Effect of cholecystectomy for gallstones on the surface of the papilla of Vater and the diameter of the common bile duct

BACKGROUND AND STUDY AIMS

To date, little is known about changes in the size of the papilla of Vater in patients with gallstones. Most of the research concerning these patients has investigated changes in the diameter of the common bile duct and pressure in the sphincter of Oddi region. The latest research has not confirmed the prevalent opinion that the common bile duct dilates after cholecystectomy; moreover, knowledge about changes in the form and size of the papilla of Vater remains poor. The aim of our research was to measure the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct before surgery, then 3 months and 6 months after surgery, using endoscopic ultrasound.

PATIENTS AND METHODS

In patients with symptomatic gallstones but with no evidence of cholestasis or stones in the common bile duct, the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were measured before surgery by endoscopic ultrasound. In the postoperative period, measurements were repeated in patients with an early occurrence of nausea, distension, bloating and pain in the upper abdomen and in patients without any symptoms in the same time period. The surface of the normal papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were determined in healthy subjects.

RESULTS

In all the patients included in our study, the surface of the papilla of Vater was enlarged before surgery and, after 3 months, was even larger. However, after 6 months, it was practically the same as before surgery. The diameter of the periampullary pancreatic part of the common bile duct before surgery and 6 months after surgery was within normal limits. However, a statistically significant and transient increase in the diameter was noticed in the third month after cholecystectomy. The results were almost the same for symptomatic and asymptomatic patients.

CONCLUSION

In patients with symptomatic gallstones, the surface of the papilla of Vater is increased while the diameter of the periampullary pancreatic part of the common bile duct is normal. Cholecystectomy is an intervention that causes an additional transient increase in the surface of the papilla of Vater and a transient increase in the diameter of the periampullary pancreatic part of the common bile duct. The surface of the papilla of Vater does not reach normal values but the diameter of the periampullary pancreatic part of the common bile duct is normalized 6 months after surgery. There is no relation between clinical disorders and changes in the morphology of the papilla of Vater and the periampullary pancreatic part of the common bile duct after cholecystectomy.

Relief by naloxone of morphine-induced spasm of the sphincter of Oddi in a post-cholecystectomy patient

Spasm of the sphincter of Oddi is a well-recognized effect of the narcotic class of drugs. Although it is usually clinically silent, such spasm occasionally causes debilitating pain that may be mistaken for more serious disorders. We present the case of a patient who had undergone cholecystectomy previously, but in whom morphine given in the Emergency Department precipitated pain consistent with biliary colic; the pain resolved promptly after administration of naloxone. This entity may considered in the differential diagnosis of acute onset of colicky abdominal pain in the patient given narcotics.

Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis

OBJECTIVE

Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO.

METHODS

A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed.

RESULTS

Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis.

CONCLUSIONS

Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.