Anaesthesia 2017, 72, 1344–1350 doi:10.1111/anae.

14026

Original Article
A comparison of gastric emptying of soluble solid meals and clear
fluids matched for volume and energy content: a pilot crossover
study
T. Okabe,1 H. Terashima2 and A. Sakamoto3

1 Chief Physician, Department of Anaesthesiology, Hitachi Ltd., Hitachinaka General Hospital, Hitachinaka-shi, Japan
2 Professor, Hitachinaka Medical Education and Research Center, University of Tsukuba Hospital, Hitachinaka-shi,
Japan
3 Professor, Department of Anaesthesiology, Nippon Medical School, Tokyo, Japan

Summary
We previously demonstrated that the gastric emptying time of different liquids with the same volume mainly
depended on their energy content, regardless of differences in composition. In this crossover study, we investigated
whether the same applies when soluble solid foods are ingested with water. Ten healthy volunteers ingested one of
five test diets consisting of two test meals (Calorie Mateâ 100 and 200 kcal) and three test solutions (water and glu-
cose solutions of 100 and 200 kcal), each given in a volume of 400 ml, and then underwent ultrasonography to mea-
sure the gastric antral cross-sectional area every 10 min for 120 min. The gastric emptying time was defined as the
time for the antral cross-sectional area to revert to its initial value. When test diets with the same energy content
were ingested, the gastric emptying curves were nearly identical, regardless of whether the original form was solid or
liquid. The median (IQR[range]) gastric emptying times of Calorie Mateâ of 100 kcal with water vs. isocaloric glu-
cose solution were 65 (60–78 [50–80]) vs. 65 (60–70 [50–80]) min (p = 0.58), and for Calorie Mateâ of 200 kcal
with water vs. isocaloric glucose solution they were 100 (93–108 [90–120]) vs. 105 (90–110 [90–120]) min
(p = 0.54). The median (IQR [range]) for water was 40 (30–40 [30–50]) min. Energy content may be a critical deter-
minant of the gastric emptying time when ingesting soluble solid diets with water.
.................................................................................................................................................................
Correspondence to: T. Okabe
Email: t-okabe@nms.ac.jp
Accepted: 11 July 2017
Keywords: gastric emptying time; isocaloric fluids and solid foods; pre-operative fasting; ultrasonography

Introduction times before elective procedures requiring general

Two major practice guidelines for pre-operative fasting
drawn up by American Society of Anesthesiologists
(ASA) [1] and European Society of Anaesthesiology
(ESA) [2] recommend 6 h or more from the intake of
a light meal or non-human milk and 2 h or more
from the intake of clear fluids as appropriate fasting
anaesthesia. These recommendations were based on
several studies, most of which were conducted on the
ingestion of liquids, not solids; only two studies [3, 4]
involving solids were cited in the above-mentioned
guidelines [1, 2]. More importantly, the first guideline
merely provides a brief explanation of ‘light meal’,

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Okabe et al. | Gastric emptying time of isocaloric fluids and solids
with only one example given, namely ‘toast and clear
liquid’ [1], making it difficult to exactly understand what
‘light meal’ represents. Thus, to date, there seems to
have been no hard evidence regarding the pre-operative
fasting period after ingestion of solid foods. A rational
next step, in our view, would be to establish the underly-
ing principles of gastric emptying rather than just evalu-
ating the emptying times of various solids or liquids
individually. Our previous work has already established
several principles for gastric emptying of liquids [5, 6].
The fundamental principles are as follows: if the initial
volume of liquid ingested is fixed, it is the energy con-
tent (total amount of calories) which is the critical deter-
minant of liquid gastric emptying, regardless of
compositional differences in the liquid [5]; the energy
content of the liquid ingested may be a primary determi-
nant of the gastric emptying rate rather than the volume
[5, 6]. We therefore wished to examine whether the
above principles might also apply when ingesting sol-
uble solid diets with water.
Methods
The study was designed as a crossover study, but was
not blinded due to the nature of the study protocol.
Ethical approval was received from the Hitachi Ltd.,
Hitachi General Hospital Research Ethics Committee.
Ten healthy young subjects participated in this
study as volunteers. Written informed consent was col-
lected from each participant. A questionnaire including
health history and physical activity was obtained from
each participant, confirming that all 10 subjects were
free of medical conditions associated with delayed gas-
tric emptying, for example, diabetes, severe obesity and
gastric diseases.
In line with the recommendations for pre-opera-
tive fasting before general anaesthesia [1, 2], the inges-
tion of solids was stopped 6 h, and clear fluids 2 h,
before the examination. Each subject was randomly
assigned, using sealed envelopes, to ingest one of the
five test diets (consisting of two test meals and three
test solutions) over the course of approximately 3 min
each time. After ingestion, subjects maintained a seated
position at a 45° angle except when they underwent
an ultrasound examination every 10 min, where ultra-
sonic assessment of the cross-sectional area of the gas-
tric antrum was performed with the patient in the
© 2017 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2017, 72, 1344–1350
right lateral position. To ensure technical uniformity,
all measurements were performed by only one evalua-
tor (the lead author of this study). The same subject
had another one of the five test diets on a different
day (there was no fixed interval between tests) and
underwent the same ultrasound examination. This pat-
tern was repeated until each subject had ingested all
five diets. These consisted of:
1 One piece of Calorie Mateâ (Otsuka Pharmaceuti-
cal Factory, Tokushima, Japan) + 380 ml of water
(100 kcal, total 400 ml when mixed): the Calorie
Mate 100 group.
2 Two pieces of Calorie Mate + 360 ml of water
(200 kcal, total 400 ml when mixed): the Calorie
Mate 200 group.
3 6.25% glucose solution (100 kcal, 400 ml): the glu-
cose 100 group.
4 12.5% glucose solution (200 kcal, 400 ml): the glu-
cose 200 group.
5 Four hundred ml of water: the water group.
Calorie Mate is a solid nutrient with a similar
appearance to shortbread that melts relatively easily
into a sticky mass when ingested with water.
Although it is available in five flavours, chocolate
Calorie Mate was selected for use in the present
study. The total volume of each test diet was 400 ml;
in the test meals, the volumes of water ingested with
Calorie Mate were selected to occupy the same vol-
ume (400 ml) as the test liquids in the stomach. The
compositions of the individual test diets used in the
five groups are shown in Table 1. The largest amount
of calories in the test diets was set at 200 kcal, based
on the recommendations of the Enhanced Recovery
After Surgery (ERAS) group [7]; the intake of 400 ml
of 12.6% glucose solution (total: approximately
200 kcal in 400 ml) up to 2 h before surgery is con-
sidered safe and feasible. Furthermore, we previously
demonstrated that drinks not exceeding 220 kcal were
more likely to completely pass out of the stomach
within 120 min of their ingestion [5]. Based on these
findings, the measurement period in the present study
was set at 120 min.
During ultrasound imaging, the gastric antrum
was identified in the sagittal to right parasagittal plane
using the left lobe of the liver, the pancreas, abdominal
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Anaesthesia 2017, 72, 1344–1350 Okabe et al. | Gastric emptying time of isocaloric fluids and solids

Table 1 Compositions of the five individual test diets used.

Calorie Mate Calorie Mate Glucose Glucose

Components 100 group 200 group 100 group 200 group Water group
Liquid nutrient; ml 0 0 400 400 0
Solid nutrient; g 20 40 0 0 0
Protein; g 2.15 4.3 0 0 0
Lipid; g 5.6 11.2 0 0 0
Sugars; g 10 20 25 50 0
Dietary fibre glucose; g 0.5 1 0 0 0
Sodium; mg 80 160 0 0 0
Potassium; mg 42.5 85 0 0 0
Calcium; mg 50 100 0 0 0
Magnesium; mg 12.5 25 0 0 0
Phosphorus; mg 22.5 45 0 0 0
Iron; mg 0.625 1.25 0 0 0
Water; ml 380 360 375 350 400
Total calories; kcal 100 200 100 200 0
Total volume; ml 400 400 400 400 400

Calorie Mate 100 group: one piece of Calorie Mate + 380 ml of water. Calorie Mate 200 group: two pieces of Calorie
Mate + 360 ml of water. Glucose 100 group: 400 ml of 6.25% glucose solution. Glucose 200 group: 400 ml of 12.5% glucose solu-
tion. Water group: 400 ml of water.

aorta or inferior vena cava as anatomical landmarks,
as described previously [5, 6, 8–11]. When the mini-
mal antral cross-sectional area of the gastric antrum
was imaged using ultrasonography (Hi Vision AVIUS,
Hitachi Aloka Medical, Ltd., Tokyo, Japan), the antero-
posterior (AP) and craniocaudal (CC) diameters were
both measured and recorded in the database, as
described previously [5, 6, 8–11].
The following formula was used to calculate the
antral cross-sectional area:
cross-sectional area ¼ p  AP  CC=4
The time required for the cross-sectional area to
return to the level within the 10% error range of
the initial value was defined as the gastric emptying
time. A graph with a time scale on the x-axis and
measured values of the antral cross-sectional area on
the y-axis was used to obtain gastric emptying
curves. Statistical analyses for comparisons of each
group were performed with the Kruskal–Wallis H-
test. When the analysis of variance was found to be
significant at the 95% confidence level, multiple
comparisons between groups were performed using
the Mann–Whitney U-test with Bonferroni correc-
tions. A p value of < 0.05 was considered to be sig-
nificant. All statistical analyses were conducted using
Excel Statistical Program File Ystat 2013 (developed
by Yamazaki S, Igakutosyo Syuppan Co., Ltd.,
Tokyo, Japan).
Results
Ten healthy men consented to, were enrolled in, and
completed the study. Their mean (SD) physical charac-
teristics were: age 29.6 (5.2) years; height 169.2
(4.2) cm; weight 62.6 (7.7) kg; and body mass index
22.1 (2.5) kg.m2. Figure 1 shows typical ultrasound
images obtained during this study.
Figure 2 shows the gastric emptying curves.
Between groups with the same energy content,
namely the Calorie Mate 100 group vs. the glucose
100 group and the Calorie Mate 200 group vs. the
glucose 200 group, there were near-overlapping
changes in the cross-sectional area of the gastric
antrum over time. The mean antral cross-
sectional area in the water group decreased in an
exponential manner, and returned to its baseline
value 40 min after ingestion.
The median (range [IQR]) gastric emptying times
obtained in the Calorie Mate 100, Calorie Mate 200,
glucose 100, glucose 200 and water groups were 65
(60–78 [50–80]), 100 (93–108 [90–120]), 65 (60–70
[50–80]), 105 (90–110 [90–120]) and 40 (30–40 [30–
50]) min, respectively (Fig. 3). In all groups,
the ingested material passed from the stomach into the

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Okabe et al. | Gastric emptying time of isocaloric fluids and solids Anaesthesia 2017, 72, 1344–1350

(a) (b)

(c) (d)

Figure 1 (a) Sagittal sonogram of the empty gastric antrum. The antrum is found between the left lobe of the liver
and the pancreas, at the level of the aorta or inferior vena cava. (b) Sagittal sonogram of the gastric antrum 10 min
after the ingestion of 400 ml of 12.5% glucose solution (the glucose 200 group). The antrum appeared distended with
a hypo-echoic fluid content. (c) Sagittal sonogram of the gastric antrum 10 min after the ingestion of two pieces of
Calorie Mate with 360 ml of water (the Calorie Mate 200 group). The antrum appeared distended with hyperechoic
particles suspended in hypo-echoic fluid. (d) Sagittal sonogram of the gastric antrum 10 min after the ingestion of
400 ml of water (the water group). The antrum appears distended with hypo-echoic fluid. Arrow denotes gastric
antrum; L, liver; P, pancreas; Ao, aorta.

small intestine within 120 min of ingestion. No signifi- Discussion

cant differences were observed between the Calorie
Mate 100 group and the glucose 100 group (p = 0.57)
or between the Calorie Mate 200 group and glucose
200 group (p = 0.54), indicating that when the energy
content and total volume of the ingested material are
equal, gastric emptying times may become the same,
independent of compositional differences and physical
state of the ingested material. The gastric emptying
time of the Calorie Mate 200 group was significantly
longer than that of the Calorie Mate 100 group
(p = 0.01) and, similarly, the gastric emptying time of
the glucose 200 group was significantly longer than
that of the glucose 100 group (p = 0.01), showing that
gastric emptying takes longer when the energy content
of the ingested material is higher. The gastric emptying
time of the water group (calorie-free) was significantly
shorter than those of the other groups (p = 0.02 vs.
the Calorie Mate 100 group; p = 0.02 vs. the glucose
100 group; p = 0.01 vs. the Calorie Mate 200 group;
p = 0.01 vs. the glucose 200 group).
This study suggests that when the energy content and
total volume of ingested materials are equal, gastric
emptying times may be the same independent of com-
positional differences and whether the original form of
the material is solid or liquid. This result follows the
two principles for liquid gastric emptying we identified
in our previous studies [5, 6]: firstly, that for a given
volume of liquid, the total amount of calories (energy
content) is a critical determinant of liquid gastric emp-
tying regardless of compositional differences [5]; and
secondly, that the energy content of the liquid
ingested, rather than its volume, may be a primary
determinant of the gastric emptying rate [5, 6]. The
present study indicates that these principles also hold
true when the ingested material is originally in solid
form. It therefore is possible to suggest that patients
may take tea with milk and shortbread 2 h or more
before general anaesthesia as long as the energy con-
tent and total volume are less than, or equal to,
200 kcal and 400 ml, respectively. However, since the

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Anaesthesia 2017, 72, 1344–1350
Figure 2 Gastric emptying curves over time after
ingesting one of the five test diets. Calorie Mate 100
group (■), one piece of Calorie Mateâ + 380 ml of
water (100 Kcal, 400 ml); Calorie Mate 200 group (○),
two pieces of Calorie Mateâ + 360 ml of water
(200 Kcal, 400 ml); Glucose 100 group (□), 400 ml of
6.25% glucose solution (100 Kcal); Glucose 200 group
(●), 400 ml of 12.5% glucose solution (200 Kcal);
Water group (◇), 400 ml of water (0 Kcal). Values
are mean  SE.
solid nutrient (Calorie Mateâ) used in the present
study melted into a sticky mass when ingested with
water, it is premature to apply the above result to the
ingestion of various solid foods.
Previous studies indicated that the gastric empty-
ing time is longer for solids with high calorific con-
tents [12–18], and solids may take more time to
leave the stomach than liquids because of the time
required for grinding processes [15, 19–21]. The for-
mer finding supports the results of the present study
(Fig. 3, Calorie Mate 100 group vs. Calorie Mate 200
group), and is reasonable based on the principles we
have previously described. The latter finding needs to
be carefully interpreted because the solid and liquid
diets used in the previous studies had clear differ-
ences in energy contents, which may affect gastric
emptying times more than the physical properties by
virtue of the time required for grinding processes.
Calorie Mate, used as the solid diet in the present
study, has a similar appearance to shortbread and
was expected to melt relatively easily into a sticky
mass in the stomach when ingested with water.
Ultrasonographic findings indicated that Calorie Mate
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Okabe et al. | Gastric emptying time of isocaloric fluids and solids
Figure 3 Gastric emptying times in the five groups.
Each data-point is presented as a box and whisker
plot. The box denotes the first and third quartiles, with
the whiskers representing the range. The median is
indicated by the line or, in the water group, a circle.
Calorie Mate 100 group, one piece of Calorie Mateâ +
380 ml of water (100 Kcal, 400 ml); Calorie Mate 200
group, two pieces of Calorie Mateâ + 360 ml of water
(200 Kcal, 400 ml); Glucose 100 group, 400 ml of
6.25% glucose solution (100 Kcal), Glucose 200 group,
400 ml of 12.5% glucose solution (200 Kcal); Water
group, 400 ml of water (0 Kcal).
was broken up into smaller pieces and uniformly dis-
tributed throughout the fluid component of the stom-
ach (Fig. 1C). The gastric emptying curves of the
Calorie Mate 100 group and Calorie Mate 200 group
exhibited similar changes to those of the glucose 100
group and glucose 200 group, respectively, which is
in accordance with the comparability of each energy
content (Fig. 2). As a corollary, no significant differ-
ences were observed in gastric emptying times among
groups with the same energy content, that is, the
Calorie Mate 100 group vs. the glucose 100 group
and the Calorie Mate 200 group vs. the glucose 200
group (Fig. 3). Thus, a solid diet with the property of
melting into a sticky mass when ingested with water
may not cause delayed gastric emptying associated
with grinding processes. These results also suggest
that an increase in the viscosity of gastric contents
due to the ingestion of Calorie Mate does not exert a
major effect on gastric emptying. In support of this
possibility, Juvonen et al. reported that viscosity did
not markedly affect gastric emptying times [22]. They
compared lower and higher viscosity beverages, and
although the difference in viscosity was very large
© 2017 The Association of Anaesthetists of Great Britain and Ireland
Okabe et al. | Gastric emptying time of isocaloric fluids and solids
(less than 250 mPa-s vs. greater than 3000 mPa-s),
the gastric emptying rate was only 1.1-fold greater.
Feinle et al. investigated the validity of magnetic reso-
nance imaging as a method for measuring the empty-
ing of a mixed solid/liquid meal [23]. Consistent with
the results of the present study, they concluded that
magnetic resonance imaging may be used to reliably
measure the gastric emptying not only of liquids but
also of mixed solid/liquid meals in humans, and
found no significant differences in gastric emptying
times between liquids and mixed solid/liquid test
meals of an identical macronutrient composition,
energy content and weight. Despite this significant
finding, they did not explain why liquids and mixed
solid/liquid test meals had the same gastric emptying
times, and also did not attempt to elucidate the
underlying principles of gastric emptying. It is note-
worthy that two different modalities, ultrasonography
and magnetic resonance imaging, provided similar
results. Distinct from the study conducted by Feinle
et al., we obtained a novel insight; when the energy
content and total volume of the ingested material are
equal, gastric emptying times may become the same
independent of ‘compositional differences’ and
whether the original form of the material is solid or
liquid.
There were some limitations to the present study.
As has been already noted, the results cannot be
applied to the ingestion of other types of solid food.
Similarly, the results may not necessarily be applied to
patients undergoing anaesthesia and surgery, because
all subjects who participated in the present study were
young and physically and mentally healthy, which dif-
fers from actual clinical settings. Furthermore, the
number of subjects (n = 10) was relatively small, sug-
gesting that the present study needs to be regarded as
a pilot or exploratory study.
However, we believe that the stepwise establish-
ment of the underlying principles of gastric emptying
will result in evidence being obtained to support prac-
tice guidelines for pre-operative fasting and will con-
tinue our investigations.
Acknowledgements
This trial was registered on the University Hospital
Medical Information Network (UMIN) Clinical Trials
© 2017 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2017, 72, 1344–1350
Registry (ref.: UMIN000023833). No external funding
or competing interests declared.
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