Dean
D. T. Maglinte,
MD
Stanley
#{149}
M. Chernish,
The Optimal Dose What Is Enough?2 This extended commentary is written in response to the comments of Dr Skucas concerning the dose of glucagon. Although objections to the routine use of a hypotonic agent occasionally arise, the diagnostic
value
of glucagon
for its my-
orelaxant effects in gastrointestinal radiobogy (including abdominal magnetic resonance [MR] imaging and computed tomography
[CT])
is well
known,
glucagon is used in leading centers in the United States seems, however, is an unsettled this opportunity
and
diagnostic (1-4). It
studies
the
dose
recommendation
dose
of 1 mg
From
the
(D.D.T.M.) Hospital
Departments
and Medicine of Indiana and
of Radiology (S.M.C.), Methodist Indiana University
School
of Medicine,
1701 N Senate
Blvd, India-
napolis, accepted
IN 46202. January
Received January 23. Address reprint
17, 1992; requests
to D.D.T.M. 326
Radiology
#{149}
mg,
intravenously)
for upper
gas-
trointestinal radiography that was the stimulus for the double-blind crossover study
referred
to by Dr Skucas
(7). As
correctly stated by Dr Skucas, when a dose larger than needed is given, further relaxation does not occur, and the effect
is to prolong
When
the
period
This
was
of
0.025 mg of glucagon
a 33%
to 15 volunfashion, the stom-
response
of the
stomach
and a 93% response of the duodenal loop (Table 1) (7). When 0.25 mg of glucagon was given to 15 additional subjects in double-blind fashion, however, the
stomach
became
atonic
in 11 people
and moderately hypotomc in all 15. The duodenal bulb and duodenum became atonic in all 15 people for varying periof time
(Table
2) (8). Tables
1 and
2
were originally prepared to allow the thoughtful radiologist to tailor the dose to the diagnostic problem and allow enough time to complete the procedunes at a comfortable pace. For studies of the colon, we do not have double-blind studies similar to of
those
obtained
in the
upper
gastrointes-
tinal tract. This is so for obvious reasons. Miller et al studied intramuscular doses of glucagon for hypotonic colon examinations and compared their effects with those of atropine and placebos in 12 subjects (9) (Dr Skucas helped with this study
while
at Indiana
University
mend a dose of at least 0.7 mg or 10 .tg/kg for hypotonic barium enema examinations. No side effects were reported to these doses of glucagon. At this dose (10 g/kg), they noted that the effect lasted about 2-3 minutes. This dose and duration of action would
be enough
probably
ach became atonic in one volunteer and hypotonic in five, whereas the duodenab loop became atonic in four volunteers and moderately hypotonic in 14.
ods
glucagon administered with a very slow intravenous injection (over 1 minute with a 25-gauge needle) to achieve the desired smooth muscle relaxation and diminish the occurrence of untoward reactions (5). What is the optimal dose of glucagon for barium examinations of the gastrointestinal tract? Factors such as the cost of the drug and the duration of examination are important considerations. Because glucagon is not inexpensive and can prolong examination time in the upper gastrointestinal tract, the minimum effective dose should be used
2
0.05
was given intravenously teers in double-blind
should be tailored to the specific organ being examined. Our initial commentary was a response to information rebated to significant untoward reactions to the use of 1-2 mg of glucagon intramuscularly in MR imaging of the abdomen (5). Because of the length of time required to complete this procedure with current pulse sequences, we stand by our
(6). In fact, it was the senior author’s preliminary experience (6) with the use of small doses of glucagon (0.025 and
relaxation.
that the optimal dose question. We appreciate to clarify this impor-
or endoscopy,
of Glucagon:
only
tant issue. Simply stated, the optimal dose is the dose that is enough to get the job done. Enough is the important word, since the dose of glucagon required varies with the gastrointestinal organ under consideration. When MR imaging or CT is performed, the dose selected is usually that which is capable of relaxing all areas of the gastrointestinal tract, whereas with barium
MD
Hos-
pital). This study demonstrated the effectiveness of intramuscular administration of 2 mg of glucagon to relax the colon. Taylor et al (10) studied the myoelectrical activity of the colon and recturn in 22 subjects by using intraluminal suction electrodes, serosal electrodes, and surface electrodes. The intravenous bolus doses of glucagon varied from 0.5 g/kg to 20 gig/kg. Taylor et al reported no response to glucagon below 10 pg/ kg. If the patients were of average weight (about 70 kg), then their dose per patient was about 700 g or 0.7 mg per patient. Since this was their lowest effective dose for the colon, we recom-
to relax
a cobonic
spasm. When one uses doses more than 1 mg, the intensity of side effects tends to increase significantly (5). Dr Skucas points to a study by Abell and Malagelada (11), in which the patients developed nausea when dysrhythmia occurred, but none vomited.
The subjects
were
given
infusions
of
either glucagon or 5% dextrose for a period of 2 hours. Dysrhythmia was observed either during the latter part of the 2nd hour of the glucagon infusion (seven volunteers) or during the hour after the end of the glucagon infusion (two volunteers). There were five subjects who developed dysrhythmia and experienced nausea. The other subjects experienced no symptoms. There was
no documentation glucagon
of the total
rhythmia
administered developed.
occurred
toward
dose
of
by the time dysThat dysrhythmia the
end
of
the
infusion
suggests that a certain amount of glucagon degradation products had accumubated before the development of dysrhythmia. Thus, even though glucagon is destroyed rapidly in the body, an additive effect occurred to create symptoms. It therefore appears from their study that the late onset of nausea (1-3 hours later) was probably due to the local effect of the drug on the stomach. In contrast to this, the nausea and vomiting we alluded to occurred almost immediately, suggesting that its develop-
ment
is central
in origin.
We doubt
that
the nausea reported by Abell and Malagebada is relevant to the nausea and vomiting that we have observed to develop immediately following an overly fast rate of intravenous injection.
It might,
however,
late-onset lan glucagon
when
more
partly
nausea following administration,
than
explain
the
intramuscuespecially
1 mg is given
(5).
As for the effectiveness of repeated infusion of small doses for studies of the gastrointestinal tract as suggested by Jehenson (12), we are not aware of any good studies to give us precise direction as to dosage recommendation. As of this
May
1992
decrease
Table
1
Mean
Onset
rent
and Duration
of Drug
Action
in 15 Volunteers
Given
a Placebo
or
travenously
Glucagon Intravenous Placebo
Dose
0.025
0.05
of Glucagon
0.2
Moderate hypotonicity No. of subjects responding Atonic
Moderately
hypotonic
0
0.1
1.2
2.1
3.5
0
0.8
3.3
4.8
7.4
0
1 (7)
0
5 (33)
4 (27) 9 (60) Duodenal
Onset
(sec)
0
Duration (mm) Atonicity
Moderate hypotonicity No. of subjects responding and reprinted, Atonic Moderately hypotonic
0.5
0.1
Source-Modified
with
0 1
2.5 permission,
from
reference
4 (27) 14 (93)
(7)
45.3
46.3
area
3.1
5.2
4.9
6.0
8.8
8 (53)
14 (93) 15 (100)
14 (93)
appears
cur-
adequate
for ab-
endoscopy of hypotonia
1.5 7.
the
0.5 mg in-
vent the occasional occurrence of symptomatic reactive hypoglycemia in susceptible individuals (5,13). The dosages of glucagon needed for
12(80) 15(100)
Loop
53.9
54.5
0
8 (53) 14 (93)
With
of scanners,
mance of per oral small bowel barium studies. If 1 mg of glucagon is given intramuscularly, we suggest giving the patient orange juice with sugar to pre-
Stomach Duration (mm) Atonicity
dosage.
dominal CT if relaxation of the small bowel is the only effect desired; otherwise, 0.75 ntg is suggested. We have not found any need for glucagon for perfor-
(mg)
0.1
in this
generation
will depend on the duration needed for the particular to be e:amined. U
Acknowledgments:
We thank
Kelvin, MD, for reviewing Fran Shaul for secretarial
15(100)
Frederick
the manuscript, assistance.
and
15(100)
References Note-Numbers
in parentheses
1.
are percentages.
Table 2 Average Duration in Minutes of AtOnicity and Moderate Hypotonicity Stomach, Duodenal Bulb, Duodenum, and Proximal and Distal Small
Subjects
Given
a Placebo
2.
332. Caroline
3.
the colon. In: Gedgaudas-McClees RK, ed. Gastrointestinal imaging. New York: Churchill Livingstone, 1987; 110. Moss A, Thoeni RF. Computed tomogra-
or Glucagon Glucagon
Gastrointestinal
of the Bowel in 15
Tract
Placebo
Stomach Atonic Moderately hypotonic Duodenal bulb Atonic Moderately hypotonic
0.0 (2) 0.6 (2) 0.0 (0) 1.3 (3)
Dose
phy
0.5 mg
1 mg
2mg
4.9 (11)
8.7 (14) 13.1
10.1 14.7
15.1 21.7
4.
8.5
Proximal
0.0 (0) 1.4 (3)
hypotonic
7.5
10.1
12.5
16.7
5.
16.2
18.3
24.0
7.8 12.2
10.1 16.5
12.5 18.7
16.1 23.7
Moderately hypotonic Distal small bowel Atomc Moderately
and
8.3
9.4
0.1 (1)
11.5
14.9
13.7 19.7
19.7 25.0
8.6
9.4 14.7
14.0 20.3
19.7 24.3
0.0 (0)
hypotonic
Source-Modified
0.0 (0)
0.1 (1) reprinted,
Note-Numbers in parentheses sponded unless otherwise noted.
with
11.9
permission,
are numbers
from
of subjects
reference
response.
All 15 subjects
re-
Winkler
time,
all statements
repeated,
are speculation
and
doses
For poorly It
do not
elicit as strong a response as the previous dose (10). Thus, from available scientific data, an experienced fluoroscopist will need to administer 0.1 mg (0.3 mL) of glucagon intravenously for an upper gastrointestinal examination in a mobile patient.3
3 Clucagon is marketed in 1-mg ampules that will hold only 3 mL of solution. Clucagon is mixed with I mL diluent and brought to 3 mL
by removing 2 mL of air and adding 0.9% sodium chloride or 5% dextrose At this dilution, 0.3 mL is equivalent
Volume
183
#{149} Number
2
2 mL of in water. to 0.1 mg.
mobile
and for inexperienced mg is recommended. pears that 0.75 mg
minimum relaxation,
patients,
however,
fluoroscopists, 0.2 Although it apintravenously is the
dose necessary for colonic for ease of preparation, we
use 1 mg for barium enema examinations in our practice. In older patients who have difficulty retaining the barium, relaxing the colon with glucagon tends to improve their cooperation in this regard. Thus, we use it before barium is infused; otherwise, it may be given when spasm of the colon occurs. As stated, intravenous administration of 1 mg is necessary for an abdominal MR imaging study. Faster imaging sequences in the future should lead to a
tract.
H.
SM, Maglinte
of
In: Moss
Pelvis
imaging
DDT.
Ra-
Glucagon:
reactions-review Radiology 1990;
and 177:
7.
8.
Maglinte DDT, Caudill UD, Krol KU, Chernish SM, Brown DL. The minimum effective dose of glucagon in upper gastrointestinal radiography. Gastrointest Radiol 1982; 7:119-122. Miller RE, Chernish SM, Greenman GF, Maglinte DOT, Rosenak BD, Brunelle RU. Gastrointestinal response to minute doses of glucagon. Radiology 1982; 143:317-320. Miller
RE, Chernish
Rosenak
of what can or will happen. be noted that when doses are
the succeeding
M, Hricak
Chernish
study
estimates should
Radiology
145-146.
6.
8.
who achieved
of the gastrointestinal
common untoward recommendations.
small bowel
Atonic
D.
with MR: technique for improvement. diobogy 1986; 158:848-849.
Duodenum Atonic Moderately
DF, Maglinte
A, Gamsu C, Genant H, eds. Computed tomography of the body. Philadelphia: Saunders, 1983; 570, 580.
0.25 mg
12.5
Laufer I. Upper gastrointestinal tract: technical aspects-double contrast gastrointestinal radiology with endoscopic correlation. Philadelphia: Saunders, 1979; 63,
9.
10.
BD. of dose
SM, Brunelle
Double-blind response
RL,
radiographic
to intravenous
glu-
cagon for hypotonic duodenography. Radiology 1978; 127:55-59. Miller RE, Chernish SM, Skucas J, Rosenak BD, Rodda BE. Hypotonic colon examination with glucagon. Radiology 1974; 113: 555-562. Taylor I, Duthie
HL, Cumberland
Smallwood
Glucagon
R.
DC,
and the colon.
Gut 1975; 16:973-978.
11.
Abell TU, Malagelada JR. Glucagonevoked gastric dysrhythmias in humans shown by improved electrogastrographic technique. Castroenterology 1985; 88:1932-
12.
Jehenson PM. Reducing doses of glucagon used in radiologic examinations (letter). Radiology 1991; 179:286-287. Chernish SM, Maglinte DDT, Brunelle RU. The laboratory response to glucagon dosages used in gastrointestinal examinations. Invest Radiol 1988; 23:847-852.
1940.
13.
Radioloiv
327
#{149}
D. T. Maglinte,
MD
Stanley
#{149}
M. Chernish,
The Optimal Dose What Is Enough?2 This extended commentary is written in response to the comments of Dr Skucas concerning the dose of glucagon. Although objections to the routine use of a hypotonic agent occasionally arise, the diagnostic
value
of glucagon
for its my-
orelaxant effects in gastrointestinal radiobogy (including abdominal magnetic resonance [MR] imaging and computed tomography
[CT])
is well
known,
glucagon is used in leading centers in the United States seems, however, is an unsettled this opportunity
and
diagnostic (1-4). It
studies
the
dose
recommendation
dose
of 1 mg
From
the
(D.D.T.M.) Hospital
Departments
and Medicine of Indiana and
of Radiology (S.M.C.), Methodist Indiana University
School
of Medicine,
1701 N Senate
Blvd, India-
napolis, accepted
IN 46202. January
Received January 23. Address reprint
17, 1992; requests
to D.D.T.M. 326
Radiology
#{149}
mg,
intravenously)
for upper
gas-
trointestinal radiography that was the stimulus for the double-blind crossover study
referred
to by Dr Skucas
(7). As
correctly stated by Dr Skucas, when a dose larger than needed is given, further relaxation does not occur, and the effect
is to prolong
When
the
period
This
was
of
0.025 mg of glucagon
a 33%
to 15 volunfashion, the stom-
response
of the
stomach
and a 93% response of the duodenal loop (Table 1) (7). When 0.25 mg of glucagon was given to 15 additional subjects in double-blind fashion, however, the
stomach
became
atonic
in 11 people
and moderately hypotomc in all 15. The duodenal bulb and duodenum became atonic in all 15 people for varying periof time
(Table
2) (8). Tables
1 and
2
were originally prepared to allow the thoughtful radiologist to tailor the dose to the diagnostic problem and allow enough time to complete the procedunes at a comfortable pace. For studies of the colon, we do not have double-blind studies similar to of
those
obtained
in the
upper
gastrointes-
tinal tract. This is so for obvious reasons. Miller et al studied intramuscular doses of glucagon for hypotonic colon examinations and compared their effects with those of atropine and placebos in 12 subjects (9) (Dr Skucas helped with this study
while
at Indiana
University
mend a dose of at least 0.7 mg or 10 .tg/kg for hypotonic barium enema examinations. No side effects were reported to these doses of glucagon. At this dose (10 g/kg), they noted that the effect lasted about 2-3 minutes. This dose and duration of action would
be enough
probably
ach became atonic in one volunteer and hypotonic in five, whereas the duodenab loop became atonic in four volunteers and moderately hypotonic in 14.
ods
glucagon administered with a very slow intravenous injection (over 1 minute with a 25-gauge needle) to achieve the desired smooth muscle relaxation and diminish the occurrence of untoward reactions (5). What is the optimal dose of glucagon for barium examinations of the gastrointestinal tract? Factors such as the cost of the drug and the duration of examination are important considerations. Because glucagon is not inexpensive and can prolong examination time in the upper gastrointestinal tract, the minimum effective dose should be used
2
0.05
was given intravenously teers in double-blind
should be tailored to the specific organ being examined. Our initial commentary was a response to information rebated to significant untoward reactions to the use of 1-2 mg of glucagon intramuscularly in MR imaging of the abdomen (5). Because of the length of time required to complete this procedure with current pulse sequences, we stand by our
(6). In fact, it was the senior author’s preliminary experience (6) with the use of small doses of glucagon (0.025 and
relaxation.
that the optimal dose question. We appreciate to clarify this impor-
or endoscopy,
of Glucagon:
only
tant issue. Simply stated, the optimal dose is the dose that is enough to get the job done. Enough is the important word, since the dose of glucagon required varies with the gastrointestinal organ under consideration. When MR imaging or CT is performed, the dose selected is usually that which is capable of relaxing all areas of the gastrointestinal tract, whereas with barium
MD
Hos-
pital). This study demonstrated the effectiveness of intramuscular administration of 2 mg of glucagon to relax the colon. Taylor et al (10) studied the myoelectrical activity of the colon and recturn in 22 subjects by using intraluminal suction electrodes, serosal electrodes, and surface electrodes. The intravenous bolus doses of glucagon varied from 0.5 g/kg to 20 gig/kg. Taylor et al reported no response to glucagon below 10 pg/ kg. If the patients were of average weight (about 70 kg), then their dose per patient was about 700 g or 0.7 mg per patient. Since this was their lowest effective dose for the colon, we recom-
to relax
a cobonic
spasm. When one uses doses more than 1 mg, the intensity of side effects tends to increase significantly (5). Dr Skucas points to a study by Abell and Malagelada (11), in which the patients developed nausea when dysrhythmia occurred, but none vomited.
The subjects
were
given
infusions
of
either glucagon or 5% dextrose for a period of 2 hours. Dysrhythmia was observed either during the latter part of the 2nd hour of the glucagon infusion (seven volunteers) or during the hour after the end of the glucagon infusion (two volunteers). There were five subjects who developed dysrhythmia and experienced nausea. The other subjects experienced no symptoms. There was
no documentation glucagon
of the total
rhythmia
administered developed.
occurred
toward
dose
of
by the time dysThat dysrhythmia the
end
of
the
infusion
suggests that a certain amount of glucagon degradation products had accumubated before the development of dysrhythmia. Thus, even though glucagon is destroyed rapidly in the body, an additive effect occurred to create symptoms. It therefore appears from their study that the late onset of nausea (1-3 hours later) was probably due to the local effect of the drug on the stomach. In contrast to this, the nausea and vomiting we alluded to occurred almost immediately, suggesting that its develop-
ment
is central
in origin.
We doubt
that
the nausea reported by Abell and Malagebada is relevant to the nausea and vomiting that we have observed to develop immediately following an overly fast rate of intravenous injection.
It might,
however,
late-onset lan glucagon
when
more
partly
nausea following administration,
than
explain
the
intramuscuespecially
1 mg is given
(5).
As for the effectiveness of repeated infusion of small doses for studies of the gastrointestinal tract as suggested by Jehenson (12), we are not aware of any good studies to give us precise direction as to dosage recommendation. As of this
May
1992
decrease
Table
1
Mean
Onset
rent
and Duration
of Drug
Action
in 15 Volunteers
Given
a Placebo
or
travenously
Glucagon Intravenous Placebo
Dose
0.025
0.05
of Glucagon
0.2
Moderate hypotonicity No. of subjects responding Atonic
Moderately
hypotonic
0
0.1
1.2
2.1
3.5
0
0.8
3.3
4.8
7.4
0
1 (7)
0
5 (33)
4 (27) 9 (60) Duodenal
Onset
(sec)
0
Duration (mm) Atonicity
Moderate hypotonicity No. of subjects responding and reprinted, Atonic Moderately hypotonic
0.5
0.1
Source-Modified
with
0 1
2.5 permission,
from
reference
4 (27) 14 (93)
(7)
45.3
46.3
area
3.1
5.2
4.9
6.0
8.8
8 (53)
14 (93) 15 (100)
14 (93)
appears
cur-
adequate
for ab-
endoscopy of hypotonia
1.5 7.
the
0.5 mg in-
vent the occasional occurrence of symptomatic reactive hypoglycemia in susceptible individuals (5,13). The dosages of glucagon needed for
12(80) 15(100)
Loop
53.9
54.5
0
8 (53) 14 (93)
With
of scanners,
mance of per oral small bowel barium studies. If 1 mg of glucagon is given intramuscularly, we suggest giving the patient orange juice with sugar to pre-
Stomach Duration (mm) Atonicity
dosage.
dominal CT if relaxation of the small bowel is the only effect desired; otherwise, 0.75 ntg is suggested. We have not found any need for glucagon for perfor-
(mg)
0.1
in this
generation
will depend on the duration needed for the particular to be e:amined. U
Acknowledgments:
We thank
Kelvin, MD, for reviewing Fran Shaul for secretarial
15(100)
Frederick
the manuscript, assistance.
and
15(100)
References Note-Numbers
in parentheses
1.
are percentages.
Table 2 Average Duration in Minutes of AtOnicity and Moderate Hypotonicity Stomach, Duodenal Bulb, Duodenum, and Proximal and Distal Small
Subjects
Given
a Placebo
2.
332. Caroline
3.
the colon. In: Gedgaudas-McClees RK, ed. Gastrointestinal imaging. New York: Churchill Livingstone, 1987; 110. Moss A, Thoeni RF. Computed tomogra-
or Glucagon Glucagon
Gastrointestinal
of the Bowel in 15
Tract
Placebo
Stomach Atonic Moderately hypotonic Duodenal bulb Atonic Moderately hypotonic
0.0 (2) 0.6 (2) 0.0 (0) 1.3 (3)
Dose
phy
0.5 mg
1 mg
2mg
4.9 (11)
8.7 (14) 13.1
10.1 14.7
15.1 21.7
4.
8.5
Proximal
0.0 (0) 1.4 (3)
hypotonic
7.5
10.1
12.5
16.7
5.
16.2
18.3
24.0
7.8 12.2
10.1 16.5
12.5 18.7
16.1 23.7
Moderately hypotonic Distal small bowel Atomc Moderately
and
8.3
9.4
0.1 (1)
11.5
14.9
13.7 19.7
19.7 25.0
8.6
9.4 14.7
14.0 20.3
19.7 24.3
0.0 (0)
hypotonic
Source-Modified
0.0 (0)
0.1 (1) reprinted,
Note-Numbers in parentheses sponded unless otherwise noted.
with
11.9
permission,
are numbers
from
of subjects
reference
response.
All 15 subjects
re-
Winkler
time,
all statements
repeated,
are speculation
and
doses
For poorly It
do not
elicit as strong a response as the previous dose (10). Thus, from available scientific data, an experienced fluoroscopist will need to administer 0.1 mg (0.3 mL) of glucagon intravenously for an upper gastrointestinal examination in a mobile patient.3
3 Clucagon is marketed in 1-mg ampules that will hold only 3 mL of solution. Clucagon is mixed with I mL diluent and brought to 3 mL
by removing 2 mL of air and adding 0.9% sodium chloride or 5% dextrose At this dilution, 0.3 mL is equivalent
Volume
183
#{149} Number
2
2 mL of in water. to 0.1 mg.
mobile
and for inexperienced mg is recommended. pears that 0.75 mg
minimum relaxation,
patients,
however,
fluoroscopists, 0.2 Although it apintravenously is the
dose necessary for colonic for ease of preparation, we
use 1 mg for barium enema examinations in our practice. In older patients who have difficulty retaining the barium, relaxing the colon with glucagon tends to improve their cooperation in this regard. Thus, we use it before barium is infused; otherwise, it may be given when spasm of the colon occurs. As stated, intravenous administration of 1 mg is necessary for an abdominal MR imaging study. Faster imaging sequences in the future should lead to a
tract.
H.
SM, Maglinte
of
In: Moss
Pelvis
imaging
DDT.
Ra-
Glucagon:
reactions-review Radiology 1990;
and 177:
7.
8.
Maglinte DDT, Caudill UD, Krol KU, Chernish SM, Brown DL. The minimum effective dose of glucagon in upper gastrointestinal radiography. Gastrointest Radiol 1982; 7:119-122. Miller RE, Chernish SM, Greenman GF, Maglinte DOT, Rosenak BD, Brunelle RU. Gastrointestinal response to minute doses of glucagon. Radiology 1982; 143:317-320. Miller
RE, Chernish
Rosenak
of what can or will happen. be noted that when doses are
the succeeding
M, Hricak
Chernish
study
estimates should
Radiology
145-146.
6.
8.
who achieved
of the gastrointestinal
common untoward recommendations.
small bowel
Atonic
D.
with MR: technique for improvement. diobogy 1986; 158:848-849.
Duodenum Atonic Moderately
DF, Maglinte
A, Gamsu C, Genant H, eds. Computed tomography of the body. Philadelphia: Saunders, 1983; 570, 580.
0.25 mg
12.5
Laufer I. Upper gastrointestinal tract: technical aspects-double contrast gastrointestinal radiology with endoscopic correlation. Philadelphia: Saunders, 1979; 63,
9.
10.
BD. of dose
SM, Brunelle
Double-blind response
RL,
radiographic
to intravenous
glu-
cagon for hypotonic duodenography. Radiology 1978; 127:55-59. Miller RE, Chernish SM, Skucas J, Rosenak BD, Rodda BE. Hypotonic colon examination with glucagon. Radiology 1974; 113: 555-562. Taylor I, Duthie
HL, Cumberland
Smallwood
Glucagon
R.
DC,
and the colon.
Gut 1975; 16:973-978.
11.
Abell TU, Malagelada JR. Glucagonevoked gastric dysrhythmias in humans shown by improved electrogastrographic technique. Castroenterology 1985; 88:1932-
12.
Jehenson PM. Reducing doses of glucagon used in radiologic examinations (letter). Radiology 1991; 179:286-287. Chernish SM, Maglinte DDT, Brunelle RU. The laboratory response to glucagon dosages used in gastrointestinal examinations. Invest Radiol 1988; 23:847-852.
1940.
13.
Radioloiv
327
#{149}
