Blackwell Science, LtdOxford, UKJGHJournal of Gastroenterology and Hepatology0815-93192004 Blackwell Publishing Asia Pty LtdXXX 2004204502516Review ArticleReview of EGGF-Y

Chang

Journal of Gastroenterology and Hepatology (2005) 20, 502–516 DOI: 10.1111/j.1400-1746.2005.03751.x

REVIEW

Electrogastrography: Basic knowledge, recording, processing and

its clinical applications

FULL-YOUNG CHANG

Division of Gastroenterology, Taipei Veterans General Hospital and National Yang-Ming University School of
Medicine, Taipei, Taiwan

Abstract The slow wave (SW) of the gastrointestinal (GI) tract mainly functions to trigger the onset
of spike to elicit smooth muscle contraction, which provides the essential power of motility. Smooth mus-
cle myogenic control activity or SW is believed to originate in the interstitial cells of Cajal (ICC). The
electrical coupling promotes interaction between muscle cells, and ICC additionally contribute to SW
rhythmicity. Stomach SW originates in the proximal body showing the continuous rhythmic change in
the membrane potential and propagates normally to the distal antrum with a regular rhythm of approx-
imately 3 c.p.m. A technique using electrodes positioned on the abdominal skin to pick up stomach
rhythmic SW refers to electrogastrography (EGG). The stomach SW amplitude is very weak, while many
visceral organs also produce rhythmic electricities, for example heartbeat, respiration, other organs of the
GI tract and even body movements. Thus noise other than SW should be filtered out during the record-
ing, while motion artifacts are visually examined and deleted. Finally, the best signal among all record-
ings is selected to compute EGG parameters based on spectral analysis. The latter is done not only to
tranform frequency domain to time domain but also to provide information of time variability in fre-
quency. Obtained EGG parameters include dominant frequency/power, % normal rhythm, % bradyga-
stria, % tachygastria, instability coefficient and power ratio. Clinical experience in EGG has been
markedly accumulated since its rapid evolution. In contrast, lack of standardized methodology in terms
of electrode positions, recording periods, test meals, analytic software and normal reference values
makes the significance of EGG recording controversial. Unlike imaging or manometrical studies, stom-
ach motility disorders are not diagnosed based only on abnormal EGG parameters. Limitations of EGG
recording, processing, computation, acceptable normal parameters, technique and reading should be
known to conduct subjective assessments when EGG is used to resolve stomach dysfunction. Under-
standing basic SW physiology, recording methodology and indications may open EGG as a new domain
to approach the stomach motor dysfunction.
© 2005 Blackwell Publishing Asia Pty Ltd

Key words: action potential, electrogastrography, Helicobacter pylori, myoelectricity, power, rhythm,
slow wave.

INTRODUCTION the emotional and humoral states.2 The stomach muscle

itself also presents a myogenic character to mediate
The purpose of stomach physiological functions stomach motility. Both slow wave (SW; electrical con-
includes secretion, digestion, mixing and emptying. In trol activity) and spike (electrical response activity) are
order to achieve this, controlled mechanisms are the well-known components of stomach myoelectric-
required to coordinate ordered movement.1 Efferent ity.3,4 The slow wave is an omnipresent myoelectrical
signals from the higher neuronal levels of central, spinal activity, which originates in the stomach proximal body,
and enteric nervous systems determine stomach motil- showing continuous rhythmic change in the membrane
ity. These systems also modulate reflex responses fol- potential and thereby propagating normally to the distal
lowing stimulation in the afferent pathways including antrum with a regular rhythm approximately 3 c.p.m. in

Correspondence: Dr Full-Young Chang, Division of Gastroenterology, Taipei Veterans General Hospital, 201 Shih-Pai Road,
Section 2, Taipei 11217, Taiwan. Email: changfy@vghtpe.gov.tw
Accepted for publication 16 January 2004.
Review of EGG
humans.5–7 Physiologically, SW triggers the onset of
spike, which in turn elicits muscle contraction.3,8,9 Thus
SW is essential to determine the stomach motility
including gastric emptying (GE).4,10 A technique using
electrodes positioned on the abdominal skin to record
stomach rhythmic myoelectricity refers to electrogas-
trography (EGG), and the greatest advantage of EGG is
its non-invasiveness.7,9,11 The first human EGG was
recorded by Alvarez as early as 80 years ago.12 Unfor-
tunately, EGG progress in clinical medicine had been
slow compared to the marked success achieved by the
electrocardiography. The limitations of EGG evolution
included difficulties in recording and acquisition of very
weak-amplitude signals due to the old electronic equip-
ment, visually analyzed signals unable to provide
meaningful information, interference from other
physiological signals and motion artifacts, and less
understanding of stomach motor physiology at that
time.13 But a major breakthrough in EGG evolution
occurred in the last two decades due to the rapid devel-
opment in computer science and medical engineering.
Today EGG is popular throughout the world for clinical
medicine and investigators. Stomach SW is recorded
from surfaced electrodes, while the subsequently com-
puterized analysis of filtered SW provides various EGG
parameters.11,14,15 Until now EGG has not been
approved by the Food and Drug Administration (FDA),
hence both homemade and commercial instruments are
available to diagnose stomach motor dysfunction.7,11,16–
18
Even the compact portal EGG has been marketed for
the ambulatory recording.19 The EGG recording does
provide the SW information in terms of rhythmicity,
frequency, amplitude and propagation.20 Clinical expe-
rience in EGG has been markedly accumulated since its
rapid evolution within the last two decades. However,
the lack of standardized methodology in terms of elec-
trode positions, recording periods, test meals, analytic
software and normal reference values makes the signif-
icance of EGG recording controversial in diagnosing
stomach motor dysfunction. Many pitfalls remain in the
computer-generated EGG parameters and extreme
caution should be taken when these parameters are
introduced to explain the significance of stomach dys-
motility.21 Understanding the basic SW pathophysiol-
ogy, recording methodology and indications may open
EGG as a new domain for exploring stomach motor
dysfunction. Appropriate application of non-invasive
EGG can provide more information and insight in
understanding the mechanisms that regulate stomach
motility.
STOMACH MYOELECTRICITY
The smooth muscle myogenic electricity or SW of the
gastrointestinal (GI) tract is believed to originate in the
interstitial cells of Cajal (ICC).6,13 The ICC are usually
located at the myenteric and submucosal borders of cir-
cular muscle.3,22 The ICC are a distinctive population of
muscle-like stellate cells and thus share many features of
smooth muscle. In contrast, they have few contractile
filaments but abundant cytoplasmic organells that may
503
promote spontaneous electrical activity.22 They make
close contact with each other, muscle cells and nerve
terminals.3,23 Morphological studies suggest that ICC
have three main physiological functions: as SW pace-
makers of the GI tract, to facilitate active propagation of
electrical activity and to mediate neurotransmission.22,24
Huiszinga et al. indicated that the controlling gene
required for the pacemaker of ICC is w/kit because lack
of this gene resulted in disordered myoelectrical rhythm
and stomach dysmotility.25 In stomach, the pacemaker
refers to the boundary between circular and longitudi-
nal muscle layer of corpus, antrum and pylorus.22 It is
obvious that every portion of the stomach except the
fundus has its own pacemaker because isolated muscle
strip remains to exhibit electricity.26 It has been shown
that even an isolated ICC of GI tract can produce spon-
taneous active wavelike depolarization very similar to
SW.27 The number and dense network of human ICC,
particularly IC-MYST belonging to the stomach,
increases from corpus to antrum.28 It seems that many
pacemakers exist together in the stomach and a problem
arises as to which one governs or coordinates the whole
harmony of stomach myoelectricity. The EGG-recorded
SW demonstrates a profile of increased velocity and
amplitude with transmission through the high body to
distal stomach, to the pylorus.29,30 It is of interest that
the stomach SW never transmits across to duodenum
because a higher SW frequency of up to 12 c.p.m.
occurs there. Theoretically, SW can transmit to any
direction within the stomach.1 Its propagation or cou-
pling direction appears to be limited by the frequency
gradient. The steeper the frequency gradient, the faster
the conduction velocity.3,29 For the stomach, the intrin-
sic pacemaker rhythm is highest in the proximal
stomach, while the rhythm frequency diminishes pro-
gressively to the corpus, antrum and pylorus. Perhaps
the SW of the distal stomach has been superimposed on
the spike potentials induced by the proximally transmit-
ted SW.3 Consequently, the 2-D property of stomach
ICC networks in relation to 3-D syncytium of smooth
muscle cells with characteristic resistance and capaci-
tance reduces the net current that must be generalized
by the individual ICC to depolarize smooth muscle,
while the spreading of stimulation signals originating in
the ICC via coupling and propagating with amplifica-
tion occurs within ICC networks. This means that the
electrical activity in circular and longitudinal muscle
layers is synchronous, while its coupling occurs between
these two muscle layers through ICC.22 In some situa-
tions the ectopic pacemaker could be recorded in
antrum to show either tachygastria or retrograde prop-
agation.29 The automatism theory regarding spontane-
ously generated SW is yet to be updated. The old theory
pointed out that the oscillating sodium pumps due to
abundant mitochondria in ICC were responsible for the
spontaneous formation.31 A recently proposed theory
borrowed from the pacemaker activity of cardiac muscle
suggests that ionic conductance expressed by ICC and
smooth muscle cells behaves as active transport using
the voltage-dependent conductance to reestablish ionic
gradients, especially extruding Ca++, which carries
inward current necessary for spontaneous autorhyth-
micity.32,33 In addition, the electrical coupling-promoted
504
interaction between smooth muscle cells and ICC also
contributes to SW rhythmicity.22
Key points: (i) the smooth muscle myogenic electric-
ity or SW of the GI tract is believed to originate in the
interstitial cells of Cajal; and (ii) EGG-recorded SW
displays a character of transmission of increased velocity
and amplitude from high body to distal stomach.
SLOW WAVE PHYSIOLOGY
A typical SW configuration of intracellular recording is
somewhat like the square root symbol including the
rapid upstroke of depolarization, partial repolarization
from the peak to a sustained plateau, which may be
superimposed on spikes if contraction occurs, and
finally the complete repolarization to resting membrane
potential again.1,3 The stomach smooth muscle resting
membrane potential usually ranges from -48 to -75 mV
to show a character that is more negative in the distal
stomach except fundic muscle, which is electrically
silent, whereas its mechanical threshold ranges from
-52 to -40 mV.1 This means that the smooth muscle cell
depolarizes to a level above threshold, and the spike or
contraction follows at this moment. Each portion of the
stomach has its own SW characteristic pattern.1,33 In
brief, the electrically silent fundus has a resting mem-
brane potential of approximately -48 mV, just in the
range of the mechanical threshold, to facilitate a sus-
tained contraction here; the midcorpus or pacemaker
region has a resting membrane potential of -61 mV
with a spontaneous complex action potential, then the
features of sharp upstroke of rapid depolarization, neg-
ativity of resting membrane potential and duration of
SW are progressively apparent in the rest of the corpus,
antrum and pylorus, and finally the obviously superim-
posed oscillations of spikes in the plateau mean that
contraction appears in the antrum and pylorus. In the
pylorus the plateau potential is longer, resulting in con-
stantly superimposed spikes leading to sustained pyloric
closure. Although the magnitude of SW generated from
a single ICC is very weak, the intimate couplings within
ICC network and the gap junction proteins connecting
to smooth muscle may amplify SW, leading to muscle
contraction. Accordingly, pacemaker-generated SW
along the ICC networks propagate distally to pace
antral muscle.3,22,34,35 The electrical coupling of ICC and
smooth muscle is crucial because it not only provides
electrical conduction but also contributes to the rhyth-
micity of the pacemaker, while the stomach contraction
is phase locked according to the frequency of
SW.1,22,29,36,37 This means that the normal maximal fre-
quency of stomach contraction should not exceed this
of SW. The SW amplitude and duration are modulated
by various excitatory and inhibitory neurotransmitters
and neural inputs. For example, acetylcholine and
tachykinins enhance SW, while the external stimulation-
prolonged amplitude and duration of SW may produce
sustained contraction.1,3 The observed pathophysiolog-
ical and pharmacological effects of various origins on
SW will be mentioned later on. The pacemaker-
produced SW not only propagates distally but also
F-Y Chang
Waveform
Figure 1 Recorded stomach slow wave before the spectral
analysis. The surface recorded slow wave is usually displayed
in sine configuration, while meal ingestion enhances slow wave
amplitude. The time scale of the X-axis is divided into 30-s
intervals and the amplitude scale of the Y-axis is divided into
500-mV intervals.
transmits perpendicularly in pacing through both circu-
lar and longitudinal muscle cells.1,3 Using the specially
placed electrodes SW can be recorded in either the sero-
sal or mucosal sides of the GI tract and correlates well
with the surface recording.38,39 The surface-recorded
SW displays a sine configuration rather than the square
root symbol of intracellular recording because the
former is the summation of transmitted signals from
various portions of stomach, whereas the latter is only a
point or a small area recording to reflect the true depo-
larization (Fig. 1).21,37,39–41 Most importantly, the spikes
occurring in SW depolarization are not readily recorded
using surface electrodes.14,21 It should be noted that
whenever we see the sine wave configuration recorded
by EGG, this does not mean the true occurrence of
stomach contraction.11,36,42
Key points: (i) GI tract smooth muscle cell depolar-
izes to a level above the threshold, then the spike or con-
traction follows; (ii) whenever we see the sine wave
configuration recorded by EGG, this does not mean the
true occurrence of stomach contraction; and (iii) the
normal maximal frequency of stomach contraction does
not exceed that of SW.
OBSTACLES OF EGG RECORDING
Because the transmitted stomach SW can be recorded
using surface placed electrodes, the acquisition and
analysis of recorded signals are the main interests of
current EGG knowledge. Many obstacles are required
to be overcome when EGG recording system is used to
evaluate the stomach dysmotility.13,22 First, the ampli-
tude of surface-recorded SW is very weak, in the range
of 50–500 mV, compared to cardiac myoelectric-
ity.13,16,37,43 Consequently, an amplifier is needed when
this very low voltage signal is acquired by the EGG sys-
tem.9,11,17 Second, the abdominal cavity is not silent
because many visceral organs also produce rhythmic
electricities, for example heartbeat, respiration, other
organs of the GI tract and even body movements.44 For-
tunately, some of these noises have distinct characteris-
tics, which enable them to be discriminated from
stomach SW. For example, the heartbeat and respira-
tion are quick with strong amplitude in contrast to the
stomach SW. Therefore they are readily removed using
a well-designed filter.17,43 However, the EGG windows
or rhythm cut-off values employed by many well-known
Review of EGG
investigators to filter out noise are not standardized,
including 0.5–9 c.p.m. for children,45 0.5–15 c.p.m.,46
0.6–15 c.p.m.,7 1–18 c.p.m.,43 1.6–11.5 c.p.m.,46 1.8–
16 c.p.m.,47 <12 c.p.m.,44 etc. Mintchev et al. suggested
that the first-order anti-aliasing filter with at least five-
fold difference between the filter cut-off frequency and
sampling frequency is recommended for recording
compliance.44 In order to reduce the range of tachyga-
stria, they also advised that the cut-off rhythm be set at
12 c.p.m. In addition, the usual home AC electricity of
60 Hz often interferes with signal acquisition and a
well-designed digital filter is important for signal pick
up.44 Usually, a 10–15-min period is needed to settle
down the electrode–jelly–skin interface because of the
possibility of inherent EGG interference in the record-
ing.43 Within the cut-off rhythms, other GI organs pro-
duce physiological myoelectricities. For instance, the
small intestine has its own SW frequency, beginning at
11–12 c.p.m. in the duodenum with decreasing gradi-
ent to distal ileum.3,48,49 The SW belonging to the colon
are very complicated, the pacemaker of myenteric bor-
der of circular muscle has a rhythm up to 17 c.p.m.,
whereas that originating in the submucosal border is
approximately 5–6 c.p.m., which is very similar to small
intestine and stomach corpus.3 It is alsofound that even
total gastrectomy subjects display a 3-c.p.m. rhythm,
which is believed to be colonic in origin.50 Regarding
the rhythm <3 c.p.m., some investigators recommend
that the recorded 1-c.p.m. rhythm is most likely an arti-
fact of the EGG system rather than of the GI tract
itself.21,43,51 These include inherent artifacts in the EGG
system, spontaneously generated electrode potential,
movement artifacts etc.52 Accordingly, an obtained
value <1 c.p.m. (based on computer-aided analysis)
should be very carefully judged.9,51 It is suggested that a
high-pass filter with cut-off rhythm set at 0.6 c.p.m.
may completely filter out most noise <1 c.p.m.21
Another major component of noise has been the move-
ment artifact. Because the whole recording usually
requires hours to complete, it is difficult to keep the
study subjects still without any minor movement during
the whole recording period. Hence it is necessary to
advise the patients to avoid talking and to keep body
movement to a minimum during the EGG record-
ing.11,43 Fortunately, body movement-related artifacts
are not rhythmic and produce strong spikes in the raw
recording (Fig. 2).44,53 These artifacts should be visually
examined and deleted, otherwise erroneous parameters,
even with regard to the dominant frequency, will result
if they are inappropriately incorporated in the auto-
matic digital analysis.7,11,49,53,54 Currently a computer-
based network system is being developed to try to elim-
inate motion artifacts automatically, thereby replacing
visual analysis.55 It is not known whether this new tech-
nique is useful or whether it will be incorporated in the
next-generation EGG system. The impedance between
skin and the placed electrodes also produces artifacts.
Currently the recommended preparation for EGG
recording includes shaving the electrode-placement
areas to remove friction; gentle abrasion with gauze; use
of jelly or cream-filled electrodes to increase conduc-
tion; and electrode should be placed in appropriate
areas.9,11,13,14 From the latter viewpoint no standardized
505
(a)
(b)
Figure 2 Body movement noise and its processing. Upper
panel: arrows indicate the body movement-related noise
appearing in the raw slow wave recording. This noise usually
has a non-rhythmic pattern. Lower panel: Use of software to
delete obvious noise that might interfere in the digital com-
putation. The rest signals were reconstructed before spectral
analysis. Y-axis: min after start of recording.
position has been agreed on until now.9,11,13,43,56 Because
the antrum has the greatest SW amplitude among var-
ious portions of the stomach, investigators recommend
that the placed electrodes should approach the antrum
as close as possible along the long axis of stomach to
obtain the best signals. Sometimes ultrasound or fluo-
roscopy may help to identify antrum, but it is not nec-
essary in routine measurement.9,11,29,56,57 Both unipolar
and bipolar techniques have been employed to record
SW. The former readily displays potential variation,
whereas the latter is popularly used because of its
advantages of highest signal-to-noise ratio, and less
prevalent artifacts from body movements, respiration
and other physiological signals.9,13,37 It is uncertain how
many electrodes should be used to record a fine SW.
Most likely, channel number depends upon the interest
of investigators and how many channels they could use
for their EGG systems. However, different channels
may exhibit quite distinct SW configurations.9,56 Many
authorities suggest that only the best signal among all
recordings is selected to represent the expected mea-
surement (Fig. 3).11,13,37,54,58 In contrast, multichannel
systems are used by the investigators for the purpose of
mapping SW propagation, coupling and unusual phys-
iological origins.11,30,50,51,59 This type of new EGG appli-
cation is beyond the scope of the present paper.
Key points: (i) an amplifier is needed in the EGG sys-
tem to display very-low-voltage SW, and a filter is nec-
essary to remove noise; (ii) the recorded 1-c.p.m.
rhythm is most likely an artifact of the EGG system
rather than of the GI tract itself; (iii) the major compo-
nent of noise is the movement artifact, which is not
rhythmic and which occurs as a strong spike in the raw
EGG recording; and (iv) many authorities suggest that
only the best signal among all recordings is selected to
compute EGG parameters.
506
Channel 1
Waveform
Channel 2
Waveform
Channel 3
Waveform
EGG RECORDING, PROCESSING
AND PARAMETERS
Spectral analysis
After carefully considering these influences on signal
pick-up, a raw recorded SW configuration is obtained.
What can we learn or judge from this raw recording?
Usually, recorded SW are variable in frequency, ampli-
tude and stability. It seems that the clinical significance
of EGG is hidden within this variation. Unlike the mas-
sive information obtained from the raw recording of
electrocardiography, it is very difficult to identify varia-
tion based on the visual analysis only, in EGG. Due to
the rapid progress in PCs and electronics, power spec-
tral analysis is the most commonly used analytic math-
ematic method to quantify the variation of recorded
SW.7,21,44,58,60–62 This is because spectral analysis does
not only transform frequency domain to time domain,
but it also provides information on time variations in
frequency.7,60 In brief, each line of spectrum density dis-
plays a 256-s portion of recorded signal, while the data
window of each spectral density consists of the final
75% (192 s) of the previous window and the next 25%
(64 s) of new signal.62 This means that each consecutive
line has only 25% new information. These 256-point
series then undergo Fourier transformation and a peri-
odogram is produced (Fig. 4). The biggest advantage of
spectral analysis is its ability to extract the stomach
signal from noise, thus signals originating in other GI
organs may be separated.7,60 Frequency spectral analysis
is based on the assumption that all signals are displayed
in sine waves, thus the harmonic peaks appearing in the
high-frequency range are easily produced. This occur-
rence within the high-frequency range usually leads to
F-Y Chang
Figure 3 The appropriate
selection of a recording for the
electrogastrographic (EGG)
computation to obtain EGG
parameters. In this multichan-
nel EGG system, various chan-
nels recorded distinct slow
wave configurations in terms of
sine pattern, noise interference
and meal response. Only the
best recording (e.g. channel 1)
to show least noise and a pow-
erful amplitude before and
after meal was suggested to
compute EGG parameters.
The time scale of the X-axis is
divided into 1-min intervals
and the amplitude scale of the
Y-axis is divided into 200-mV
intervals.
the erroneous diagnosis of tachygastria.21 Using spectral
analysis to assess SW, several precautions should be
borne in mind to exclude the false diagnoses. First, the
leakage effects associated with the finite duration of the
recording and the use of discrete Fourier transform
should be considered when the frequency domain anal-
ysis is performed, while the misinterpretation of ‘brady-
gastric’ and ‘tachygastric’ ranges in the percentage
distribution of EGG frequency component is possible if
inappropriate signal conditioning and digitalization are
employed.44 Second, the spectral analysis showing mul-
tiple peaks without an obvious peak are most likely
motion artifacts or poor recording with generated noise.
Third, the peaks with very low power are also likely to
be due to the poor recording effect.21 Accordingly, three
methods based on spectral analysis are introduced into
clinical application. The first is short-time Fourier
transform (STFT) or running spectral analysis; the next
is adaptive spectral analysis; and the third is the very
recently developed exponential distribution.60,63,64
Understanding the details of these methods for EGG
signal analysis are also beyond the scope of the present
paper. In brief, Lin and Chen concluded that STFT
results in the lowest frequency resolution but is more
accurate for power analysis, whereas the less swift
change in signal frequency precludes the detection of
dysrhythmia for a brief duration.60 In contrast, adaptive
spectral analysis produces the highest frequency resolu-
tion and is best for measuring dysrhythmia with brief
duration but it is not recommended to estimate power.
For the exponential distribution, its performance for
EGG is just within the STFT and adaptive spectral
analysis. Until now, the recorded procedures and anal-
ysis methods are quite distinct and variable among
research centers and investigators.62,65,66 However,
Review of EGG 507

(a)

Waveform
Figure 4 The recorded
stomach slow wave and its
spectral analysis. (a) The
selected signal before and after
meal, according to channel 1.
(b)
The time scale of X-axis is
divided into 1-min intervals
and the amplitude scale of the
Y-axis is divided into 200-mV
intervals. (b) The Hanning
window displayed a 3-D
Spectrum

pseudo power spectra obtained

from the short-term Fourier
transform of this channel. The
shaded area is the defined
range of normal rhythm (2–
4 c.p.m.). These spectra were
automatically computed and
accumulated every 64 s in the
order following the arrow.

STFT is the most commonly installed method among

commercially available EGG systems. Because an intact
SW functions within main frequency, the incidence of
dysrhythmia, electrical stability and amplitude, and the
parameters dealing with these SW variables are there-
fore introduced after the STFT analysis of visually
Dominant pow

deleted artifacts and the best SW has been

selected.7,11,67
Key points: (i) spectral analysis is the most commonly
used analytic mathematic method to quantify the vari-
ation of the recorded SW; and (ii) the advantage of
spectral analysis is its ability to extract the stomach sig-
nal from noise.

Frequency analysis
Because the frequency domain based on the STFT has
separated gastric signals from noise and quantified the
former, thus the dominant frequency (DF) is defined as
the frequency appearing with peak power value of spec-
tra (Fig. 5), whereas the dominant power (DP) is the
power value observed at DF.14,68 According to our expe-
rience and that of other investigators, normal DF is very
similar to the natural SW rhythm, which is approxi-
mately 3 c.p.m.47,57,69,70 Both DF and DP have been rec-
ognized as the main EGG parameters. The SW is not
always stable in its absolute frequency and amplitude
throughout the whole recording, particularly in motor
disorders.11 It is obvious that we cannot define only the
DF at 3 c.p.m. as normal, and other values other than
3 c.p.m. as abnormal. Hence, a normal range of com-
puted frequency or DF is needed to define abnormality
in clinical recording. Currently, bradygastria is defined
Dominant frequency
Figure 5 Principle for computing the main electrogastro-
graphic parameters of dominant frequency and power. Based
on the Fourier transform of recorded myoelectricity, both fast-
ing and post-prandial power spectra were, respectively, con-
structed. For this example of post-prandial recording, the
arrow indicates the peak value, which has been acknowledged
as the dominant frequency (3.22 c.p.m.) and dominant power
(35.0 dB) after computation.
as the value below normal range, whereas tachygastria is
that above the normal range.7,11,14,43 Because STFT is
usually computed every 1–2 min, thereafter each spec-
trum is based on its peak to compute DF to define
either normal rhythm or tachy/bradygastria while the
508 F-Y Chang

cumulated values would be divided into percentages to Amplitude analysis

show % normal rhythm, % bradygastria and % tachy-
gastria, respectively. For example, % normal rhythm is People always expect that the SW amplitude should be
computed by the ratio of the number of normal spectra well correlated with stomach contraction. It has been
divided by the number of total spectra.68 Koch and shown that stomach contraction-related spikes of
Stern also noted that % normal rhythm = power at nor- increasing amplitude have been observed in the fasting
mal range/total power from 1 to 15 c.p.m. ¥ 100%.43 migratory motor complex.84 Clinically, it is very hard to
Every caution should be undertaken to avoid the mis- observe which one is the increased amplitude recorded
interpretation of harmonics as tachygastria because the by EGG because the SW amplitude is influenced by
former are also within the range of the latter.21,68 Basi- various patient factors, for example skin conductance,
cally, the harmonics reviewed from spectral analysis are electrode position, stomach configuration, wall thick-
always double or triple the original DF. Harmonics are ness of abdomen and stomach, recording systems
easily deleted if the spectra are carefully examined and etc.11,13,37,47,56 However, the EGG power may correlate
the peaks fall on the expected positions as double or tri- with antral contraction; this is why the antral position
ple the DF. Moreover, the occurrence of tachygastria is has been suggested as the best recording site to repre-
influenced by the electrode position and configura- sent EGG parameters.84,85 Because of marked variation
tion.37 Unfortunately, the normal range is very hard to in interassay and intra-assay recorded amplitudes, EGG
define due to variations in the recording system, and the power in the unit of either mV2 or dB has been intro-
lack of standard analyzed methods.47 Table 1 illustrates duced to replace the true recorded amplitude.9,13,14,68
the published normal ranges defined by many investi- The latter (dB) is calculated as 10¥log10B (B = power in
gators. The variations in those defined normal ranges its linear unit).14 Power should be a unitless number
again suggest that a unique normal range is necessary. based on the amplitude of microvolt of EGG signal.7 To
Key point: (i) dominant frequency is defined as the quantify the significance of EGG power, it is best to
frequency appearing with peak power value of spectra, compare it before and after a test during the recording,
whereas dominant power is the power value observed at because a test meal has an obvious impact to increase
the dominant frequency. DF, and amplitude/power.9,16,17,41,47,84,86 This meal effect
may be expressed as the difference in dB or power ratio
(PR), which means the ratio of the post-prandial power
Table 1 Examples of defined ranges of slow wave frequency divided by the fasting power in mV2. Accordingly, PR is
in various electrogastrographic recordings the value calculated by dividing the baseline power in a
given frequency by the power in the subsequent time
Reference period of interest.43 Usually, the normal PR should be
≥2.9 In contrast, PR <1 is likely a poor motor response
Normal range (c.p.m.) to the meal and an inconsistent increase in PR may indi-
2–4 11,29,45–47,54,70–74 cate that an inadequate test meal has been used.11 Until
2–4.5 65 now, no standard test meal has been recommended for
2.4–3.6 42,43,49,51,68,69,76–81 EGG recording. This means that the meal composition
2.4–3.7 18 may have an obvious impact on the post-prandial
2.5–3.75 65 increased DF, DP and % normal rhythm.87 This distinct
2.5–4 82 meal effect again confirms the lack of standard meth-
Bradygastria (c.p.m.) odology for EGG recording. It is of interest what kind of
0–2 70,74 physiological factor is responsible for the meal effect on
0.5–2 72 power. Meal-increased antral contraction, rather than
1–2 75
the shortening antrum–skin distance, is directly related
to PR.66 However, PR increase is the effect of the short-
0.5–2.4 68,77
ened electrode–antrum distance brought about by
1–2.4 43,78
stomach distension. This effect is still observed in atro-
<2.4 18,81
pine blocked stomach contraction.41,43 In addition,
0.5–2.5 82 stomach distension also results in increasing power and
1–2.5 7,65 bradygastria.75 The latter is also confirmed in the canine
0–3 49 stomach by progressive water instillation leading to
Tachygastria (c.p.m.) diminished DF from 5 c.p.m. to 1.5 c.p.m.88 Drinking
3.6–9.9 43,49,76,79 of pure water has no effect on contraction but it
3.6–10 78 increases amplitude with diminished DF, whereas solid
>3.6 81 food increases both amplitude and DF.89 In contrast,
3.7–9 68 milk drinking diminishes DP, probably this characteris-
3.7–10 18 tic of the test meal leads to a contradictory result.54 The
3.7–11 67 decrease in EGG power also means a degradation or
3.75–10 7,65 change in SW regularity such as gastroparesis; even
3.9–9.9 77 some normal subjects may have this.68 In summary,
4–9 37,70–74,82,83 stomach distension resulting in a reduced distance to
4.5–9 75 the recording electrodes, and meal-enhanced stomach
contraction mutually act to increase EGG power.
Review of EGG
Key points: (i) to quantify the significance of EGG
power, it is best to compare it before and after a test, for
example a test meal because it increases dominant fre-
quency, and amplitude/power; and (ii) both stomach
distension resulting in a reduced distance to the record-
ing electrodes, and meal-enhanced stomach contraction
mutually act to increase EGG power.
Stability analysis
Because the SW may vary in its frequency and ampli-
tude during the whole recording, DF and % normal
rhythm have been the main interest as regards rhythm.
However, some situations with very regular rhythm and
markedly varied rhythm can display the same DF and %
normal rhythm when they undergo STFT analysis.68
For example, a recording of all 1–2 min spectra peaks
fell within previously defined normal range (e.g. 2–
4 c.p.m.) is computed, we would regard this subject as
100% normal rhythm. But his respective spectra peaks
may be markedly varied, for example 2.1, 2.8, 3.2, 3.5,
2.2 c.p.m. etc. Taking another example, all spectral
peaks of a recording displayed a very regular pattern,
close to 2.8 c.p.m., and this obtained 100% normal
rhythm. These two examples have an obvious variation
in regularity but produce a similar % normal rhythm;
how can we differentiate between these extreme record-
ings? A parameter of instability coefficient (IC) is intro-
duced to define this characteristic variation. Based on
the spectral data, IC is given as standard deviation
divided by the mean value of frequency.68,90 Likewise,
IC refers to the variations of spectra-based DF or DP
over a certain recording period of a study subject rather
than a group of subjects. This means that the lower the
IC value, the more stable the SW displayed. Now IC is
employed mostly for rhythm and very occasionally for
power.68,70,81 Accordingly, Chen et al. noted that the
fasting stomach usually has an unstable power (IC of
DP) compared to the post-prandial recording, and sug-
gested the usefulness of this power characteristic to
identify motor quiescence.85
Key points: (i) IC is the standard deviation divided by
the mean value of frequency; and (ii) the lower the IC
value, the more stable the SW displayed.
Recording period and EGG reproducibility
Because STFT computation divides time into many
consecutive segments and then transforms to frequency
domain, it appears that the recording period may have
an impact on the computed frequency and power.
Short-term recording with fewer segment numbers may
produce a bias in STFT computation, whereas long-
term recording with many segments seems to avoid the
bias. Nevertheless, it is very difficult to stop a subject
from moving for longer periods during the whole
recording. What is the optimal period for the best
recording and subsequent STFT analysis? For instance,
Levanon et al. noted that a short recording of only
15 min resulted in 61% error in DF and 38% in DP,
509
and they recommendeded that a recording period of
30–60 min is appropriate to produce reliable and pre-
dictable results.91 In general the most commonly used
recording period in fasting has been 30 min,42,57,79,81,92–94
sometimes 60 min is used.67,71,72,82,95 For the post-pran-
dial recording, it varies from 30 min,70,81 1 h,67,71–73,82,96
90 min,94 2 h,42,54,92 to 3 h74 Even a longer ambulatory
recording up to 12 h has been applied.53 Briefly, the
optimal recording for either the fasting or post-prandial
period is likely to 30–60 min, which is tolerable to most
studied subjects and is best used for the EGG with less
chance of computed bias. The EGG has been useful to
measure stomach electrical rhythm. The question arises
as to its reproducibility to measure parameters. Riezzo
et al. noted its stable character in 3-day consecutive
recordings showing similar frequencies and powers.96
Meanwhile, a study found 100% reproducibility in nor-
mal subjects but only 91.7% reproducibility for dyspep-
tic subjects if recordings were 1 week apart.65 In
contrast, a markedly varied EGG amplitude is obtained
in replicated studies42 or longer 7-h recording.37 Thus it
is necessary to know the usefulness and limitations of
EGG in measuring stomach motility.
Key point: (i) a recording period of 30–60 min is
appropriate to produce reliable and predictable results
and the most commonly used recording period in fast-
ing is 30 min.
PHYSIOLOGICAL IMPACTS ON EGG
As previously mentioned, the position of pasted elec-
trodes, skin preparation, test meal, stomach distension/
contraction and EGG systems all influence the obtained
EGG parameters. Interestingly, neither age nor gender
have a definite impact on EGG parameters in adults or
children.47,91,97,98 The body mass index may influence
power in adults56 but not in children.48 The maturation
of SW in infants and children is of interest. Studies indi-
cate that % normal rhythm is quite lower in premature
infants and shows a progressively increased normality
with less dysrhythmia.99,100 In addition, the normal
rhythm is usually absent at birth and will appear at 2–
4 months. Maturity of EGG rhythm is achieved at 4–
11 years, and it is most likely that enteric feeding is a
stimulation for development of normal rhythm in pre-
mature infants.45,101
Among the enteric nervous systems that have the
ability to modulate SW, both muscarinic and adrenergic
pathways are reported to be activated, leading to dys-
rhythmia in some events.102 We know that a test meal
ingestion results in increased % normal rhythm and
power. Interestingly, sham feeding also increases EGG
power via the cephalic–vagal pathway.103 Rectal disten-
sion has changes in stomach myoelectricity to show
tachygastria, loss coupling and diminished power but
no change in jejunal myoelectricity, the former is medi-
ated via both vagal and non-vagal pathways.48 In con-
trast, distal stomach distension-related nausea with
increased EGG power and dysrhythmia are activated by
the pathways and mechanical receptors that are non-
5HT, non-cholinergic and non-prostaglandin in ori-
510
gin.75 The calorie and volume of the test meal influence
post-prandial DF and DP.88 Similarly, either cold or hot
drinks have an impact on stomach myoelectricity lead-
ing to the increased frequency.104
Because EGG is a non-invasive procedure to measure
stomach motility, it is of interest whether the EGG
parameters have any link to stomach or antral contrac-
tion. High power is always present in the distal portion
of the stomach, mainly the antrum.29,56,57 This means
that the EGG power should directly link with contrac-
tion. The regularity of antral contraction is important
for GE because the latter requires coordination with
other organs.11,36,79 Thus the stomach rhythms outside
the normal range are likely to lead to poor stomach con-
traction and delayed GE. In fact, some studies already
indicate absent or ineffective contraction in the events
of tachygastria and bradygastria.5,7 In contrast, a canine
study addressed bradygastria, meaning strong antral
contraction, which involved prolongation of contrac-
tion-related SW intervals.105 It is of interest whether the
EGG parameter may predict GE. Based on surface-
recorded SW, attempts to identify the distinctive phases
of stomach interdigestive migrating motor complex
have been difficult.84 However, the EGG power enables
correlation with stomach contraction, particularly the
lower amplitude in 3 c.p.m. pattern, meaning the
absent coupling with action potential plateau and then
the delayed GE.7,42,84,85 In contrast, investigators
pointed out the limitation of EGG to display antral con-
traction after a meal.42,71,72 Xu et al. noted that the main
EGG parameters were associated with GE while only
the phase III of migrating motor complex showed the
one-to-one contraction according to the simultaneously
manometric and EGG recordings.36 Even a high power
may be due to the hypertrophic change of antrum in the
event of mechanical obstruction.79 In contrast, some sit-
uations with dysrhythmia are not always associated with
poor GE.7,77 In summary, GE is the final coordination
of many organs, for example the fundus, antrum,
pylorus and duodenum, it is possible that normal EGG
parameters do not guarantee normal GE.11
Key points: (i) enteric feeding is a stimulation for pre-
mature infants to develop normal EGG rhythm; (ii) the
calorie and volume of the test meal are the factors lead-
ing to increased post-prandial dominant frequency and
power; and (iii) GE is the final coordination of fundus,
antrum, pylorus and duodenum, and it is possible that
normal EGG parameters do not guarantee normal GE.
PHARMACOLOGICAL EFFECTS
ON EGG
Many prokinetics and peptides have an obvious motor
effect on the GI tract. It is possible that their motor
effect may be reflected as changed EGG parameters.
Likewise, cisapride corrects dysrhythmias and symp-
toms in patients with gastroparesis, dyspepsia and gas-
troesophageal reflux disease.18,73,106,107 Domperidone
also has similar effects on diabetic gastroparesis.108
Erythromycin has been an effective prokinetic agent.109
Low dose of erythromycin is not effective in correcting
F-Y Chang
abnormal rhythm of gastroparesis,110 whereas its high
dose diminishes the regularity of normal rhythm and
amplitude of normal subjects.111 Another study illus-
trated the erythromycin effect on dysrhythmia without
any influence on amplitude.42 Octreotide does diminish
antral contractions and DP in the fasting and post-pran-
dial recordings.110 Glucagon also has an effect, leading
to dysrhythmias and the absent antral contraction.112
Nausea and vomiting are very commonly observed
among patients receiving chemotherapy. It is interesting
as to whether chemotherapy-related symptoms are also
associated with dysrhythmia. For example, fasting dys-
rhythmia occurs in 63% of patients after chemotherapy
but EGG failed to predict the severities of nausea, vom-
iting and anorexia while normal GE existed among
these subjects.113 Another study indicated the small
effect of chemotherapy on EGG parameters.114 Tran-
scatheter arterial chemoembolization is commonly
employed to treat inoperable hepatocellular carcinoma
in Asian patients. This procedure also induces post-
prandial dysrhythmia but the changed EGG parameter
is not correlated with nausea symptom.115
Key point: (i) reports indicate drug effects on EGG
parameters, and the significance of these changed
parameters remains to be resolved.
EGG PARAMETERS AND CLINICAL
EVENTS
Accordingly, EGG parameters are mainly divided into
frequency and power. Therefore abnormal rhythm,
namely dysrhythmia, is more comprehensively acknowl-
edged for its clinical significance. However, it must be
stated again that EGG does not diagnose a specific dis-
ease, even stomach motor dysfunction. It chiefly pro-
vides rhythm, and amplitude/power of stomach
myoelectricity.7,11 Many studies involving EGG mea-
surement have appeared in the literature to address the
relationships between EGG parameters and clinical
events. Diabetic gastroparesis is a well-known stomach
dysmotility.116 Hence it is important to assess its influ-
ence on EGG parameters. Studies have already indi-
cated the obvious dyrhythmia.7,18,79,106,108,117–120 In
contrast, some studies also found a lack of abnormal
EGG parameters compared to controls, for example
DF, % dysrhythmia and PR, despite meal inges-
tion.121,122 In regard to the probable influence of blood
glucose level on EGG parameters, Hasler et al. deter-
mined this influence via endogenous prostaglandin
pathway.123 These discrepant results are likely to be due
to the distinct patient groups, study case numbers,
EGG systems, definitions of EGG parameters and the
test meals used. Nausea in pregnancy and gastric dys-
rhythmias are also closely related, because the resolved
symptom is followed with normal rhythm.69,90 Of them,
changing hormones have been reported to lead to dys-
rhythmias.124 Motion sickness is also a well-known event
associated with gastric dysrhythmia, particularly tachy-
gastria, which is likely activated via the a-adrenergic
pathway.62,102,125 In contrast, another study did not
observe such kinds of rhythmic change in rotation vec-
Review of EGG
tion-induced nausea.126 In children with cyclic vomiting
syndrome, they have obvious tachygastria before and
after a test meal, whereas abnormal EGG is observed
only in the post-prandial recording.82 Cheung and
Vaitkus commented that the inherent and intersubject
variability make EGG less reliable as an indicator of
motion sickness.37 Bulimia nervosa is an eating disorder
associated with less normal rhythm and PR, the reason
for the lower power response remains unknown.49 Func-
tional dyspepsia (FD) is a very common upper GI
(UGI) disorder, it is necessary to know whether EGG
has any value in FD patients. Among the FD children,
EGG shows less normal rhythm and higher IC, irre-
spective of test meal. The post-prandial power is
inversely correlated with total symptom score.95 Adult
studies also confirm the abnormal EGG parameters in
FD patients, although they are not necessary to show
the similar abnormalities in various patient
groups.57,65,70,71,73,74,83,92,127–129 Helicobacter pylori (Hp)
infection is very common among the FD patients, its
role in the pathogenesis of FD remains debatable.38,130–
132
Helicobacter pylori infection causes inflammation and
the co-existing motor disorders in FD patients.133 Inter-
estingly, Hp eradication not only improves dyspeptic
symptoms but also corrects the abnormal rhythm and
power in FD patients.83,129 In contrast, studies also
found a lack of influence of Hp infection or eradication
in FD patients.70,74 Unlike gastroparesis, mechanical
obstruction of the stomach outlet does not result in dys-
rhythmia but showd very regular rhythm with high
amplitude, the latter is likely the hypertrophic change
responding to obstruction.79 Similarly, the dysrhythmia
is not apparent, whereas an obvious post-prandial
power response is observed among the stomach cancer
patients.81 Progressive systemic sclerosis is usually asso-
ciated with poor antral motility, but EGG shows
unchanged DF, IC of DF and DP except the lower
occurrence of bradygastria.46 The influence of surgical
procedure on EGG is also interesting. In neurologically
impaired children, feeding gastrostomy does not lead to
abnormal EGG compared to an obvious effect of dys-
rhythmia elicited by fundoplication.134 Vagotomy has no
effect and does not induce EGG changes.72 In the rarely
occurring ischemic gastroparesis, the abnormal rhythm
resolves after vascular repair.135 The primary lesion of
esophageal achalasia is not far away from the origin of
stomach myoelectricity. However, the victims continue
to have unchanged DF, % normal rhythm and PR.67
Gastroesophageal reflux patients also have lesions in the
lower esophagus, they do have less % normal rhythm,
increased IC of DF in fasting and post-prandial record-
ings.109 The EGG recording of chronic intestinal
pseudo-obstruction patients shows dysrhythmia, indi-
cating the dysfunction of stomach neural and muscular
activities together.136 Peritoneal dialysis has been an
appropriate model to evaluate the impact of intraperi-
toneal fluid on EGG. A study found that the rhythm
remained unchanged but showed an exaggerated power
response in the fluid-filled stage compared to that of
emptying, perhaps the fluid in abdominal cavity
enhances SW signals.137 Hemodialysis in uremia pati-
ents also has a transient impact on the EGG parameters
(e.g. reduced % normal rhythm).138 Neurological dis-
511
orders are sometimes associated with abnormal EGG
parameters. For example, reduced % normal rhythm,
less stable DF and less power after meal are observed in
the myotonic dystrophy patients.78 Unchanged DF but
reduced power response and increased DF after meal
exist in the Parkinson’s disease patients.94 Finally,%
normal rhythm, DF, DP and IC are the same in spinal
cord injury patients compared to controls, illustrating
that stomach myoelectricity is not mediated centrally
via the spinal cord.93
Key points: (i) EGG does not diagnose a specific dis-
ease even stomach motor dysfunction, chiefly it pro-
vides rhythm, and amplitude/power of stomach
myoelectricity.
FUTURE EGG
Until now, there has been no standard recommendation
for recording position, period and test meal throughout
the whole world. In addition, the EGG systems, ana-
lytic/computed systems and defined normal ranges are
discrepant among many investigators. It appears that an
acceptable consensus is needed to define the abnormal-
ities based on the EGG recording when it is used to
assess stomach motor dysfunction.11,13 Using neural
network knowledge automatically to delete motion arti-
facts may be a potential development for future EGG
recording and analysis.55 In that event, an ambulatory
EGG recording system will be available for the long-
term observation of probable motor dysfunctions,
which are not necessarily observable during today’s
short-term recording. Currently, EGG measurement
has focused only on the SW rhythm and power. If the
next-generation EGG systems integrate multichannel
function plus advanced analysis, they will provide more
information in terms of SW coupling and conduction,
and even the ectopic pacemakers responsible for
obtained dysrhythmias may be defined and mapped.11,30
We expect that treatment focused on suppression,
removal or destruction of ectopic pacemakers is possi-
ble and optional in the future. Finally, electrical pacing
or stimulation is a new SW approach in non-pharma-
cological treatment attempting to restore the normal
GE in patients with refractory gastroparesis. Until now,
three methods including low-frequency stimulation,
high-frequency stimulation and sequential neural elec-
trical stimulation are proposed for this purpose.139 The
first pacing is able to normalize gastric dysrhythmias
and entrain gastric SW and enhance GE.139–141 The sec-
ond measure is not effective to correct dysrhythmias
and solid GE but is able to reduce nausea and vomiting
with slightly improved liquid GE in gastroparetic
patients.141–143 The last stimulation via microprocessor-
controlled sequential activation of annular electrodes
encircling the distal stomach induces propagated con-
traction and a powerful emptying. This method looks
favourable but the problem of coordination with pyloric
opening/closing remains resolved.140,144,145 Future con-
trolled studies are necessary to establish the efficacy and
safety of various electrical stimulations used to restore
refractory gastroparesis.
512
Key points: (i) future generation EGG systems
should provide more information in terms of SW cou-
pling and conduction, and even the ectopic pacemakers
responsible for the dysrhythmias may be defined and
mapped; and (ii) electrical pacing or stimulation are
new non-pharmacological methods to restore normal
GE in patients with refractory gastroparesis.
CONCLUSION
Procedures for measuring stomach dysmotility are not
always widely available in many institutions and may
not be reimbursed. We know that the stomach motor
function involves many organs apart from itself. Using
only a single method to define abnormal motor dys-
function may produce diagnostic bias. The EGG is an
attractive non-invasive procedure to provide informa-
tion on SW rhythm and power, whereas SW conduction
and its coupling are less studied and less well-known.
Also, similar abnormal EGG parameters exist in many
different clinical events. Unlike the image studies, we
cannot diagnose stomach dysmotility depending only
on the abnormal rhythms and powers. Accordingly, it is
possible that stomach dysrhythmia leads to poor GE.
However, the latter does not always occur. The limita-
tions of EGG recording, processing, computation,
acceptable normal ranges, techniques to conduct and
reading should be known to avoid subjective assess-
ments when EGG measurement is used to resolve stom-
ach dysfunction. Consequently, a properly indicated
EGG measurement may extend our knowledge of SW
in stomach dysmotility.
REFERENCES
1 Quigley EMM. Gastric motor and sensory function, and
motor disorders of the stomach. In: Feldman M, Fried-
man LS, Sleisenger MH, eds. Sleisenger and Fordtran’s
Gastrointestinal and Liver Disease, Pathophysiology/Diagno-
sis/Management, 7th edn. Philadelphia: WB Saunders,
2002; 691–713.
2 Dockray GJ. The brain-gut axis. In: Yamada T, Alpers
DH, Lain L, Owyang C, Powerll DW, eds. Textbook of
Gastroenterology, 3rd edn. Philadelphia: Lippincott
Williams & Wilkins, 1999; 67–81.
3 Makhlouf GM. Smooth muscle of the gut. In: Yamada T,
Alpers DH, Lain, L, Owyang C, Powerll DW, eds. Text-
book of Gastroenterology, 3rd edn. Philadelphia: Lippin-
cott Williams & Wilkins, 1999; 82–105.
4 Wood JD, Alpers DH. Fundamentals of neurogastroen-
terology: basic science. In: Drossman DA, Corazziari E,
Talley NJ, Thompson WG, Whitehead WE, eds. The
Functional Gastrointestinal Disorders, 2nd edn. McLean:
Degnon Associates, 1999; 31–90.
5 You CH, Chey WY. Study of electromechanical activity
of the stomach in humans and in dogs with particular
attention to tachygastria. Gastroenterology 1984; 86:
1460–8.
6 Hinder RA, Kelly KA. Human gastric pacesetter poten-
tial. Site of origin, spread, and response to gastric resec-
F-Y Chang
tion and proximal gastric vagotomy. Am. J. Physiol. 1978;
139: 29–33.
7 Kock KL. Electrogastrography: physiological basis and
clinical application in diabetic gastropathy. Diabet. Techn.
Ther. 2001; 3: 51–62.
8 Sarna SK. Gastrointestinal electrical activity; terminol-
ogy. Gastroenterology 1975; 68: 1631–5.
9 Smout AJPM, Jebbink HJA, Samson JM. Acquisition and
analysis of electrogastrographic data, the Dutch experi-
ence. In: Chen JZ, McCallum RW, eds. Electrogastrogra-
phy, Principles and Applications. New York: Raven Press,
1994; 3–30.
10 Kelly KA. Pacing the gut. Gastroenterology 1992; 103:
1967–9.
11 Camilleri M, Hasler WL, Parkman HP, Quigley EMM,
Soffer E. Measurement of gastrointestinal motility in GI
laboratory. Gastroenterology 1998; 115: 747–62.
12 Alvarez WC. The electrogastrogram and what it shows.
JAMA 1922; 78: 1116–19.
13 Levanon D, Chen JDZ. Electrogastrography: its role in
managing gastric disorders. J. Pediatr. Gastroenterol. Nutr.
1998; 27: 431–43.
14 Chen JC, McCallum RW. Clinical applications of elec-
trogastrography. Am. J. Gastroenterol. 1993; 88: 1324–36.
15 Abell TL, Malagelada JR. Electrogastrography: current
assessment and future perspectives. Dig. Dis. Sci. 1988;
33: 982–92.
16 Chang FY, Lee CT, Lee SD, Jang HC, Tsai DS, Fu SE.
An assembled electrogastrography to examine the meal
effect on gastric slow wave. J. Gastroenterol. Hepatol.
1996; 11: 506–10.
17 Chang FY, Lu CL, Chen CY et al. Real-time display of
stomach slow wave and its parameters in a newly
designed electrogastrographic system. J. Gastroenterol.
2001; 36: 10–17.
18 Chang CS, Lien HC, Yeh HZ, Poon SK, Tung CF, Chen
GH. Effect of cisapride on gastric dysrhythmia and emp-
tying of indigestible solids in type-II diabetic patients.
Scand. J. Gastroenterol. 1998; 33: 600–4.
19 Chen JZ, Lin Z, McCallum RW. Toward ambulatory
recording of electrogastrogram. In: Chen JZ, McCallum
RW, eds. Electrogastrography, Principles and Applications.
New York: Raven Press, 1994; 127–53.
20 Familoni BO. Validity of the cutaneous electrogastro-
gram. In: Chen JZ, McCallum RW, eds. Electrogastrogra-
phy, Principles and Applications. New York: Raven Press,
1994; 103–25.
21 Verhagen MAMT, Schelen LJV, Samson M, Smout
AJPM. Pitfalls in the analysis of electrogastrographic
recordings. Gastroenterology 1999; 117: 453–60.
22 Sanders KM. A case for interstitial cells of Cajal as pace-
makers and mediators of neurotransmission in the gas-
trointestinal tract. Gastroenterology 1996; 111: 492–515.
23 Thuneberg L. Interstitial cells of Cajal: intestinal pace-
maker cells. Adv. Anat. Embryol. Cell Biol. 1982; 71: 1–
130.
24 Daniel EE, Berezin I. Interstitial cells of Cajal: are they
major players in control of gastrointestinal motility? J.
Gastrointest. Motil. 1992; 4: 1–24.
25 Huiszinga JD, Thuneberg L, Kluppel M, Malysz J,
Kikkelsen HB, Bernstein A. The w/kit gene required for
interstitial cell of Cajal and for intestinal pacemaker
activity. Nature 1995; 373: 347–9.
Review of EGG
26 El-Sharkawy TY, Morgan KG, Szurszewski JH. Intrac-
ellular electrical activity of canine and human gastric
smooth muscle. J. Physiol. (Lond.) 1978; 279: 291–307.
27 Langon P, Ward SM, Carl A, Norell MA, Sanders KM.
Spontaneous electrical activity of interestial cells of Cajal
isolated from canine proximal colon. Proc. Natl Acad. Sci.
USA 1989; 86: 7280–4.
28 Faussone-Pellegrini MS, Pantalone D, Cortesini C. An
ultrastructural study of the interstitial cells of Cajal of the
human stomach. J. Submicrosc. Cytol. Pathol. 1989; 21:
439–60.
29 Chen JDZ, Zou X, Lin X, Ouyang S, Liang J. Detection
of gastric slow wave propagation from the cutaneous elec-
trogastrogram. Am. J. Physiol. 1999; 277: G424–30.
30 Kelly KA, Code CF. Canine gastric pacemaker. Am. J.
Physiol. 1971; 220: 112–18.
31 Connor JA, Prosser CL, Weems WA. A study of pace-
maker activity in intestinal smooth muscle. J. Physiol.
(Lond.) 1974; 240: 671–701.
32 Lee HK, Sanders KM. Comparison of ionic currents
from interstitial cells and smooth muscle cells of canine
colon. J. Physiol. (Lond.) 1993; 460: 135–52.
33 Sanders KM. Ionic mechanisms of electrical rhythmicity
in gastrointestinal smooth muscles. Ann. Rev. Physiol.
1992; 54: 439–53.
34 Morgan KG, Muir TC, Szurszewski JH. The electrical
basis for contraction and relaxation in canine fundal
smooth muscle. J. Physiol. (Lond.) 1981; 311: 475–88.
35 Sanders KM, Vogalis F. Organization of electrical activity
in the canine pyloric canal. J. Physiol. (Lond.) 1989; 416:
49–66.
36 Xu X, Wang Z, Hayes J, Chen JDZ. Is there a one-to-one
correlation between gastric emptying of liquids and gas-
tric myoelectrical or motor activity in dogs? Dig. Dis. Sci.
2002; 47: 365–72.
37 Cheung B, Vaitkus P. Perspectives of electrogastrography
and motion sickness. Brain Res. 1998; 47: 421–31.
38 Hamilton JW, Bellahsene BE, Reichelderfer M, Webster
JG, Bass P. Human electrogastrograms, comparison of
surface and mucosal recordings. Dig. Dis. Sci. 1986; 31:
33–9.
39 Familoni BO, Bowes KL, Kingma YJ, Cote KR. Can
transcutaneous recording detect gastric electrical abnor-
malities? Gut 1991; 32: 141–6.
40 Smout AJPM, van der Schee EJ, Grashuis JL. What is
measured in electrogastrograsphy? Dig. Dis. Sci. 1980;
25: 179–87.
41 Mintchev MP, Kingma YJ, Bowes KL. Accuracy of cuta-
neous recording of gastric electrical activity. Gastroenter-
ology 1993; 104: 1273–80.
42 DiBaise JK, Park FL, Lyden E, Brand RE, Brand RM.
Effects of low dose of erythyromycin on the 13C Spirulina
platensis gastric emptying breath test and electrogastro-
gram: a controlled study in healthy volunteers. Am. J.
Gastroenterol. 2001; 96: 2041–50.
43 Koch KL, Stern RM. Electrogastrographic data acquisi-
tion and analysis, the Penn State experience. In: Chen JZ,
McCallum RW, eds. Electrogastrography, Principles and
Applications. New York: Raven Press, 1994; 31–44.
44 Mintchev MP, Rashev PZ, Bowes KL. Misinterpretation
of human electrogastrograms related to inappropriate
data conditioning and acquisition using digital comput-
ers. Dig. Dis. Sci. 2000; 45: 2137–44.
513
45 Chen JDZ, Co E, Liang J et al. Patterns of gastric myo-
electrical activity in human subjects with different ages.
Am. J. Physiol. 1997; 272: G1022–7.
46 Marycz T, Muehldorfer SM, Gruschwitz MS et al.
Gastric involvement in progressive systemic sclerosis:
electrogastrographic and sonographic findings. Eur. J.
Gastroenterol. Hepatol. 1999; 11: 1151–6.
47 Riezzo G, Chiloiro M, Guerra V. Electrogastrography in
healthy children, evaluation of normal values, influence
of age, gender and obesity. Dig. Dis. Sci. 1998; 43: 1646–
51.
48 Abo M, Kono T, Wang Z, Chen JDZ. Impairment of gas-
tric and jejunal myoelectrical activity during rectal dis-
tension in dogs. Dig. Dis. Sci. 2000; 45: 1731–6.
49 Koch KL, Bingaman S, Tan L, Stern RM. Visceral per-
ceptions and gastric myoelectrical activity in healthy
women and in patients with bulimia nervosa. Neurogas-
troenterol. Motil. 1998; 10: 3–10.
50 Homma S, Shimakage N, Yagi M et al. Electrogastrog-
raphy prior and following total gastrectomy, sub-total
gastrectomy, and gastric tube formation. Dig. Dis. Sci.
1995; 40: 893–900.
51 Homma S, Hasegawa J, Maruta T et al. Isopower maps of
the electrogastrogram (EGG) after total gastrectomy or
total colectomy. Neurogastroenterol. Motil. 1999; 11: 441–
8.
52 Smout AJPM, Van der Schee EJ. Computer analysis of
cutaneously recorded gastric electrical activity. Automed-
ica 1987; 9: 331–45.
53 Kaiho T, Shimoyama I, Nakajima Y, Ochiai T. Gastric
and non-gastric signals in electrogastrography. J. Auton.
Nerv. Syst. 2000; 79: 60–6.
54 Chen JDZ, McCallum RW. Effect of milk on myoelec-
trical activity in normal human stomach: an electrogas-
trographic study. Med. Biol. Eng. Comput. 1992; 30:
1324–36.
55 Liang J, Cheung JY, Chen JD. Detection and deletion of
motion artifacts in electrogastrogram using feature and
neural networks. Ann. Biomed. Eng. 1997; 25: 850–7.
56 Chang FY, Lu CL, Chen CY, Lee SD, Jang HC, Fu SE.
Factors responsible for computed electrogastrographic
parameters in humans. Am. J. Gastroenterol. 1997; 92:
2090–3.
57 Lin X, Chen JZ. Abnormal gastric slow waves in
patients with functional dyspepsia assessed by multi-
channel electrogastrography. Am. J. Physiol. 2001; 280:
G1370–5.
58 Geldof H, van der Schee J. Electrogastrography, clinical
applications. Scand. J. Gastroenterol. 1989; 24 (Suppl.):
S75–82.
59 Kothapalli B. Electrogastrogram stimulation using a
three-dimensional model. Med. Biol. Eng. Comput. 1993;
31: 482–6.
60 Lin Z, Chen J. Comparison of three running spectral
analysis methods. In: Chen JZ, McCallum RW, eds. Elec-
trogastrography, Principles and Applications. New York:
Raven Press, 1994; 75–103.
61 Chen J, McCallum RW. Electrogastrography: measure-
ment, analysis and prospective applications. Comput.
Med. Biol. 1991; 29: 339–50.
62 Stern RM, Koch KL, Steward WR, Lindblad IM. Spec-
tral analysis of tachygastria recorded during motion sick-
ness. Gastroenterology 1987; 92: 92–7.
514
63 Chen J, Vandewalle J, Sansen W, Vantrappen G, Janssens
J. Adaptive spectral analysis of cutaneous electrogastric
signals using autoregressive moving average modelling.
Comput. Med. Biol. 1990; 28: 531–6.
64 Chen J. A computerized data analysis system for electro-
gastrography. Comput. Biol. Med. 1992; 22: 45–58.
65 Koch KL, Hong SP, Xu L. Reproducibility of gastric
myoelectrical activity and the water load test in patients
with dysmotility-like dyspepsia symptoms and in control
subjects. J. Clin. Gastroenterol. 2000; 31: 125–9.
66 Shimada Y, Watanabe M, Shibahara N, Kita T, Itoh T,
Terasawa K. Electrogastrographic power ratio in humans
is not related to changes in antrum–skin distance but to
antral motility. J. Gastroenterol. 1998; 33: 310–17.
67 Verhagen MAMT, Samson M, Smout AJPM. Gastric
myoelectrical and antroduodenal motor activity in
patients with achalasia. Neurogastroenterol. Motil. 1998;
10: 211–18.
68 Chen JZ, McCallum RW. Electrogastrographic para-
meters and their clinical significance. In: Chen JZ,
McCallum RW, eds. Electrogastrography, Principles and
Applications. New York: Raven Press, 1994; 45–73.
69 Koch KL, Stern RM, Vasey MW, Botti JJ, Creasy GW,
Dwyer A. Gastric dysrhythmias and nausea of pregnancy.
Dig. Dis. Sci. 1990; 35: 961–8.
70 Lu CL, Chen CY, Chang FY et al. Impaired postprandial
gastric myoelectrical activity in Chinese patients with
non-ulcer dyspepsia. Dig. Dis. Sci. 2001; 46: 242–9.
71 Leahy A, Besherdas K, Clayman C, Mason I, Epstein O.
Abnormalities of the electrogastrogram in functional gas-
trointestinal disorders. Am. J. Gastroenterol. 1999; 94:
1023–8.
72 Kauer WKH, Stein HJ, Balint A, Siewert JR. Transcuta-
neous electrogastrography: a non-invasive method to
evaluate post-operative gastric disorders? Hepatogastroen-
terology 1999; 46: 1244–8.
73 Besherdas K, Leahy A, Mason I, Harbord M, Epstein O.
The effect of cisapride on dyspepsia symptoms and the
electrogastrogram in patients with non-ulcer dyspepsia.
Aliment. Pharmacol. Ther. 1998; 12: 755–9.
74 Miyaji H, Azuma T, Ito S et al. The effect of Helicobacter
pylori eradication therapy on gastric antral myoelectrical
activity and gastric emptying in patients with non-ulcer
dyspepsia. Aliment. Pharmacol. Ther. 1999; 13: 1473–80.
75 Ladabaum U, Koshy SS, Wood ML, Hooper FG,
Owyang C, Hasler W. Differential symptomatic and elec-
trogastrographic effects of distal and proximal human
gastric distension. Am. J. Physiol. 1998; 275: G418–24.
76 You CH, Lee KY, Chey WY, Menguy R. Electrogastro-
graphic study of patients with unexplained nausea, bloat-
ing and vomiting. Gastroenterology 1980; 79: 311–14.
77 Barbar M, Steffen R, Wyllie R, Goske M. Electrogastrog-
raphy versus gastric emptying scintigraphy in children
with symptoms suggestive of gastric motility disorder. J.
Pediatr. Gastroenterol. Nutr. 2000; 30: 194–8.
78 Rönnblom A, Hellström PM, Holst JJ, Theodorsson E,
Danielsson Å. Gastric myoelectrical activity and gut hor-
mones secretion in myotonic dystrophy. Eur. J. Gastro-
enterol. Hepatol. 2002; 13: 825–31.
79 Brzana RJ, Koch KL, Bingaman S. Gastric myoelectrical
activity in patients with gastric outlet obstruction and
idiopathic gastroparesis. Am. J. Gastroenterol. 1998; 93:
1803–9.
F-Y Chang
80 Abell TL, Malagelada JR, Lucas AR et al. Gastric elec-
tromechanical and neurohormonal function in anorexia
nervosa. Gastroenterology 1987; 93: 958–65.
81 Chang FY, Lu CL, Chen CY et al. The electrogastro-
graphic characteristics in patients of stomach cancer. Dig.
Dis. Sci. 2001; 46: 1458–65.
82 Chong SKF. Electrogastrography in cyclic vomiting syn-
drome. Dig. Dis. Sci. 1999; 44: 64S–73S.
83 Lin Z, Chen JDZ, Parolisi S, Shifflett J, Peura DA,
McCallum RW. Prevalence of gastric myoelectrical
abnormalities in patients with nonulcer dyspepsia and H.
pylori infection, resolution after H. pylori eradication. Dig.
Dis. Sci. 2001; 46: 739–45.
84 Geldof H, van der Schee EJ, Grashuis JL. Electrogastro-
graphic characteristics of interdigestive migrating com-
plex in humans. Am. J. Physiol. 1986; 250: G165–71.
85 Chen J, Richards RD, McCallum RW. Identification of
gastric contractions from the cutaneous electrogastro-
grasphy. Am. J. Gastroenterol. 1994; 89: 79–85.
86 Desvarannes SB, Mizafi M, Dubois A. Relation between
postprandial gastric emptying and cutaneous electrogas-
trogram in primates. Am. J. Physiol. 1991; 261: G248–
55.
87 Levanon D, Zhang M, Orr WC, Chen JDZ. Effects of
meal volume and composition on gastric myoelectrical
activity. Am. J. Physiol. 1998; 274: G430–4.
88 Lin HC, Zhao XT, Chung B, Gu YG, Elashoff JD. Freu-
quency of gastric pacesetter potential depends on volume
and site of distension. Am. J. Physiol. 1996; 270: G470–5.
89 Chen J, McCallum RW. Response of the electric activity
in the human stomach to water and a solid meal. Med.
Biol. Eng. Comput. 1991; 29: 351–7.
90 Riezzo G, Pezzolla F, Darconza G, Giorgio I. Gastric
myoelectrical activity in the first trimester of pregnancy: a
cutaneous electrogastrographic study. Am. J. Gastroen-
terol. 1992; 87: 702–7.
91 Levanon D, Zhang M, Chen JDZ. Efficiency and efficacy
of the electrogastrogram. Dig. Dis. Sci. 1998; 43: 1023–
30.
92 Lin Z, Eaker EY, Sarosiek I, McCallum RW. Gastric
myoelectrical activity and gastric emptying in patients
with functional dyspepsia. Am. J. Gastroenterol. 1999; 94:
2384–9.
93 Lu CL, Montgomery P, Zhou X, Orr WC, Chen JDZ.
Gastric myoelectrical activity in patients with cervical spi-
nal cord injury. Am. J. Gastroenterol. 1998; 93: 2391–6.
94 Soykan I, Lin Z, Bennett JP, McCallum RW. Gastric
myoelectrical activity in patients with Parkinson’s disease,
evidence of a primary gastric abnormality. Dig. Dis. Sci.
1999; 44: 927–31.
95 Chen JDZ, Lin X, Zhang M, Torres-Pinedo RB, Orr
WC. Gastric myoelectrical activity in healthy children
and children with functional dyspepsia. Dig. Dis. Sci.
1998; 43: 2384–91.
96 Riezzo G, Pezzolla F, Thouvenot J, Giorgio I. Reproduc-
ibility of cutaneous electrogastrography in the fasting
state in man. Pathol. Biol. 1992; 40: 889–94.
97 Parkman HP, Harris HD, Miller MA, Fisher RS. Influ-
ence of age, gender, and menstrual cycle on the normal
electrogastrogram. Am. J. Gastroenterol. 1996; 91: 127–
33.
98 Pfaffenbach B, Adamek RJ, Huhn K, Wegenrer M. Elec-
trogastrography in healthy subjects. Evaluation of normal
Review of EGG
values, influence of age and gender. Dig. Dis. Sci. 1995;
40: 1445–50.
99 Koch KL, Tran TN, Stern RM, Bingaman S, Spery N.
Gastric myoelectrical activity in premature and term
infants. J. Gastrointest. Motil. 1993; 4: 41–7.
100 Patterson M, Rintala R, Lloyd DA. A longitudinal study
of electrogastrography in normal neonates. J. Pediatr.
Surg. 2000; 35: 59–61.
101 Liang J, Co E, Zhang M, Pineda J, Chen JDZ. Develop-
ment of gastric slow waves in preterm infants measured
by electrogastrography. Am. J. Physiol. 1998; 274: G503–
8.
102 Hasler WL, Kim MS, Chey WD, Stevenson V, Stein B,
Owyang C. Central cholinergic and a-adrenergic medi-
ation of gastric slow wave dysrhythmias evoked during
motion sickness. Am. J. Physiol. 1995; 268: G539–47.
103 Stern RM, Crawford HE, Stwart WR, Vasey MW, Koch
KL. Sham feeding: cephalic–vagal influence on gastric
myoelectric activity. Dig. Dis. Sci. 1989; 34: 521–7.
104 Sun WM, Penagini R, Hebbard G et al. Effects of drink
temperature on antropyloroduodenal motility and gastric
electrical activity in humans. Gut 1995; 37: 329–34.
105 van der Schee EL, Grashuis JL. Contraction related, low
frequency components in canine electrogastrographic
signals. Am. J. Physiol. 1983; 245: G470–5.
106 Rothstein RD, Alavi A, Reynolds JC. Electrogastrogra-
phy in patients with gastroparesis and effect of long-term
cisapride. Dig. Dis. Sci. 1993; 38: 1518–24.
107 Orr WC, Zhang M, Mcclanahan J, Sloan S, Chen JDZ.
Gastric myoelectric activity in older adults treated with
cisapride for gastro-oesophageal reflux disease. Aliment.
Pharmacol. Ther. 2000; 14: 337–43.
108 Koch KL, Stern RM, Stewart WR, Vasey MW, Sullivan
ML. Gastric emptying and gastric myoelectrical activity
in patients with symptomatic diabetic gastroparesis:
effect of long-term domperidone treatment. Am. J. Gas-
troenterol. 1989; 84: 1069–75.
109 Janssens J, Peeters TL, Vantrappen G et al. Improvement
of gastric emptying in diabetic gastroparesis by erythro-
mycin: preliminary studies. N. Engl. J. Med. 1990; 322:
1028–31.
110 Chen JDZ, Lin ZY, Edmunds MC III,, McCallum RW.
Effects of octreotide and erythromycin on gastric myo-
electrical and motor activities in patients with gastropare-
sis. Dig. Dis. Sci. 1998; 43: 80–9.
111 Chen J, Yeaton P, McCallum RW. Effect of erythromycin
on gastric myoelectrical activity in normal humans sub-
jects. Am. J. Physiol. 1992; 263: G24–8.
112 Abell TL, Malagelada JR. Glucagon-evoked gastric dys-
rhythmias in humans shown by an improved electrogas-
trographic technique. Gastroenterology 1985; 88: 1932–
40.
113 DiBaise JK, Brand RE, Lyden E, Tarantolo SR, Quigley
EMM. Gastric myoelectrical activity and its relationship
to the development of nausea and vomiting after intensive
chemotherapy and autologous stem cell transplantation.
Am. J. Gastroenterol. 2001; 96: 2873–81.
114 Cheng W, Chan GCF, Tam PKH. Cytotoxic chemother-
apy has minimal direct effect on gastric myoelectrical
activity in children with 5HT3 antagonist prophylaxis.
Med. Pediatr. Oncol. 2000; 34: 421–3.
115 Chang CS, Lin HC, Yeh HZ, Poon SK, Yang SS, Chen
GH. Electrogastrographic study of the effect of tran-
515
scatheter arterial chemoembolization on gastric
myoelectrical activity. Scand. J. Gastroenterol. 1998; 33:
1164–9.
116 Horowitz M, Wishart JM, Jones KL, Hebbard GS. Gas-
tric emptying in diabetes, an overview. Diabet. Med.
1996; 13: S16–22.
117 Chen J, McCallum RW. Gastric slow wave abnormalities
in patients with gastroparesis. Am. J. Gastroenterol. 1992;
87: 477–82.
118 Abell TL, Camilleri M, Hench VS et al. Gastric electro-
mechanical function and gastric emptying in diabetic gas-
troparesis. Eur. J. Gastroenterol. Hepatol. 1991; 3: 163–7.
119 Koch KL. Electrogastrography. In: Schuster MM, Crow-
ell MD, Koch KL, eds. Schuster Atlas of Gastrointestinal
Motiity in Health and Disease, 2nd edn. Hamilton: BC
Decker, 2002; 185–201.
120 Chen J, Lin Z, Pan J, McCallum R. Abnormal gastric
myoelectrical activity and delayed gastric emptying in
patients with symptoms suggestive of gastroparesis. Dig.
Dis. Sci. 1996; 41: 1538–45.
121 Jebbink HJK, Bruijs PPM, Bravenboer B, Akkerman
LMA, van Berge-Henegouwen GP, Smout AJPM. Gas-
tric myoelectrical activity in patients with type 1 diabetes
mellitus and autonomic neuropathy. Dig. Dis. Sci. 1994;
39: 2376–83.
122 El-Salhy M, Sitohy B. Abnormal gastrointestinal endo-
crine cells in patients with diabetes type 1: relationship to
gastric emptying and myoelectrical activity. Scand. J.
Gastroenterol. 2001; 36: 1162–9.
123 Hasler WL, Soudah HC, Dulai G, Owyang C. Mediation
of hyperglycemia-evoked gastric slow wave dysrhythmias
by endogenous prostaglandins. Gastroenterology 1995;
108: 727–36.
124 Walsh JW, Hasler WL, Nugent CE. Progesterone and
estrogen are potential mediators of gastric slow wave dys-
rhythmias in nausa of pregnancy. Am. J. Physiol. 1996;
270: G506–14.
125 Xu LH, Koch KL, Summy-Long L et al. Hypothalamic
and gastric myoelectrical responses during vection-
induced nausea in healthy Chinese subjects. Am. J. Phys-
iol. 1993; 265: E578–84.
126 Reid K, Grundy D, Khan M, Read NW. Gastric emp-
tying and the symptoms of vection-induced nausea. Eur.
J. Gastroenterol. Hepatol. 1995; 7: 103–8.
127 Lin XM, Levanon D, Chen JDZ, Impaired postprandial
gastric slow waves in patients with functional dyspepsia.
Dig. Dis. Sci. 1998; 43: 1678–84.
128 Jebbink HJ, van Berge-Henegouwen GP, Bruijs P,
Akkermans LM, Smout AJ. Gastric myoelectrical activity
and gastrointestinal motility in patients with functional
dyspepsia. Eur. J. Clin. Invest. 1995; 25: 429–37.
129 Thor P, Lorens K, Tabor S, Herman R, Konturek JW,
Konturek SJ. Dysfunction in gastric myoelectric and
motor activity in Helicobacter pylori positive gastritis
patients with non-ulcer dyspepsia. J. Physiol. Pharmacol.
1996; 47: 469–76.
130 Talley NJ, Janssens J, Lauritsen K, Racz I, Bolling-
Sternevald E. Eradication of Helicobacter pylori in func-
tional dyspepsia: randomised double blind placebo con-
trolled trial with 12 months’ follow up. BMJ 1999; 318:
833–7.
131 Talley NJ, Vakil N, Ballard EDII, Fennerty MB. Absence
of benefit of eradicating Helicobacter pylori in patients with
516
nonulcer dyspepsia. N. Engl. J. Med. 1999; 341: 1106–
11.
132 McColl KEL, Murray L, El-Omar E et al. Symptomatic
benefit from eradicating Helicobacter pylori infection in
patients with non-ulcer dyspepsia. N. Engl. J. Med. 1998;
339: 1869–74.
133 Fock KM, Khoo TK, Chia KS, Sim CS. Helicobacter
pylori infection and gastric emptying of indigestible solids
in patients with dysmotility-like dyspepsia. Scand. J. Gas-
troenterol. 1997; 32: 676–80.
134 Richards CA, Andrews PLR, Spitz L, Mila PJ. Nissen
fundoplication may induce gastric myoelectrical distur-
bance in children. J. Pediatr. Surg. 1998; 33: 1801–5.
135 Liberski SM, Koch KL, Amip RG, Stern RM. Ischemic
gastroparesis: resolution after revascularizatrion. Gastro-
enterology 1990; 99: 252–7.
136 Debinski HS, Ahmed S, Milla PJ, Kamm MA. Electro-
gastrography in chronic intestinal pseudo-obstruction.
Dig. Dis. Sci. 1996; 41: 1292–7.
137 Punkkinen J, Pikkarainen P, Konkka I, Turjanmaa V.
Effect of peritoneal dialysis on gastric myoelectrical activ-
ity in patients with chronic renal failure. Dig. Dis. Sci.
2001; 46: 2651–7.
138 Ko CW, Chang CS, Wu MJ, Chen GH. Transient
impact of hemodialysis on gastric myoelectrical activity of
uremic patients. Dig. Dis. Sci. 1998; 43: 1159–64.
F-Y Chang
139 Bortolotti M. The electrical way to cure gastroparesis.
Am. J. Gastroenterol. 2002; 97: 1874–83.
140 McCallum RW, Chen JDZ, Lin Z, Schirmer BD, Will-
iams RD, Ross RA. Gastric pacing improves emptying
and symptoms in patients with gastroparesis. Gastroenter-
ology 1998; 114: 456–61.
141 Lin Z, Forster J, Sarosiek I, McCalum RW. Treatment of
gastroparesis with electrical stimulation. Dig. Dis. Sci.
2003; 48: 837–48.
142 Eagon JC, Kelly KA. Effect of electrical stimulation on
gastric electrical activity, motility and emptying. Neuro-
gastroenterol. Motil. 1995; 7: 39–45.
143 Tougas G, Huizinga JD. Gastric pacing as a treatment for
intractable gastroparesis: shocking news? Gastroenterology
1998; 114: 598–601.
144 Mintchev MP, Sanmiguel CP, Amars M, Bowes K.
Microprocessor-controlled movement of solid gastric
content using sequential neural electrical stimulation.
Gastroenterology 2000; 118: 258–63.
145 Hasler WL. The brute force approach to electrical
stimulation of gastric emptying: a future treatment for
refractory gastroparesis? Gastroenterology 2000; 118: 433–
42.