Functional MR cholangiography of the cystic duct and sphincter of Oddi using gadoxetate disodium: is a 30-minute delay long enough?

Dysfunction of Biliary Sphincter of Oddi-Clinical, Diagnostic and Treatment Challenges

Biliary Sphincter of Oddi dysfunction (SOD) is one of the main causes of post-cholecystectomy pain. In this review, we aimed to provide an update on the current knowledge on biliary SOD, with an emphasis on diagnostics and therapy. Overall, current but scarce data support biliary sphincterotomy for patients with type 1 and 2 SOD, but not for type 3. However, sphincterotomy is associated with post-treatment pancreatitis rates of from 10% to 15%, thus calling for improved diagnostics, patient selection and treatment modalities for SOD. The role of pharmacologic therapy for patients with SOD is poorly explored and only two randomized controlled trials are available. Currently, studies comparing treatment outcomes are few. There is an unmet need for randomized sham/placebo-controlled clinical trials related to both pharmacological and non-pharmacological treatments of SOD.

Risk factors of pancreatitis after endoscopic sphincterotomy. Review of literature and practical remarks based on approximately 10,000 ERCPs

Post-endoscopic pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Depending on the presence of risk factors, PEP can occur in 4,1% to about 43% of patients. According to the European Society of Gastrointestinal Endoscopy (ESGE) guidelines, only three to patient-associated risk factors have been identified: suspected sphincter of Oddi dysfunction (SOD) (OR 4.09), female gender (OR 2.23), and previous pancreatitis (OR 2.46). Another three procedure-associated factors include cannulation attempt duration > 10 minutes (OR 1.76), more than one pancreatic guidewire passage (OR 2.77, CI: 1.79 - 4.30), and pancreatic injection (OR 2.2, CI: 1.60 - 3.01). Importantly, analyses of cumulative risk due to coexistence of several factors emphasize the importance of female sex, difficult cannulation, CBD diameter <5 mm, young age, and many other factors. Unfortunately, studies performed to date have included only small numbers of patients with several co-existing risk factors. Therefore, further analysis of other risk factors and the cumulative risk related to their co-occurrence is necessary. Based on current evidence, special care must be given to patients with several risk factors. Also, care should be given to proper qualification of patients, use of guidewires, early pre-cut incision, protective Wirsung's duct stenting, and rectal NSAID administration.

Correlation Between Bile Reflux Gastritis and Biliary Excreted Contrast Media in the Stomach

OBJECTIVE

This study aimed to evaluate the relationship between biliary excreted contrast media in the stomach and the presence of bile reflux gastritis.

METHODS

Consecutive 111 patients who underwent both gadoxetic acid-enhanced magnetic resonance cholangiography (gadoxetic MRC) and gastric endoscopy were included in this study. We performed a review of the gadoxetic-MRC image sets acquired 60 minutes after intravenous injection of contrast media and endoscopic images. We recorded amount of contrast media in the stomach. The sensitivity, specificity, and accuracy of duodenogastric bile reflux diagnosis were evaluated for the gadoxetic MRC. Statistical analysis was performed using the Fisher exact test and the linear-by-linear association test.

RESULTS

Among the 111 patients, 39 had 60-minute delayed images showing the presence of contrast media in the stomach. Of these 39 patients, 13 had bile reflux gastritis and 5 showed bile in the stomach without evidence of erythematous gastritis. Of the 72 patients who did not show contrast media in the stomach, none had bile reflux gastritis and 2 patients showed bile staining in the stomach without evidence of erythematous gastritis. Bile reflux gastritis was significantly more frequent in patients with contrast media in the stomach on gadoxetic MRC than in those without. Patients with high-grade extension of contrast media in the stomach had significantly frequent bile reflux gastritis than did those with low-grade extension.

CONCLUSION

Biliary excreted contrast media in the stomach on 60-minute delayed gadoxetic MRC has a correlation with the presence of bile reflux gastritis on endoscopic examination.

Evaluation of cystic duct patency: comparison of functional MR cholangiography with gadoxetate disodium and hepatobiliary scintigraphy in suspected acute cholecystitis

PURPOSE

This study aims to compare assessment of cystic duct patency between gadoxetate disodium MRI and hepatobiliary scintigraphy.

MATERIALS AND METHODS

We performed a prospective study of patients who underwent gadoxetate disodium MRI within 16 h of scintigraphy.

RESULTS

The gallbladder filled on MRI and scintigraphy in 8 patients, none with acute cholecystitis. The mean time to gallbladder filling was 14.6 and 18.9 min for MRI and scintigraphy, respectively. The gallbladder did not fill on both MRI and scintigraphy in 3 patients, all of whom had acute cholecystitis.

CONCLUSION

Evaluation of cystic duct patency using gadoxetate disodium MRI is comparable to hepatobiliary scintigraphy.

Sphincter of Oddi Dysfunction: Updates from the Recent Literature

Sphincter of Oddi dysfunction (SOD) has long been a controversial topic, starting with whether it even exists, as a sphincterotomy-responsive entity to treat, for either: (1) post-cholecystectomy abdominal pain and/or (2) idiopathic recurrent acute pancreatitis (IRAP). Many of its aspects had required further research to better prove or refute its existence and to provide proper recommendations for physicians to diagnose and treat this condition. Fortunately, there has been major advancement in our knowledge in several areas over the past few years. New studies on challenging the classification, exploring alternative diagnostic methods, and quantifying the role of sphincterotomy in treatment of SOD for post-cholecystectomy pain and for IRAP were recently published, including a randomized trial in each of the two areas. The goal of this paper is to review recent literature on selected important questions and to summarize the results of major trials in this field.

Rome IV. Gallbladder and Sphincter of Oddi Disorders

The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.

Accumulation of Bile in the Gallbladder: Evaluation by means of Serial Dynamic Contrast-Enhanced Magnetic Resonance Cholangiography with Gadolinium Ethoxybenzyl Diethylenetriaminepentaacetic Acid

The aim of this study was to evaluate the process of biliary excretion of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) into the biliary tract and to assess the accumulation patterns in the gallbladder using MR cholangiography obtained with Gd-EOB-DTPA which is a liver-specific hepatobiliary contrast agent. Seventy-five patients underwent Gd-EOB-DTPA enhanced MR imaging. Serial multiphasic hepatobiliary phase imaging was qualitatively reviewed to evaluate the process of the biliary excretion of contrast agent into the bile duct and the gallbladder. The accumulation pattern of contrast agent into gallbladder was classified into two groups (group 1 = orthodromic type and group 2 = delayed type). Furthermore, the results in differences of the presence of T1 hyperintense bile or sludge of gallbladder, gall stones, wall thickening of gallbladder, chronic liver disease, and liver cirrhosis between two groups were compared. Forty-eight of 75 patients (64%) were included in group 1, and remaining 27 (36%) were in group 2. The frequency of the presence of T1 hyperintense bile or sludge of gallbladder was significantly higher in patients with group 2 than that in patients with group 1 (P = 0.041). MR cholangiography obtained with Gd-EOB-DTPA showed that there may be an association between the biliary accumulation pattern in the gallbladder and the pathological condition.