Causes and management of recurrent biliary pain after successful nonoperative gallstone treatment

OBJECTIVE

To evaluate the frequency and causes of recurrent biliary colic after successful extracorporeal shock wave lithotripsy of gallstones.

METHODS

Follow-up of 77 patients for 2 yr (median) after complete gallstone clearance by lithotripsy and adjuvant oral litholysis. All patients with recurrent biliary colic were examined thoroughly (laboratory data, ultrasonography, gastroscopy); the examination included gallbladder motility testing. If the patients suffered from additional gastrointestinal complaints, further symptom-guided investigations (pH-metry, lactose absorption study, enteroclysis, colonic transit time, colonoscopy) were performed. Patients without documented gallstone recurrence underwent ERCP and sphincter of Oddi manometry. Cholecystectomy was advised for patients in whom gallstones recurred, and patients with sphincter of Oddi dysfunction underwent endoscopic sphincterotomy. If other gastrointestinal disorders were diagnosed, appropriate treatment was initiated.

RESULTS

Twenty-seven patients (35%) experienced biliary colic during follow-up. Gallstone recurrence was documented in 17 patients, and 16 of the patients who underwent cholecystectomy became symptom-free again (follow-up: 12 months). Gallbladder hypomotility was revealed in seven of the 17 patients with gallstone recurrence compared to none of the 10 patients without gallstone recurrence (p < 0.05). Microlithiasis was not detected in bile samples from the patients whose gallstones did not recur. Sphincter of Oddi dysfunction was found in four patients, and sphincterotomy cured all of them (follow-up: 9 months). Two of the remaining six patients had functional gastrointestinal disorders (reflux, constipation) and became asymptomatic after specific treatment.

CONCLUSIONS

Biliary colic often recurs after successful gallstone lithotripsy. Recurrent gallbladder stones are the main cause, but another cause is sphincter of Oddi dysfunction. Neither gallbladder hypomotility nor microlithiasis seems to cause biliary symptoms in patients without recurrence of gallstones.

[Esophagus and anorectal motility in patients with dysfunction of Oddi's sphincter]

Esophageal and anorectal motility have not been systematically evaluated in patients with sphincter of Oddi dysfunction (SOD). We have investigated 8 consecutive patients (6 females, 52.5 +/- 9.5 y) with type I-SOD (according to the Milwaukee-classification), 12 patients (9 females, 50.4 +/- 12.3 y) with type III-SOD, and 20 healthy volunteers (15 females, 48.5 +/- 15.2 y) by means of a standardized questionnaire for esophageal and anorectal symptoms, esophageal manometry, colonic transit time evaluation, and anorectal manometry. Symptom-scores did not differ significantly between type-I and type III-SOD-patients, respectively. Furthermore, there were no relevant differences of the symptom-scores of the SOD-patients vs. healthy subjects. However, the lower esophageal sphincter pressure (LESP) was significantly higher in patients with type I-SOD (26.8 +/- 7.4 mmHg) than in both, type III-SOD-patients (20.3 +/- 4.0 mmHg, p < 0.05) and healthy subjects (18.6 +/- 3.5 mmHg, p < 0.001), respectively. Mean colonic transit time did not differ significantly between both groups of patients (type I-SOD, 27.9 +/- 21.4 h, vs. type III-SOD, 28.5 +/- 15.1 h, p < 0.05). The anal sphincter resting pressure (ARP) was significantly higher in patients with type I-SOD (90.8 +/- 15.5 mmHg) than in healthy subjects (74.1 +/- 10.3, p < 0.01), but did not differ significantly from that in patients with type III-SOD (82.1 +/- 11.5 mmHg, p = 0.17). Computer-assisted "beat-to-beat"-evaluation showed an abnormal heart rate variability in 3/8 patients with type I-SOD. These results give evidence for a systemic involvement of the lower esophageal and the anal sphincter in patients with type I-SOD, which does not occur in patients with type III-SOD.

[Sphincter of Oddi disfunction in "idiopathic" recurrent pancreatitis]

OBJECTIVE

As the pathogenesis of acute recurrent pancreatitis remains unclear in 30% of patients, it was the aim of this study to find out whether and how often changes in sphincter of Oddi motility is present in these patients and whether endoscopic treatment promises success.

PATIENTS AND METHODS

18 patients (three men, 15 women; mean age 41.5 [30-56] years) with "idiopathic" acute recurrent pancreatitis seen consecutively between April 1991 and November 1995, were included in the study. In none had laboratory examinations, sonography, computed tomography and endosonography (n = 11) demonstrated any unusual findings. Neither exocrine (pancreaolauryl test in 8, secretin-pancreozymin test in 10 patients), nor endocrine (oral glucose tolerance test) pancreatic insufficiency had been found. Endoscopic retrograde cholangiopancreatography had excluded morphological changes in the biliary-pancreatic system. All patients underwent endoscopic manometry. When a basal sphincter of Oddi pressure > or = 40 mm Hg was demonstrated in the pancreatic sphincter segment, combined endoscopic sphincterotomy was done of both the biliary and the pancreatic component.

RESULTS

Nine patients had a raised basal sphincter pressure in the pancreatic segment of the sphincter, but in only four in the biliary one as well. The phasic sphincter motility was normal in all patients. In four patients iatrogenic pancreatitis developed after the procedure (mild in three, moderately severe in one). Eight of the nine patients who had a sphincterotomy remained symptom-free during a mean follow-up period of 21 months, but only three of the nine with normal manometric findings.

CONCLUSION

Half of the patients with acute recurrent pancreatitis of unknown cause have sphincter of Oddi dysfunction, usually limited to the pancreatic segment of the sphincter, Endoscopic sphincterotomy can prevent recurrent pancreatitis in most of the patients.

Effect of erythromycin on human biliary motility

BACKGROUND

To investigate the effects of intravenous erythromycin on human gall-bladder and sphincter of Oddi motor function.

METHODS

Twelve consecutive patients with suspected sphincter of Oddi dysfunction were studied. Gall-bladder function was assessed by ultrasonography, and sphincter of Oddi motility was evaluated by means of endoscopic manometry.

RESULTS

All patients were found to have normal gall-bladder function. The percentage of maximal gall-bladder emptying following a standardized, liquid test meal was significantly increased by erythromycin, whereas the postprandial residual gall-bladder volume was significantly decreased after erythromycin (P < 0.01). Endoscopic manometry revealed the presence of sphincter of Oddi dysfunction in two of the 12 patients. Erythromycin significantly decreased the basal sphincter of Oddi pressure and slowed the sphincter of Oddi phasic contraction frequency in all patients (P < 0.01). However, the mean duration of the sphincter phasic contractions (P < 0.05) and their amplitude (P = 0.05) were increased by the compound.

CONCLUSIONS

Erythromycin stimulates gall-bladder motility but induces varying effects on human sphincter of Oddi motility.

[Endoscopic manometry in suspected dysfunction of the sphincter of Oddi]

BASIC PROBLEM AND OBJECTIVE OF STUDY

Dysfunction of the sphincter of Oddi may be a cause of persistent problems after cholecystectomy. The aim was to find out whether various factors are of value in predicting abnormal manometric results and thus aid in deciding whether endoscopic manometry is indicated.

PATIENTS AND METHODS

97 patients were investigated prospectively (13 men, 84 women; mean age 50.2 [29-72] years) in which endoscopic cholangiopancreatography (ERCP) had not revealed any cause of the biliary complaints. The patients were divided into three types according to four criteria: (1) history (biliary colics); (2) biochemistry (cholestasis); (3) dilated biliary tract (at ERCP); (4) contrast retention in biliary tract (at ERCP). Type I: all four criteria present; type II: positive history and one or two other criteria; type III: biliary colic only. Endoscopic manometry (EM) was performed after classification of the patients.

RESULTS

EM was successful in 83 of 97 patients (86%). All 15 patients of type I had sphincter of Oddi dysfunction (SOD) defined as basic sphincter pressure > 40 mm Hg. SOD was demonstrated in only 23 of 38 patients of type II (61%) and 15 of 30 patients of type III (50%) (P < 0.01). Increased rate of sphincter of Oddi contraction ("tachyoddi") was demonstrated in only four patients (4%), in two of them in combination with an increased basic sphincter pressure. Mild to moderate pancreatitis occurred within 24 hours of manometry in ten of 83 patients.

CONCLUSIONS

Endoscopic manometry is not necessary in patients of type I for confirming the diagnosis. But it is obligatory for patients of type II and III, because the demonstration of SOD has therapeutic consequences, and should be performed in clinical studies, if possible.

Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5-year prospective trial

OBJECTIVES

To assess the incidence of elevated sphincter of Oddi baseline pressure and the response to endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction.

DESIGN

A 5-year prospective clinical trial.

METHODS

One-hundred and eight patients with recurrent biliary-type pain after cholecystectomy were enrolled. After thorough investigation, 35 patients with suspected type II sphincter of Oddi dysfunction (SOD) and another 29 type III patients remained for further investigation. Both groups were similar with respect to demographic data and severity of pain. Biliary manometry was performed in all except three patients in either group. Endoscopic sphincterotomy was performed in all patients with abnormal sphincter of Oddi baseline pressure (> 40 mmHg). All patients were clinically re-evaluated after 4-6 weeks, and thereafter the sphincterotomized patients were followed for a median period of 2.5 years.

RESULTS

An abnormal sphincter of Oddi baseline pressure was found in 62.5% of the type II patients and in 50% of the patients with suspected type III SOD (P = 0.66). At the 4-6 week follow-up none of those patients without abnormal manometry, but 70% of the patients with type II SOD, and 39% of the type III SOD patients, respectively, reported subjective benefit after sphincterotomy (P = 0.13 type II vs. type III). However, after a median follow-up of 2.5 years, sustained symptomatic improvement after sphincterotomy was found in 60% of the type II patients, but only in 8% of the patients with type III SOD (P < 0.01).

CONCLUSION

Disregarding a lack of difference in the incidence of abnormal sphincter of Oddi baseline pressure between type II and type III SOD, the Geenen-Hogan classification helps to predict the clinical outcome after endoscopic sphincterotomy.

Effect of endoscopic sphincterotomy on sphincter of Oddi manometry results in patients with or without papillary stenosis

Patients with fibrotic papillary stenosis (PS) are at high risk for sphincter of Oddi-re-stenosis after endoscopic sphincterotomy (ES). Therefore, a prospective trial was conducted to assess the acute and long-term effects of ES on sphincter of Oddi motor function in patients with papillary stenosis. The immediate effects of ES were studies by endoscopic manometry in 12 patients with PS, and in 15 patients with common bile duct stones (CBDS, control group). Furthermore, after a median follow-up of 15 months, 11 from those 12 patients with papillary stenosis were reinvestigated with ERCP and manometry. Complete ES (defined by a common bile duct pressure and a basal sphincter of Oddi-pressure (BSOP) < 5 mm Hg) was achieved in 13/15 CBDS-patients, but only in 3/12 patients with PS (p<0.01), although sphincterotomy was extended to the maximal length as judged endoscopically. Four patients with PS had a residual BSOP > 20 mm Hg. However, all patients with PS became symptom-free immediately after ES. The phasic sphincter motility was not affected significantly different in both groups of patients (p = 0.25). Those patients with a residual BSOP > 20 mm Hg after ES developed sphincter of Oddi-re-stenosis during the follow-up (3 patients) or revealed re-stenosis at the control examination after follow-up (1 patient). After the follow-up manometrically defined complete sphincterotomy was furtheron demonstrable in only 2/11 patients with papillary stenosis. In conclusion, ES revealed a decreased efficacy to eliminate the sphincter of Oddi motor function in a substantial number of patients with papillary stenosis. This may explain the remarkably high rate of sphincter of Oddi-re-stenosis after sphincterotomy in these patients.

Pneumatic dilation in achalasia with a low-compliance balloon: results of a 5-year prospective evaluation

To evaluate long-term efficacy and side effects after pneumatic dilation with low-compliance balloons, 40 patients with achalasia were prospectively studied during a 5-year period. All patients were investigated before, 4-6 weeks after, and at 28 +/- 15 months (final visit) after pneumatic dilation. Additionally, 12 patients underwent 24-hour esophageal pH-metry before and 26 +/- 14 months after dilation. Initial symptomatic success was obtained in 35 of 40 patients (87.5%). The remaining five and another seven patients with recurrent dysphagia underwent a second dilation, and two of these patients finally underwent esophagomyotomy. Effective dilation was reflected by a significant decrease of the symptom scores (p < 0.01) and an increase of the gastric cardia diameter both at 4-6 weeks after dilation and at the final visit (p < 0.01). Dilation reduced the lower esophageal sphincter pressure from 28.3 +/- 0.8 mmHg to 16.4 +/- 6.4 mmHg at the 4-6 weeks exam and to 14.7 +/- 5.5 mmHg at the final visit, respectively (p < 0.01). Neither the diameter of the esophageal body nor the motility of the tubular esophagus was affected by pneumatic. Esophageal pH-metry showed an increase of the number and duration of reflux episodes (pH < 4) after dilation (p < 0.05), whereas only one patient reported heartburn and another asymptomatic patient revealed esophagitis I0 at endoscopy. Therefore, pneumatic dilation with low compliance balloons proved to be safe and long lasting treatment of achalasia. Although prolonged esophageal acid exposure was measurable after dilation, clinically relevant gastroesophageal reflux occurred in only 5% (n = 2).

Does pre-treatment with bile acids enhance efficacy of biliary extracorporeal shock wave lithotripsy?

To determine the effect of chenodiol and ursodiol pre-treatment prior to shock wave lithotripsy of gallstones, two groups of 50 gallbladder stones (n = 100), obtained at cholecystectomy, were matched according to their size, shape and weight. All stones were stored in a bile perfused gallbladder model for two weeks. In the first group (A), serving as control, native bile was used, whereas in the other group (B), ursodiol- and chenodiol-enriched bile was perfused, both bile acids at therapeutic concentrations. After two weeks of pre-treatment, electromagnetic shock wave lithotripsy (19 kV, 1 Hz) was performed until stones were fragmented to a size smaller 2 mm. Neither stone density, as assessed by computed tomography, nor their cholesterol content were different in group A and B. A trend towards higher fragmentation efficacy was observed for stones < 15 mm and for those with a CT-density < 100 HU. No influence of either stone shape (rounded vs. angular) or cholesterol content was observed with regard to fragmentation efficacy. Comparing the number of shock waves (SW) required for fragmentation (< 2 mm) there was no significant difference between group A (1850 +/- 1300 SW) and group B (1970 +/- 1500 SW, n.s.). These in vitro results do not support a significant role of bile acids as a rationale pre-treatment prior to lithotripsy of gallstones.

[Diagnostic and therapeutic possibilities in suspected Oddi's sphincter dysfunction]

Endoscopic manometry and quantitative cholescintigraphy are the diagnostic cornerstones for the detection of suspected sphincter of Oddi dysfunction. In patients with recurrent biliary pain after cholecystectomy, endoscopic manometry proves an elevated sphincter of Oddi baseline pressure as the most common finding. The probability for the detection of an elevated baseline pressure in these patients is significantly correlated with the presence of certain clinical features (i.e. biliary pain and/or cholestasis and/or dilated bile duct and/or delayed drainage of contrast material after ERCP). Therefore, these features enable a clinical classification of patients with suspected sphincter of Oddi dysfunction. Isolated baseline pressure elevations in the pancreatic portion of the sphincter of Oddi were reported in patients with recurrent, idiopathic, acute pancreatitis. In patients with biliary sphincter dysfunction, therapeutic relief can be expected from pharmacological therapy, but controlled studies are lacking. However, the clinical value of endoscopic sphincterotomy could be established in this field. Despite endoscopic manometry is not a prerequisite for the performance fo endoscopic sphincterotomy in every case of suspected sphincter of Oddi dysfunction, in most patients endoscopic manometry allows the only definitive diagnosis of sphincter dysfunction. Further on, the clinical value of semi-invasive methods as alternative treatment strategies (i.e. botulinum-toxin, transcutaneous electric nerve stimulation, balloon dilation) for sphincter of Oddi dysfunction has to be evaluated in the future.

Shock wave treatment of salivary duct stones: substantial progress with a minilithotripter

Extracorporeal shock wave lithotripsy has recently been introduced as the first non-operative treatment alternative for patients with sialolithiasis. Using conventional multipurpose lithotripters, however, successful treatment was achieved in only 36%-53% of patients. Therefore we developed an miniaturized lithotripter meeting the special requirements for extracorporeal shock wave treatment in the head and neck region. During a 1-year prospective trial clinical efficacy and safety were compared in 40 patients treated with a conventional electromagnetic lithotripter (group A) to 33 patients treated with the newly developed, miniaturized device (group B). The groups did not differ statistically regarding stone size or number or the proportion of stones located in the submandibular or parotid gland. Successful stone targeting, a prerequisite for shock wave treatment, was achieved by means of in-line ultrasonography in 30 of the 40 patients in group A and in 29 of 33 patients of group B. The number of shock wave impulses administered per session and the maximum shock wave intensities did not differ in the two groups. Significantly more frequent treatments with a longer mean duration of each session were required in group A (2.4 +/- 1.0 treatments, 47 +/- 11 min) than in group B (1.9 +/- 0.7 treatments, 28 +/- 9 min; P < 0.05). After a 3 month follow-up significantly more patients were free of stones in group B (22/33) than in group A (16/40; P < 0.05). Correspondingly, the number of patients free of complaints was significantly higher in group B (27/33) than in group A (22/40; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy, risks, and limits of extracorporeal shock wave lithotripsy for salivary gland stones

Stones of the salivary glands may cause recurrent swelling, ascending inflammation, and colic-like pain. Previously, in order to get rid of these stones, the gland usually had to be removed surgically in spite of the associated risks to adjacent structures, especially the facial nerve. We treated 104 salivary gland stones in patients 14 to 78 years old using the Storz Modulith SL 10 lithotripter. Each session (average 3.6 per patient) consisted of 1000 impulses at 2 Hz and 16 to 18 kV. No anesthesia was required. Earplugs were applied to patients being treated for parotid gland stones. With the aid of SWL and drug-induced salivation, 17 (59%) of the patients with parotid gland stones and 42 (56%) of those with submandibular gland stones obtained either total stone clearance or sufficient fragmentation to permit spontaneous passage. Four patients required surgery. The remaining patients are still being treated. The noninvasive SWL for salivary gland stones is noninvasive and painless and has a considerable success rate. It can be performed on an outpatient basis.

Biliary lithotripsy with a new electromagnetic shock wave source. A 2-year clinical experience

During a two-year study period 170 consecutive patients with gallbladder stones, suitable for lithotripsy, were treated with a new electromagnetic lithotriptor (Modulith) and oral bile acids; 142 patients were treated as outpatients. Sufficient fragmentation were obtained in 94% when 2112 +/- 137 shocks in 211 sessions with an energy setting of 17.8 +/- 0.8 kV were administered. Only 4/170 patients needed transient analgesia. Overall, side effects were transient and mild, but three patients developed biliary pancreatitis, which was treated by endoscopic sphincterotomy in two of them. A total of 67/100 patients were free of stones after one year. Subgroup analysis showed that 80% of the patients (stone diameter 5-20 mm), 64% (20-30 mm) and 65% (multiple stones), respectively, can expected to be free of stones after 12 months. In addition, 25 patients with large, endoscopically not extractable common bile duct stones were treated by lithotripsy with the Modulith. After endoscopic placement of a nasobiliary tube, stone targeting was possible by ultrasonography in 14 patients and by fluoroscopy in another 11 cases. In 23 of the 25 patients (92%) stone clearance by endoscopy was achieved after application of 2516 +/- 565 shocks with an energy preset of 18 kV. One patient refused further endoscopic procedures after successful fragmentation and another required local stone dissolution therapy. Side effects occurred more frequently (P < 0.05) after lithotripsy of bile duct stones than of gallbladder stones, but they were without major clinical relevance. The new lithotriptor Modulith thus enables safe and highly effective lithotripsy of gallbladder calculi on an outpatient basis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anal incontinence in patients with Addison's disease: a gluco- and mineralocorticoid independent sphincter malfunction?]

Anorectal motor function was evaluated in 15 female patients with Addison's disease and androgen deficiency and 15 age-matched healthy volunteers. Medical history revealed symptoms of faecal incontinence in 5 patients. The patients showed decreased maximum retention volumes (p less than 0.01) in the rectal saline infusion test. Lowered anal sphincter resting (p less than 0.01) and squeeze pressure (p less than 0.01) was demonstrated in patients with adrenocortical insufficiency. No differences between patients and controls were found in respect of perception volume, minimal distension volume for sphincter relaxation and rectal compliance by means of intrarectal balloon distension. Electromyography of the external anal sphincter was performed in 8 patients and showed no evidence for a neurogenic defect. Relevant morphological changes of the anorectum could be excluded endoscopically in 13 of the 15 patients. Therefore impaired anorectal muscular function is responsible for faecal incontinence in patients with Addison's disease and androgen deficiency. Further investigations will show, whether these findings are the consequence of lowered androgen production.

Influence of cisapride on antroduodenal motor function in healthy subjects and diabetics with autonomic neuropathy

Antroduodenal manometry was used to assess motility in 10 healthy volunteers and 15 diabetics with cardiac autonomic neuropathy whilst they received 20 mg cisapride orally or an apparently identical placebo. Interdigestive motility was recorded after an overnight fast and for 2 hours following a 500 kcal liquid meal. Active treatment did not influence the number or duration of interdigestive motility cycles in either group although antroduodenal co-ordination in both the fasting and the fed state was enhanced by cisapride (P less than 0.05). In diabetics the postprandial antral motility index was increased by cisapride, whereas in healthy subjects antral and duodenal motility indices were increased both fasting and in the fed state (P less than 0.05). These results suggest that impaired antroduodenal co-ordination is of importance in delaying gastric emptying by diabetic subjects.

[Effect of cisapride on esophageal motility in healthy probands and patients with progressive systemic scleroderma]

Prokinetic agents might be useful in patients with progressive systemic sclerosis (PSS) who have disturbed function of the lower esophageal sphincter and impaired acid-clearance of the tubular esophagus. We therefore compared, by means of esophageal manometry, the effect of 20 mg cisapride orally vs. placebo in 12 patients with progressive systemic sclerosis and proven esophageal dysfunction as well as in 10 healthy volunteers in a double-blind, prospective trial. An increase of the lower esophageal resting pressure from 18.1 +/- 2.4 mm Hg to 23.9 +/- 8.1 mm Hg* after cisapride administration was observed in healthy volunteers, and from 10.9 +/- 3.2 mm Hg to 13.6 +/- 4.0 mm Hg* in the PSS patients. The amplitudes of peristaltic waves in the distal part of the esophagus were increased by cisapride from 83.8 +/- 10.6 mm Hg to 95.6 +/- 15.5 mm Hg* in volunteers and from 28.9 +/- 12.8 mm Hg to 36.8 +/- 16.2 mm Hg in patients (*:P less than 0.05). These results indicate that cisapride has a therapeutic rationale in the treatment of esophageal dysfunction in PSS; further clinical investigations are justified.

[Extracorporeal shock wave lithotripsy of sialoliths as a new noninvasive outpatient treatment concept]

The rapid progression of Extracorporeal Shock Wave Lithotripsy (ESWL) opens new possibilities in painless non-invasive treatment of salivary gland stones under local therapy. Procedure and first very promising success in the clinical appliance to sialolithiasis is shown as follows.