CAM 20134

Cutaneous Electrogastrography (EGG)

Category:Medicine   Last Reviewed:August 2019
Department(s):Medical Affairs   Next Review:August 2999
Original Date:August 2000    

Description:
Electrogastrography describes the recording and interpretation of electrical activity of the stomach, typically from the skin surface. The electrical activity of the stomach can be subdivided into two general categories: electrical control activity (ECA) and electrical response activity (ERA). ECA is characterized by regularly recurring electrical potentials, originating in the gastric pacemaker located in the corpus of the stomach and sweeping in an annular band with increasing velocity toward the pylorus. ECA is not associated with contractions of the stomach unless coupled with action potentials, referred to as ERA.

The usual practice is to record several cutaneous electroencephalographic (EEG) signals from various standardized positions on the abdominal wall and to select the one with the highest amplitude for further analysis. Nonetheless, the recorded signal is relatively weak and difficult to distinguish from the surrounding background "noise" related to unwanted signals, such as cardiac, respiratory, duodenal and colonic electrical activity. For this reason, direct visual analysis of the electrogastrography (EGG) signals is problematic. Various methods of filtering out background noise and automated analysis have been developed. Running spectral analysis is most common. The EGG is usually evaluated in terms of changes in the EGG amplitude and frequency. Deviations from the normal frequency of three cycles per minute may be referred to as brady- or tachyarrhythmia.

The use of EGG has been most widely studied in patients with gastroparesis and functional dyspepsia. Gastroparesis is defined as a chronic disorder of gastric motility as evidenced by delayed gastric emptying of a solid meal. Symptoms include bloating, distension, nausea and vomiting. When severe and chronic, gastroparesis can be associated with dehydration, poor nutritional status and poor glycemic control in diabetics. While most commonly associated with diabetes, gastroparesis is also found in chronic pseudo-obstruction, connective tissue disorders, Parkinson's disease and psychological pathology. Functional dyspepsia is an enigmatic disorder characterized by persistent symptoms of abdominal discomfort with no identifiable etiology, including gastric emptying. In this setting, disorders in gastric motility may be considered. Treatment of gastric motility disorders typically includes the use of prokinetic agents, such as cisapride, domperidone or metoclopramide.

Scintigraphic gastric emptying is considered the gold standard test for evaluating gastroparesis. The test consists of ingestion of a solid meal spiked with 99-technetium. Serial scintigraphic measurements are then performed every 20 minutes for 2-3 hours after the meal. Delayed gastric emptying is diagnosed if more than 50 percent of the radio-labelled food is retained at the end of the study period. While gastric emptying evaluates the efficiency of gastric emptying, EGG focuses on the underlying myoelectrical activity.

Policy:
Electrogastrography is considered INVESTIGATIONAL.   

Benefit Application
BlueCard®/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and, thus, these devices may be assessed only on the basis of their medical necessity.

Rationale
Validation of the clinical use of any diagnostic test focuses on 3 main principles: 1) the technical feasibility of the test; 2) basic statistical measurements, such as sensitivity, specificity and positive and negative predictive values in different populations of patients and compared to the gold standard; and 3) how the results of the diagnostic test will be used in the management of the patient and whether the change in treatment will result in an overall improvement in health outcomes. Based on a review of the published peer-reviewed literature, there are inadequate data to evaluate any of the above principles.

Technical Feasibility
EGG recording faces several technical challenges, many of them related to measuring cutaneous signals, rather than directly measuring electrical activity along the stomach mucosa or serosa. One of the parameters of the EGG analyzed is the power of the signal, commonly thought to increase after the digestion of a meal. However, the power of the signal can also be influenced by the proximity of the electrode to the stomach wall, which can change as the stomach distends after a meal. (1, 2) Changes in frequency, such as tachyarrhythmias and bradyarrhythmias, are commonly reported. However, EGG artifacts, such as movement artifacts and signal drift, may limit interpretation. Simultaneous recordings of cutaneous and internal EGGs suggest that cutaneous EGG records more episodes of tachyarrhythmias, probably due to the accumulation of artifacts. The use of computer-assisted analysis, which may not be able to identify and eliminate movement artifacts, must be interpreted very cautiously. Day to day variability of the EGG is another important issue, as measured by repeated EGG in the same patient over a short period of time.

Diagnostic Performance
Several studies have compared EGG with gastric emptying tests and have reported a poor correlation between the two. (3-7) Two of the larger studies are reviewed here. Chen and colleagues performed both EGG and scintigraphic gastric emptying in 97 patients with symptoms suggestive of gastroparesis. (6) Considering gastric emptying tests as the gold standard, the authors concluded that patients with delayed gastric emptying had either a lower percentage of normal slow waves or a higher prevalence of gastric dysrhythmias, or both. However, the sensitivities of these 3 parameters were 24 percent, 42 percent or 14 percent, respectively, while the corresponding specificities were 92 percent, 87 percent and 100 percent. The authors concluded that an abnormal EGG may predict delayed gastric emptying, although a normal EGG will not rule out delayed gastric emptying. One hypothesis is that normal gastric myoelectrical activity is one of many prerequisites for normal gastric emptying.

Parkman and colleagues correlated abnormalities in EGG with gastric emptying and symptom severity in 72 patients with functional dyspepsia. (7) Patients were recruited from those who were referred for a gastric emptying scintigraphy. A total of 22 patients (31 percent) had an abnormal EGG, and 22 (31 percent) had an abnormal gastric emptying test. The EGG was abnormal in 11 of the 22 patients (50 percent) with an abnormal gastric emptying test. If the gastric emptying scintigraphy is considered the gold standard, the EGG had a sensitivity of 50 percent and a specificity of 78 percent. While these data suggest that EGG cannot be substituted for gastric emptying scintigraphy, it must be noted that the 2 tests are measuring different aspects of gastric activity. Therefore, another question is the clinical significance of those with abnormal EGGs but negative emptying tests and whether the 2 tests are complementary. Patients with abnormalities in both tests tended to report increased symptom severity, but the authors did not comment on the diagnostic significance of this observation.

One study did focus on how EGG could be used as an adjunct to gastric emptying studies, by focusing on the subset of patients with known delayed gastric emptying and no dysrhythmias observed on the EGG. (8) The authors concluded that while the patients with idiopathic gastroparesis were likely to have gastric dysrhythmias, patients with mechanical obstruction were more likely to have persistent and prominent 3 cycles per minute EGG patterns, which are seen in normal EGGs. This observation suggests that patients with known gastroparesis based on gastric emptying studies may be further evaluated with an EGG. If no dysrhythmias are found, the patients may be referred for further tests to identify subtle mechanical obstructions. If EGG dysrhythmias are found, the patients might benefit from a trial of a prokinetic agent. However, this study was retrospective in nature, and the results must be confirmed in larger prospective studies.

Other studies have focused on the use of EGG in diabetic patients as a research tool to study the pathogenesis of diabetic gastroparesis. Kawagishi and colleagues studied the relationship between glucose control, autonomic neuropathy and EGG findings. They concluded that improved glycemic control and improved autonomic nerve function were associated with normalization of gastric myoelectrical activity. (9) Mantides and colleagues reported that abnormalities in the EGG are frequently detected in diabetes, even without symptoms of gastroparesis. (10)

Patient Management
No study focused on the final patient outcomes in patients undergoing EGGs. Outcomes of interest could include the avoidance of unnecessary tests or unnecessary treatment, or the institution of potentially more effective treatment. Based on the studies reviewed here, due to the low sensitivity of EGG for diagnosis of gastric motility disorders compared to scintigraphic gastric-emptying studies, it is unlikely that EGG can supplant tests of gastric emptying. As an adjunct to gastric-emptying tests, 1 study suggested that EGG could be used to distinguish patients with mechanical obstruction from idiopathic gastroparesis. (8) However, this study did not include patient outcomes.

In summary, while EGG may be an interesting research tool to study the correlation between gastric electrical activity and disease, data are inadequate to determine how the results of this test may be used to benefit patient management.

2002-2005 Update
Literature searches, performed on the MEDLINE database for the period of 2000 through October 2005, did not identify any published literature that addresses the limitations noted in this discussion. Therefore, the policy statement is unchanged. The published literature suggests that EGG is primarily used as a research tool in patients with a variety of disorders. (11-14) Other studies continue to focus on the technical performance of the test (15, 16), including the use of multichannel recording compared to single channel recording. (17) No study was identified that elucidated the diagnostic performance of EGG in different populations of patients or how this information could be used to benefit patient management. In 2001, the American Gastroenterological Association published a medical position statement on nausea and vomiting (18), which offered the following conclusion:

“Although well-documented disorders of enteric nerve and muscle such as the pseudo-obstruction syndrome may result in nausea and vomiting, the role of gastrointestinal dysmotility and gastroparesis, in particular, in the patient with isolated chronic nausea and vomiting, remains unclear. Although gastroparesis is common among patients in this category, its primacy remains in dispute, and the interrelationships between such entities as functional and psychogenic vomiting, idiopathic gastroparesis and functional dyspepsia remain unclear. For these same reasons, the place of such tests of motor function as gastric emptying studies, electrogastrography and manometry have not been defined, and the yield of such diagnostic studies has not been adequately compared with a therapeutic trial of an antiemetic and/or prokinetic agents.”

2006-2007 Update
A search of the MEDLINE database was performed through February 2007. EGG continues to be a frequently used research tool for assessing the level of gastric function and mechanisms of dysfunction for a variety of disease states.

Some recent papers assessed the reliability of EGG. One study assessed the utility of EGG to differentiate between patients with reflux disease (n=101), active gastric ulcer (n=55) and functional dyspepsia (n=59). (19) Following water loading, abnormal EGG results were obtained in 41 percent of patients with reflux disease, 56 percent of patients with active gastric ulcer and 44 percent of patients with functional dyspepsia. The absence of significant differences in the percentages of abnormal results indicates that EGG cannot differentiate between these various gastric diseases. Another study assessed short-term (1 day) and medium-term (greater than 2 weeks) reproducibility of EGG parameters in 22 healthy volunteers following ingestion of identical meals. (20) Analysis with the Cohen unweighted kappa statistic indicated moderate to good reproducibility for parameters assessing the frequency of gastric slow waves. However, parameters describing the power of gastric slow waves had only fair reproducibility. The authors concluded that the feasibility of some electrogastrographic parameters to convey clinically useful information may be hampered by the limited reproducibility of results.

A position statement on the diagnosis and treatment of gastroparesis from the American Gastroenterological Association in 2004 reported that the guideline developers discussed, but did not recommend, the use of EGG to test for gastric myoelectrical activity. (21) Overall, the literature indicates that the use of EGG is investigational. Therefore, the policy statement is unchanged.

2008 Update
A search of the MEDLINE database for the period of March 2007 through April 2008 did not identify any evidence that would alter the conclusions reached previously. Two recent studies concluded that the reproducibility and clinical utility of EGG are poor. (22, 23) This technology has not been shown to improve the net health outcome. The policy statement is unchanged.

References: 

  1. Verhagen MA, Van Schelven LJ, Samsom M et al. Pitfalls in the analysis of electrogastrographic recordings. Gastroenterology 1999; 117(2):453-60.
  2. Bortolotti M. Electrogastrography: a seductive promise, only partially kept. Am J Gastroenterol 1998; 93(10):1791-4.
  3. Koch KL, Medina M, Bingaman S et al. Gastric dysrhythmia and visceral sensations in patients with functional dyspepsia. Gastroenterology 1992; 102:A469.
  4. Koch KL, Stern RM, Stewart WR et al. Gastric emptying and gastric myoelectrical activity in patients with diabetic gastroparesis: effect of long-term domperidone treatment. Am J Gastroenterol 1989; 84(9):1069-75.
  5. Smout AJ, Jebbink HJ, Akkermans LM et al. Role of electrogastrography and gastric impedance measurements in evaluation of gastric emptying and motility. Dig Dis Sci 1994; 39(12 suppl):110S-113S.
  6. Chen JD, Lin Z, Pan J et al. Abnormal gastric myoelectrical activity and delayed gastric emptying in patients with symptoms suggestive of gastroparesis. Dig Dis Sci 1996; 41(8):1538-45.
  7. Parkman HP, Miller MA, Trate D et al. Electrogastrography and gastric emptying scintigraphy are complementary for assessment of dyspepsia. J Clin Gastroenterol 1997; 24(4):214-9.
  8. Brzana RJ, Koch KL, Bingaman S. Gastric myoelectrical activity in patients with gastric outlet obstruction and idiopathic gastroparesis. Am J Gastroenterol 1998; 93(10):1803-9.
  9. Kawagishi T, Nishizawa Y, Emoto M et al. Gastric myoelectrical activity in patients with diabetes: Role of glucose control and autonomic nerve function. Diabetes Care 1997; 20(5):848-53.
  10. Mantides A, Stefanides G, Kioulanis J et al. Cutaneous electrogastrography for the assessment of gastric myoelectrical activity in type I diabetes mellitus. Am J Gastroenterol 1997; 92(7):1190-3.
  11. Aktay AN, Splaingard ML, Miller T et al. Electrogastrography in children with cystic fibrosis. Dig Dis Sci 2002; 47(4):699-703.
  12. Levy J, Harris J, Chen J et al. Electrogastrographic norms in children: toward the development of standard methods, reproducible results, and reliable normative data. J Pediatr Gastoenterol Nutr 2001; 33(4):455-61.
  13. Koch KL. Electrogastrography: physiological basis and clinical application in diabetic gastropathy. Diabetes Technol Ther 2001; 3(1):51-62.
  14. Mathur R, Pimentel M, Sam CL et al. Postprandial improvement of gastric dysrhythmias in patients with type II diabetes: identification of responders and nonresponders. Dig Dis Sci 2001: 46(4):705-12.
  15. Koch KL, Hong SP, Xu L. Reproducibility of gastric myoelectrical activity and the water load test in patients with dysmotility-like dypepsia symptoms and in control subjects. J Clin Gastroenterol 2000; 31(2):125-9.
  16. Lin Z, Eaker EY, Sarosiek I et al. Gastric myoelectrical activity and gastric emptying in patients with functional dyspepsia. Am J Gastroenterol 1999; 94(9):2384-9.
  17. Simonian HP, Panganamamula K, Chen JZ et al. Multichannel electrogastrography (EGG) in symptomatic patients: a single center study. Am J Gastroenterol 2004; 99(3):478-85.
  18. American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001; 120(1):261-3.
  19. Chen CL, Hu CT, Lin HH et al. Clinical utility of electrogastrography and the water load test in patients with upper gastrointestinal symptoms. J Smooth Muscle Res 2006; 42(5):149-57.
  20. Jonderko K, Kasicka-Jonderko A, Krusiec-Swidergol B et al. How reproducible is cutaneous electrogastrography? An in-depth evidence-based study. Neurogastroenterol Motil 2005; 17(6):800-9.
  21. Parkman HP, Hasler WL, Fisher RS. American Gastroenterological Association medical position statement: diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127(5):1589-91.
  22. Abid S, Lindberg G. Electrogastrography: poor correlation with antro-duodenal manometry and doubtful clinical usefulness in adults. World J Gastroenterol 2007; 13(38):5101-7.
  23. Krusiec-Świdergoł B, Jonderko K. Multichannel electrogastrography under a magnifying glass - an in-depth study on reproducibility of fed state electrogastrograms. Neurogastroenterol Motil 2008 Feb 19. 

Coding Section

Codes Number Description
CPT 91132 Electrogastrography, diagnostic, transcutaneous
  91133 As above, but with provocative testing
ICD-9 Procedure 44.19 Other diagnostic procedures on stomach
ICD-9 Diagnosis 250.60-250.63 Diabetes with neurological manifestations (i.e., gastroparesis)
  536.2 Persistent vomiting
  536.3 Gastroparesis
  536.8 Dyspepsia and other specified disorders of function of stomach
  787.3 Flatulence, eructation and gas pain
HCPCS   No Code
ICD-10-CM (effective 10/01/15) E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
  E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
   R11.10  Vomiting, unspecified
   R14.0  Abdominal distension (gaseous)
   R14.1  Gas pain
   R14.2  Eructation
   R14.3  Flatulence
   K31.84  Gastroparesis
   K30  Functional dyspepsia
ICD-10-PCS (effective 10/01/15) 0DJ63ZZ Inspection of Stomach, Percutaneous Approach
  0DJ67ZZ Inspection of Stomach, Via Natural or Artificial Opening
Type of Service Medicine  
Place of Service Physician's Office  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

08/07/2019

Annual review, no change to policy intent. 

08/28/2018 

Annual review, no change to policy intent. 

08/23/2017 

Annual Review. No change in policy intent. 

08/08/2016 

Annual review, no change to policy intent. 

08/10/2015 

Annual review, no change to policy intent. Added coding. 

08/06/2014

Annual review. Adding benefit applications and updating rationale. No change to intent.


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