed gastric US at four time intervals: 30, 60, 90, and 120 min. Data were collected following a predictive model for gastric volume estimation using the formula: volume (mL) = −7.8 + (3.5 × RLD CSA) + (0.127) × age (months). Results We recruited 33 healthy children aged 2–14 yr. The mean gastric volume per weight (mL·kg −1 ) at baseline was 0.51 mL·kg −1 (95% confidence interval [CI], 0.46 to 0.57). The mean gastric volume was 1.55 mL·kg −1 (95% CI, 1.36 to 1.75) at 30 min, 1.17 mL·kg −1 (95% CI, 1.01 to 1.33) at 60 min, 0.76 mL·kg −1 (95% CI, 0.67 to 0.85) at 90 min, and 0.58 mL·kg −1 (95% CI, 0.52 to 0.65) at 120 min. Conclusion Our results show that total gastric fluid volume was < 1.5 mL·kg −1 after 60 min, suggesting that current fasting guidelines for children could be liberalized.

ABSTRACTThis article in our series on point-of-care ultrasound (US) for the regional anesthesiologist and pain management specialist describes the emerging role of gastric ultrasonography. Although gastric US is a relatively new point-of-care US application in the perioperative setting, its relevance for the regional anesthesiologist and pain specialist is significant as our clinical practice often involves providing deep sedation without a secured airway. Given that pulmonary aspiration is a well-known cause of perioperative morbidity and mortality, the ability to evaluate for NPO (nil per os) status and risk stratify patients scheduled for anesthesia is a powerful skill set. Gastric US can provide valuable insight into the nature and volume of gastric content before performing a block with sedation or inducing anesthesia for an urgent or emergent procedure where NPO status is unknown. Patients with comorbidities that delay gastric emptying, such as diabetic gastroparesis, neuromuscular disorders, morbid obesity, and advanced hepatic or renal disease, may potentially benefit from additional assessment via gastric US before an elective procedure. Although gastric US should not replace strict adherence to current fasting guidelines or be used routinely in situations when clinical risk is clearly high or low, it can be a useful tool to guide clinical decision making when there is uncertainty about gastric contents.In this review, we will cover the relevant scanning technique and the desired views for gastric US. We provide a methodology for interpretation of findings and for guiding medical management for adult patients. We also summarize the current literature on specific patient populations including obstetrics, pediatrics, and severely obese subjects.

Preoperative gastric ultrasound allows non-invasive qualitative and quantitative assessment of gastric contents aiding in preoperative risk assessment. We hypothesized that appropriately fasted diabetic surgical patients taking GLP-1 agonists would have higher gastric volumes than those not taking GLP-1 agonists. This prospective, observational cohort study enrolled diabetic patients undergoing elective surgery, comparing those taking (n = 106) and not taking (n = 100) GLP-1 agonists. The primary outcome was gastric volume assessed via gastric ultrasound in the right lateral decubitus position. Secondary outcomes included presence of a full stomach (solids/thick liquids or greater than 1.5 mL/kg clear liquid), need for surgery delay, Perlas grade, and occurrence of intraoperative aspiration. The impact of GLP-1 agonist type, duration of use, and timing of last dose on gastric volume was also examined. Diabetic patients on GLP-1 agonists had significantly higher median gastric volumes compared to patients not on GLP-1 agonists (0.61 mL/kg vs 0.16 mL/kg, P < 0.001) and increased odds of a full stomach (OR 11.3, 95 % CI 5.2–24.7, P < 0.0001). GLP-1 agonist use correlated with higher Perlas grades (P < 0.001). Gastric volumes were significantly higher with GLP-1 agonist use within 7 days of surgery relative to use within 7–14 days or more than 14 days from surgery (P < 0.001 for both comparisons). GLP-1 agonist therapy was associated with higher residual gastric volumes and higher risks of full stomachs in fasted diabetic patients. GLP-1 agonist use within 7 days of surgery was also associated with higher gastric volumes relative to holding therapy for over 7 days, supporting current consensus-based guidelines. •GLP-1 agonist therapy was associated with higher residual gastric volumes.•Higher gastric volumes seen with cessation of GLP-1 agonists within 7 days of surgery.•No difference in gastric volumes when holding GLP-1 agonists 7–14 days and > 14 days.•This opposes consensus-based guidelines on preoperative cessation of GLP-1 agonists.

This study aimed to assess whether elevating the head of the bed to 45° was associated with sensitivity >90% of the qualitative ultrasound assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg−1. We also assessed the performance of qualitative assessment, composite ultrasound scale, and clinical algorithm, for the diagnosis of fluid volume > 1.5 ml.kg−1 according to whether the head of the bed was elevated to 45° or not. Prospective randomized observer-blind crossover trial. Hospices Civils de Lyon, France. Healthy adult volunteers. Two separate study sessions in fasting volunteers: with and without head-of-bed elevation to 45°, in a randomized order. Each session consisted of three tests, each corresponding to a randomized and different volume of water (either 0, 50, 100, 150 or 200 ml); the same volumes were used in both sessions and in a randomized order. Gastric ultrasounds were performed three minutes after the ingestion of water by an investigator blinded to the volume ingested. Diagnostic performance of each approach for the diagnosis of gastric fluid volume > 1.5 ml.kg−1. Twenty volunteers were included, and 120 measurements were analyzed. The sensitivity of the qualitative assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg−1 with and without head-of-bed elevation was 91% (95%CI: 75–98) and 75% (95%CI: 57–89), respectively. The clinical algorithm with head-of-bed elevation had significantly better sensitivity than the qualitative assessment with no head-of-bed elevation; there was no significant difference for other comparisons. The results suggest that qualitative examination of gastric antrum in the supine position with head-of-bed elevation to 45° can discriminate between low and high gastric fluid volume with high sensitivity, while neither the composite ultrasound scale nor the clinical algorithm improved the diagnostic performance of gastric ultrasound for the diagnosis of gastric fluid volume > 1.5 ml.kg−1. •Three approaches have been described for interpretation of gastric ultrasound•These approaches are of increasing complexity and their diagnostic performances is unclear•Qualitative assessment had high sensitivity to detect fluid volume > 1.5 ml.kg−1•Composite scale and clinical algorithm had similar diagnostic performance

Interpretation of postmortem morphine concentrations in forensic toxicology provides several pitfalls such as missing information on tolerance, analyte stability, or postmortem redistribution (PMR). Recently, it had been shown that computed tomography (CT)-guided collection of biopsies using a robotic arm (virtobot) provides a valuable strategy for systematic studies on time-dependent PMR. Using this technique, time-dependent PMR of morphine and its metabolites was investigated in 12 cases. At admission to the institute (t1), femoral and heart blood (right ventricle) as well as biopsies from the right lung, the right kidney, liver, spleen, and muscle tissue were collected. At autopsy approximately 24 h later (t2), samples from the same body regions were collected again. Additionally, gastric contents, urine, brain tissue, and heart blood from the left ventricle was collected. Morphine, normorphine, hydromorphone, morphine-3-glucuronide, morphine-6-glucuronide, and morphine-sulfate were quantified with LC-MS/MS. In femoral blood, significant increase of morphine concentrations was observed, although ultimately not relevant for forensic interpretation. In the alternative matrices, increases as well as decreases were observed without a clear trend. The morphine metabolites did not exhibit relevant concentration changes. Investigation of underlying redistribution mechanisms indicated that concentration change (i.e., increase) of morphine in femoral blood rather resulted from diffusion processes than from release of morphine from its conjugates. Concentration changes in heart blood might have been caused by redistribution from lung tissue or gastric content. This study also proved that CT-guided collection of biopsies using a virtobot arm is an invaluable tool for future studies on PMR redistribution of other substance groups.

Point-of-care ultrasound (POCUS) is an inexpensive and often readily available tool for anesthesia providers to utilize to assess gastric content, both qualitatively and quantitatively, in the perioperative arena. Gastric POCUS requires the anesthesia provider to be trained and proficient in technique and interpretation of findings to accurately guide decision-making for patient care. The American Association of Nurse Anesthesiology, the American Society of Anesthesiologists, and the American Society of Regional Anesthesia have established guidelines supporting the use of gastric POCUS. This article aims to provide an integrative review of the literature surrounding current strategies in education and assessment of anesthesia provider competency in the perioperative utilization of gastric POCUS. Strict inclusion and exclusion criteria were used yielding eight articles in an effort to help determine feasible, efficient, reliable, and beneficial educational strategies to improve anesthesia provider competency. Findings suggest success with various educational strategies, including didactic, hands-on, electronic, and self-directed courses on gastric POCUS, supported by improved postintervention analyses of provider competency.

Background Pulmonary aspiration syndrome remains a significant complication of general anesthesia, particularly in unfasted patients. Gastric point-of-care ultrasound (POCUS) allows for both qualitative and quantitative assessment of gastric content, providing a safe and reliable method to assess gastric emptying and reduce the risk of aspiration during general anesthesia. Methods The survey was distributed to Belgian certified anesthesiologists and trainees between April 2020 and June 2021. Participants received a simulated clinical case of a patient at risk of gastric aspiration, created and approved by two certified anesthesiologists trained to perform gastric POCUS. The objectives of this study were to assess recognition of high-risk clinical situations for gastric aspiration, awareness of the gastric POCUS and its indications, and knowledge of the technical and practical conditions of the procedure among respondents trained in the technique. Furthermore, the study assessed the state of training in gastric POCUS, the desire for education, and the practical availability of ultrasound equipment. The survey used conditional branching to ensure unbiased responses to POCUS-related questions. It included multiple-choice questions, quantitative variables, and 5-point Likert scales. The margin of error was calculated using Daniel’s formula, corrected for a finite population. Results The survey was conducted among 323 anesthesiologists. Only 20.8% (27) recognized the risk of a full stomach based on the patient’s history. Anesthesiologists who recognized the indication for gastric POCUS and were trained in the procedure demonstrated good recall of the practical conditions for performing the procedure and interpreting the results. Only 13.08% (31) of all respondents had received training in gastric POCUS, while 72.57% (172) expressed interest in future training. Furthermore, 80.17% (190) of participants had access to adequate ultrasound equipment and 78.90% (187) supported teaching gastric POCUS to anesthesia trainees. Conclusions This survey offers insight into the epidemiology, clinical recognition, knowledge, and utilization of gastric POCUS among Belgian anesthesia professionals. The results emphasize the significance of proper equipment and training to ensure the safe and effective implementation of gastric POCUS in anesthesia practice. Additional efforts should focus on improving training and promoting the integration of gastric POCUS into daily clinical practice.

Background The aspiration of gastric residual volume through the gastric tube increases the risk of feed interruption episodes, prolongs the time needed to achieve full enteral feeding and regain birth weight, and may potentially damage the gastric mucous. This study aimed to develop a point-of-care ultrasound-based model to calculate gastric residual volume in preterm infants. Methods This observational study enrolled 100 preterm infants who fed by gastric tube. The collected data included general characteristics of the preterm infants, the antral cross-sectional area in the right lateral position within 30 min prior to feeding and the gastric residue volume measured through gastric tube. A linear regression analysis was conducted to assess the relationship between the antral cross-sectional area and the aspirated gastric residual volume, with the calculation of the Pearson correlation coefficient. A stepwise linear multiple regression was employed to model the relationship between the suctioned residual volume and the parameters under consideration. Subsequently, we utilized the Bland-Altman plot to assess the agreement between the gastric residual volume measured by aspiration and our model, respectively. Results Overall, 89 preterm infants were included in the final analysis. Pearson correlation analysis revealed a significant correlation between the gastric antral cross-sectional area in the right lateral decubitus position and the suctioned volume ( P  < 0.001; correlation coefficient: 0.905). We developed an ultrasound calculation model as follows: Volume (ml)= -3.74 + 9.08 × Gastric Antral Cross-Sectional Area (measured in the right lateral decubitus position) (cm2). When comparing the ultrasound calculated volume and suctioned volume, the mean was 0.05 ml kg-1 and the limit of consistency was − 1.59 to 1.69 ml kg-1 between the ultrasound calculated volume and suctioned one. Conclusion The use of ultrasound to assess gastric residual volume (GRV) offers a promising alternative to gastric tube suction, potentially reducing associated complications and enhancing enteral nutrition management in preterm infants. Our study represents a pioneering effort in the development of a point-of-care ultrasound-based calculation model for non-invasive GRV assessment in this vulnerable population. Significance What is already known on this topic 1. Nurses mainly assess the gastric residual volume by aspirating the gastric contents via an gastric tube, which interferes with the rehabilitation process to a certain extent. 2. There is a significant relationship between the antral cross-sectional area and gastric residual volume. 3. Ultrasound examination of the antrum is an easy-to-perform tool that may allow reliable assessment of the gastric residual volume in both adults and children. What this study adds 1. This study demonstrates that the cross-sectional area of the gastric antrum in the right lateral decubitus is a crucial factor for estimating gastric residual volume in preterm infants. 2. This study established a model for calculating gastric residual volume in premature infants using ultrasound. How this study might affect research, practice or policy 1. The findings of this study could potentially impact the assessment of gastric residual volume in preterm infants and facilitate the implementation of intestinal feeding.

Background Perioperative reflux aspiration presents a grave concern during sedation or general anesthesia, particularly when solid gastric contents prompt acute upper respiratory obstruction, potentially resulting in fatal consequences for patients. Currently, there are limited means for promptly assessing solid gastric contents in clinical settings. Therefore, this study examined the efficacy of ultrasound assessment for solid gastric contents, offering a rapid and non-invasive approach for early detection and decision-making regarding interventions. Methods The study included 400 patients scheduled for upper endoscopy procedures, which encompassed both gastroscope and gastroscope combined colonoscopy examinations with sedation. Ultrasound scanning of the antrum was performed while patients were positioned semi-sitting or in the right lateral decubitus (RLD) posture. The evaluation of solid gastric contents relied on direct visual observation during endoscopy. Gastric volume measurement occurred subsequent to endoscopic suction of gastric contents. Receiver operating characteristic curves were utilized to assess the effectiveness of ultrasonography in discerning solid contents. Result Seven patients undergoing gastroscope with sedation were found to have solid gastric contents. The sensitivity, specificity, positive predictive value, and negative predictive value of the ultrasound qualitative evaluation of solid contents were 85.7%, 99%, 60%, and 99.7%, respectively. Conclusion Solid stomach contents can be evaluated qualitatively with reasonable accuracy using ultrasonography. Additionally, in patients undergoing upper endoscopy and assessed to have solid gastric contents with ultrasound, administration of mild sedation is recommended. Trial registration www.chictr.org.cn (ChiCTR2100048994); registered 19/07/2021.