Pancreatitis after sphincter of Oddi manometry

Endoclip papillaplasty restores sphincter of Oddi function: Pilot study

OBJECTIVES

Endoscopic sphincterotomy (EST) damaged the sphincter of Oddi (SO) function. This study aimed to explore the feasibility and efficacy of endoclip papillaplasty in restoring SO function.

METHODS

This prospective pilot study included consecutive patients with choledocholithiasis (stone size ≥10 mm) who underwent large-EST for stone removal, followed by endoclip papillaplasty, between May 2018 and March 2019.

RESULTS

Thirty patients were enrolled in this trail. Overall, 80% of the patients had a SO basal pressure of >10 mmHg after endoclip papillaplasty. Manometric parameters, including SO basal pressure, phasic wave contraction amplitude, phasic waves per minute, recovered after endoclip papillaplasty (P > 0.05). There were no significant differences in the manometric parameters of SO between healing grades A and B. Six patients developed mild post-endoscopic retrograde cholangiopancreatography pancreatitis, including three that had pancreatic stenting. Bile duct stone recurrence developed in 3.3% of the patients (1/30) during an 18-month follow-up.

CONCLUSIONS

Endoclip papillaplasty might restore SO function and possibly prevented biliary stone and cholangitis recurrence.

Risk factors of post- endoscopic retrograde cholangiopancreatography pancreatitis in biliary type sphincter of Oddi dysfunction in Japanese patients

OBJECTIVE

Suspected sphincter of Oddi dysfunction (SOD) is a well-known risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The indication of ERCP for suspected SOD patients was very low in Japan compared to other countries. Therefore, the risk of PEP may be different in Japanese SOD patients. The objective of this study was to evaluate the risk of PEP in suspected biliary type SOD in Japan.

METHODS

From December 1996 to January 2017, 72 patients were suspected as having biliary type SOD, by questionnaire, liver function tests, hepatobiliary scintigraphy, abdominal ultrasonography, upper gastrointestinal endoscopy, endoscopic ultrasonography and magnetic resonance cholangiopancreatography. Finally, 60 patients who underwent ERCP were included in this study, and the factors associated with PEP were evaluated.

RESULTS

The overall PEP rate was 23.3% (n = 14). Diagnostic ERCP alone for SOD did not increase the risk of PEP. The correlation of PEP incidence with pancreatic duct guidewire (PGW) technique and endoscopic sphincterotomy (EST) was indicated in univariate and multivariate analysis. Pancreatic stent placement was a risk in univariate analysis but not in multivariate analysis.

CONCLUSIONS

PGW technique and EST for biliary type SOD were important risk factors for PEP. Pancreatic stenting was ineffective for prevention of PEP.

Complications of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.

Sphincter of Oddi manometry using guide-wire-type manometer is feasible for examination of sphincter of Oddi motility

BACKGROUND

Sphincter of Oddi manometry (SOM) is recognized as the standard diagnostic modality for sphincter of Oddi dysfunction (SOD). However, SOM is not commonly performed because of its technical difficulty and the high incidence of post-procedural pancreatitis. To diminish post-procedural pancreatitis, we tried to develop a new method of SOM. This study examined the feasibility of SOM with a guide-wire-type manometer, which is commonly used to measure the arterial pressure for coronary angiography, for the assessment of SO motility.

METHODS

A total of 35 procedures were performed in 8 patients with biliary type III SOD and 14 patients with other disease. We performed SOM using the guide-wire-type manometer on SOD cases and other cases [amplitude, duration, frequency and the area under the curve (AUC) of SO contractions].

RESULTS

The mean time required for the measurement was 7.5 ± 4.1 min. The amplitude, frequency and AUC of SO contractions were significantly larger in the SOD cases than in other diseases (147.2 vs. 92.8 mmHg, p = 0.042; 10 vs. 5/min, p = 0.007; 2,837 vs. 1,122 mmHg s, p = 0.003, respectively). In 6 patients who underwent endoscopic sphincterotomy (EST), the SO amplitude decreased dramatically after EST. In this study, mild pancreatitis was observed in only one patient.

CONCLUSIONS

SOM using a guide-wire-type manometer is safe, reliable and easy to apply for the clinical assessment of SO motility. The guide-wire-type manometer may become a new method to measure SO function for the diagnosis of SOD.

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Sphincter of Oddi disorder: what is the clinical issue?

Sphincter of Oddi disorder (SOD) is a functional disorder of the sphincter of Oddi (SO) and is pathophysiologically equivalent to functional gastrointestinal disorder (FGID) of the digestive tract. SOD is important as a cause of biliary pain of unknown origin and idiopathic acute recurrent pancreatitis; however, the concept of SOD has not generally spread in the same way as FGID. SOD is diagnosed using ROME III criteria which were revised in 2006 to reduce the number of unnecessary and potentially risky procedures. Many cases of SOD still need SO manometry (SOM) which is performed during endoscopic retrograde cholangiopancreatography (ERCP). It is problematic that SOD patients, who already have a high risk of post-ERCP pancreatitis, require SOM for a definitive diagnosis. SOM is an invasive examination that is accompanied by a high risk of post-procedure pancreatitis and can be performed only at a limited number of institutions because of technical difficulties. In the treatment of SOD, the effectiveness of the drugs is uncertain, and the role of drug therapy in the management of SOD has not yet been established. In recent years, endoscopic sphincterotomy (EST) has been recognized as standard treatment for SOD; however, the effect of EST is not yet clear. The development of less invasive diagnostic techniques is desirable in the future. Furthermore, patient eligibility criteria for EST and the long-term prognosis after EST should be clarified.

Prevention of Post-ERCP Pancreatitis

Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.

Quality indicators, including complications, of ERCP in a community setting: a prospective study

BACKGROUND

There are no large studies documenting quality outcomes and complication rates of ERCP in community practice. The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology Task Force on Quality proposed 5 questions regarding ERCP in community practice. The ASGE Committee on Outcomes Research recommended 8 ERCP-specific quality indicators be used to provide a better accounting of quality in ERCP.

OBJECTIVE

To determine ERCP quality outcomes, including complications, in a community practice.

DESIGN

Prospective study.

SETTING

Eight community hospitals in the Minneapolis-St. Paul, Minnesota, area.

PATIENTS

Every patient undergoing ERCP by Minnesota Gastroenterology PA from December 1, 2005, through July 31, 2006.

MAIN OUTCOME MEASUREMENTS

ASGE-recommended quality indicators, especially 30-day complication rates.

RESULTS

A total of 805 ERCP procedures were performed in 696 patients. Therapeutic ERCP accounted for 78.4%. The complication rate was 5.0% (5.7% of therapeutic and 2.3% of diagnostic procedures). Pancreatitis occurred in 3.2% of procedures (3.6% of therapeutic and 1.7% of diagnostic procedures). Infection (0.75%), hemorrhage (0.62%), and perforation (0.12%) only occurred after therapeutic ERCP. Cardiopulmonary complications occurred in 2 patients (0.25%). Precut sphincterotomy was performed in 26 cases (3.2%), and sphincter of Oddi manometry in 23 cases (2.9%). Success rates were 94.0% for biliary cannulation, 87.0% for stone extraction, and 90.2% for relieving biliary obstruction. A total of 530 patient satisfaction surveys were completed and revealed that the response to the question, "Would you have the procedure done again by this physician?" was the most sensitive indicator of patient satisfaction.

CONCLUSIONS

In this community practice, complication rates compare very favorably with those of academic centers. The technical success rates achieved or exceeded rates recommended by the ASGE/American College of Gastroenterology Task Force.

Recent developments in gastrointestinal motility

In the past decade, the results of many studies on gastrointestinal motility and perception have been published that may be relevant to the clinician. A new classification of oesophageal motor disorders has been proposed in which "ineffective oesophageal motility" largely replaces the former "non-specific oesophageal motor disorders". Recent studies have shown that the incidence of transient lower oesophageal sphincter relaxations can be reduced pharmacologically, and this may open doors to a new therapeutic approach in gastro-oesophageal reflux disease. The mechanisms through which hiatus hernia promotes reflux have become clearer. The recently developed technique of intraluminal impedance monitoring has made it possible to study oesophageal transit, non-acid reflux and its role in the generation of reflux symptoms, as well as the characteristics of belching. Measurement of gastric emptying by means of a non-radioactive isotope and breath-testing has become widely available but, unfortunately, this development has not yet been accompanied by the advent of new therapeutic options for gastroparesis. The term "enteric dysmotility" has been coined for the condition in which upper abdominal symptoms are associated with distinct small intestinal bowel motility disorders in the absence of ileus-like episodes. The role of high-amplitude propagated contractions in the pathogenesis of constipation has been further defined. In cases of suspected sphincter of Oddi dysfunction, manometry of both sphincters (IBD and pancreatic) is now felt to be advisable.

Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years

BACKGROUND

Complications of ERCP are an important concern. We sought to determine predictors of post-ERCP complications at our institution.

METHODS

GI TRAC is a comprehensive data set of patients who underwent ERCP at our institution from 1994 through 2006. Logistic regression models were used to evaluate 4 categories of complications: (1) overall complications, (2) pancreatitis, (3) bleeding, and (4) severe or fatal complications. Independent predictors of complications were determined with multivariable logistic regression.

RESULTS

A total of 11,497 ERCP procedures were analyzed. There were 462 complications (4.0%), 42 of which were severe (0.36%) and 7 were fatal (0.06%). Specific complications of pancreatitis (2.6%) and bleeding (0.3%) were identified. Overall complications were statistically more likely among individuals with suspected sphincter of Oddi dysfunction (SOD) (odds ratio [OR] 1.91) and after a biliary sphincterotomy (OR 1.32). Subjects with a history of acute or chronic pancreatitis (OR 0.78) or who received a temporary small-caliber pancreatic stent (OR 0.69) had fewer complications. Post-ERCP pancreatitis was more likely to occur after a pancreatogram via the major papilla (OR 1.70) or minor papilla (OR 1.54) and among subjects with suspected SOD with stent placement (OR 1.45) or without stent placement (OR 1.84). Individuals undergoing biliary-stent exchange had less-frequent pancreatitis (OR 0.38). Biliary sphincterotomy was associated with bleeding (OR 4.71). Severe or fatal complications were associated with severe (OR 2.38) and incapacitating (OR 7.65) systemic disease, obesity (OR 5.18), known or suspected bile-duct stones (OR 4.08), pancreatic manometry (OR 3.57), and complex (grade 3) procedures (OR 2.86).

CONCLUSIONS

This study characterizes a large series of ERCP procedures from a single institution and outlines the incidence and predictors of complications.

Prospective trial comparing solid-state catheter and water-perfusion triple-lumen catheter for sphincter of Oddi manometry done at the time of ERCP

BACKGROUND

Sphincter of Oddi manometry is the reference standard for the diagnosis of sphincter of Oddi dysfunction. Numerous studies have established ranges of normal values as well as typical readings in pathologic conditions. All these studies have been done using a water-perfused, triple-lumen catheter (TLC). A recently approved, new generation, solid-state catheter (SSC) has potential advantages, but concerns have been raised as to whether the pressures obtained by TLCs are reproducible by SSCs. To date, no data exist on the accuracy of sphincter of Oddi pressure measurements with the new-generation SSCs.

OBJECTIVE

To evaluate the accuracy of the SSC by using the TLC as the reference standard.

DESIGN

Prospective crossover trial.

SETTING

A tertiary academic center.

PATIENTS

Thirty patients with clinical indications for sphincter of Oddi manometry.

INTERVENTIONS

Sphincter of Oddi manometry with TLC and SSC in the same patient.

MAIN OUTCOME MEASUREMENTS

Accuracy of sphincter of Oddi pressure measurements.

RESULTS

A total of 376 pressure measurements in 47 sphincter segments (24 biliary, 23 pancreatic) were obtained. Manometry results were abnormal in 10 of 24 biliary sphincters and 12 of 23 pancreatic sphincters. There was complete agreement on the final results of the sphincter of Oddi manometry (normal/abnormal) between the TLC and SSC (accuracy 100%). A split-plot analysis of the 378 individual measurements was performed. The P value of .9966 was insignificant, consistent with no catheter effect on the measurements.

LIMITATIONS

Lack of blinding.

CONCLUSIONS

Measurement of sphincter of Oddi pressures with the SSC is accurate, and results were essentially identical to those of the water-perfused catheter system.

Effect of somatostatin in the prevention of pancreatic complications after endoscopic retrograde cholangiopancreatography

BACKGROUND

The unique clinical role of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating biliary tree diseases cannot be completely replaced by other modern imaging modalities such as magnetic resonance cholangiopancreatography. However, post-ERCP pancreatitis is one of the most common and life-threatening complications. Prophylactic medication in the prevention of pancreatitis during ERCP is still controversial. The objective of the present study was to investigate the role of different regimens of somatostatin in the prevention of acute pancreatitis after ERCP and analyze the risk factors contributing to post-ERCP complications.

METHODS

From July 1999 to September 2000, 133 patients with benign biliary disease who received ERCP for diagnosis or treatment were enrolled. Group A patients received a bolus of somatostatin infusion before ERCP, followed by continuous infusion for 12 hours. Group B patients received a bolus of somatostatin before ERCP only, and group C patients were the controls who did not receive somatostatin treatment. Serum amylase levels before and 24 hours after ERCP, and abdominal pain were recorded.

RESULTS

There were no significant differences in bile duct and pancreatic duct visualization, ratio of diagnostic and therapeutic ERCP, procedure time, post-procedural hyperamylasemia and pancreatitis among the 3 groups. For patients with visualization of the pancreatic duct, the incidences of hyperamylasemia (serum amylase > or = 220 U/L) were higher than in patients without visualization of the pancreatic duct (p < 0.001). All 6 patients with post-ERCP pancreatitis had pancreatic duct visualization, and recovered after conservative treatment.

CONCLUSION

Continuous infusion of somatostatin after ERCP does not seem to be helpful in the prevention of pancreatic complications after ERCP. Pancreatic duct visualization is a risk factor for pancreatic complications.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type I, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with type I SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type I SOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Is endoscopic sphincterotomy avoidable in patients with sphincter of Oddi dysfunction?

AIM

Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management.

METHODS

A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful.

RESULTS

Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile-duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured.

CONCLUSION

In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as typeI, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with typeISOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in typeISOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Solid state biliary manometry catheter: impact on diagnosis and post-study pancreatitis

Perfusion manometry of the sphincter of Oddi has been the standard for the investigation of patients with presumed sphincter of Oddi dysfunction (SOD). Microtransducer manometry (MTM) of the sphincter of Oddi represents an alternative to perfusion manometry. The technical success and reproducibility of MTM are as good as for perfusion manometry. Current data suggest that the upper limit for normal of basal sphincter of Oddi pressures measured with MTM lies at approximately 35 mm Hg. Pancreatitis risk after MTM in patients with SOD compares favorably with that after perfusion manometry. Low cost and ease of handling make MTM of the sphincter of Oddi an attractive alternative.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study

OBJECTIVES

Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study.

METHODS

A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria.

RESULTS

Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis.

CONCLUSION

This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Is sphincter of Oddi manometry a risk factor for pancreatitis? A different view

Studies suggest a causal relationship between sphincter of Oddi manometry (SOM) and acute pancreatitis, presumably due to water instillation in the ductal system. In this article, critical analysis of the existing studies attributes the high risk of acute pancreatitis with SOM to "association due to confounding" rather than to "causation." This conclusion is based on two pieces of evidence: The first is lack of biologic plausibility: Biologic evidence is lacking to support the hypothesis that water instillation during SOM can induce acute pancreatitis. The second is confounding evidence: Manometric studies show considerable variation in the risk of post-procedure pancreatitis (4% to 30%), which suggests that other important factors besides SOM influence the adverse outcome. These studies did not control for other variables, which are well known to predispose to pancreatitis and therefore may act as confounding factors. Two studies that assessed the independent role of SOM in causation of acute pancreatitis showed that SOM is not an independent predictor of acute pancreatitis. It is the underlying disorder sphincter of Oddi dysfunction, and not the "SOM" procedure, that predisposes patients to post-procedure acute pancreatitis.

Complications of sphincter of Oddi manometry: biliary-like pain versus acute pancreatitis

OBJECTIVE

Although acute pancreatitis is the most significant complication of sphincter of Oddi manometry (SOM), acute biliary-like abdominal pain--similar or identical to the patient's usual recurrent acute episodes of pain and not fulfilling clinical criteria for acute pancreatitis--can also be provoked by SOM. The aim of the article is to determine and compare the relative frequency of occurrence of, and risk factors for, post-manometry biliary-like abdominal pain and post-manometry pancreatitis.

MATERIAL AND METHODS

The clinical and laboratory features, the manometric recordings from the sphincter of Oddi, and the immediate post-manometry outcomes, were examined in 234 consecutive patients undergoing sphincter of Oddi manometry at our Unit.

RESULTS

Post-manometry pancreatitis occurred in 9% of patients, and was associated with two risk factors on multivariate analysis: a history of post-ERCP pancreatitis (odds ratio [OR] 5.9) and a raised basal sphincter pressure (> or =40 mmHg) at SOM (OR 3.5). An increased sphincter phasic wave frequency (> or =7/min) at SOM was identified as a significant (p<0.05) risk factor on univariate testing only. Post-manometry biliary-like pain occurred in 12% of patients, and was associated with 3 different risk factors on multivariate analysis: age below 50 years (OR 4.6); less than a 2-year history of recurrent abdominal pain (OR 3.0); and ERCP and/or ES carried out during the SOM procedure (OR 9.3).

CONCLUSIONS

Provocation of biliary-like pain following SOM, without clinical evidence of pancreatitis, occurs at least as frequently as post-manometry acute pancreatitis. In contrast to post-manometry pancreatitis, post-manometry biliary-like pain occurs more often in younger patients with a shorter duration of symptoms and does not appear related to the manometric features of the sphincter documented at SOM; we propose that this clinical entity may reflect the presence of bile duct or duodenal hypersensitivity/hyperalgesia.

Effects of narcotic analgesic drugs on human Oddi’s sphincter motility

AIM: To assess the effects of intramuscular analgesics (morphine, Ap-237, pethidine and tramadol) on human Oddi's sphincter motility with choledochoscope manometry.

METHODS: A total of 70 patients having T tubes after cholecystectomy and choledochotomy were assessed by choledochoscope manometry. They were randomly divided into morphine group, Ap-237 group, pethidine group and tramadol group. Basal pressure of Oddi's sphincter (BPOS), amplitude of phasic contractions (SOCA), frequency of phasic contractions (SOF), duration of phasic contractions (SOD), duodenal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed. All narcotic analgesic drugs were administered intramuscularly.

RESULTS: Levels of BPOS, SOCA and SOF were increased after injection of morphine and Ap-237 (P < 0.05), level of CBDP was increased from 4.97 ± 3.87 mmHg to 8.62 ± 7.43 mmHg (10 min later) and 7.32 ± 5.95 mmHg (20 min later) after injection of morphine (P < 0.01). No apparent change occurred after intramuscular injection of pethidine. Level of BPOS was increased from 7.01 ± 5.50 mmHg to 2.87 ± 2.78 mmHg 10 min after injection of tramadol and SOCA was decreased from 63.34 ± 35.29 mmHg to 45.90 ± 27.86 mmHg (10 min later, P < 0.05) and 35.97 ± 24.30 (20 min later, P < 0.01) after administration of tramadol.

CONCLUSION: All these findings indicate that Oddi’s sphincter manometry via choledochoscope is a practical and new way to study the dynamics of Oddi’ s sphincter. The regular dose of morphine and Ap-237 could increase BPOS, SOF and SOCA. Morphine could increase the level of CBDP, demonstrating an excitatory effect on the sphincter of Oddi. Pethidine had no effect on Oddi's sphincter motility. Tramadol shows an inhibitory effect on the motility of the sphincter of Oddi and decreases levels of BPOS and SOCA.

Normal sphincter of oddi motor function

With the introduction of endoscopic retrograde cholangiopancreatography (ERCP) manometry, the characteristics of sphincter of Oddi (SO) motor activity have been described. SO manometry is the only available method to measure SO motor activity directly and is usually performed at the time of ERCP. SO manometry is considered to be the gold standard for evaluating patients for sphincter dysfunction. This review reports the technique of SO manometry and normal values for SO manometry. SO motility is characterized by prominent phasic contractions superimposed on a tonic pressure. Elevated basal SO pressure is the most consistent and reliable criteria to diagnose SO dysfunction. Basal pressures obtained from the biliary sphincter are similar to the basal pressure obtained from the pancreatic sphincter. Abnormal SO manometric values are shown. Factors that influence SO pressures, and interpretation of SO manometric tracing are discussed. The most common and serious complication of SO manometry is post-manometry pancreatitis. In healthy volunteers with normal sphincter function, pancreatitis is almost never seen. However, in patients with SO dysfunction, the incidence of pancreatitis is high. The use of new nonperfused microtransducers may reduce this complication.

Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis

BACKGROUND

Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction.

METHODS

Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups.

RESULTS

Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.

Secretin MRCP and endoscopic pancreatic manometry in the evaluation of sphincter of Oddi function: a comparative pilot study in patients with idiopathic recurrent pancreatitis

BACKGROUND

Sphincter of Oddi dysfunction plays an important etiologic role in idiopathic acute recurrent pancreatitis. Sphincter of Oddi manometry is the most accurate test of sphincter of Oddi function, but it is associated with an increased risk of post-procedure pancreatitis and is non-diagnostic in about a third of cases. Secretin MRCP has a diagnostic efficacy comparable to ERCP, but data on its sensitivity with regard to sphincter of Oddi function are lacking. The aim of this study was to compare secretin MRCP and pancreatic sphincter of Oddi manometry for evaluation of sphincter of Oddi function in patients with idiopathic acute recurrent pancreatitis.

METHODS

Eighteen consecutive patients with idiopathic acute recurrent pancreatitis underwent secretin MRCP and pancreatic sphincter of Oddi manometry/ERCP. Data from 15 patients were suitable for analysis. Fifteen subjects with asymptomatic, non-pancreatic hyperamylasemia matched for age and gender underwent secretin MRCP and served as a control group.

RESULTS

Sphincter of Oddi manometry documented sphincter dysfunction in 6/15 patients (40%) and secretin MRCP, in 4/15 patients (26.7%). Sphincter of Oddi manometry confirmed the presence of elevated basal sphincter of Oddi pressure in two of the 4 patients with abnormal and other forms of sphincter of Oddi dyskinesia in the other two. None of the control subjects had an abnormal secretin MRCP. Secretin MRCP and sphincter of Oddi manometry were concordant in 13/15 patients (86.7%); positive and negative diagnoses for sphincter of Oddi dysfunction agreed in, respectively, 81.8% and 100% (kappa value 0.706).

CONCLUSIONS

Secretin MRCP seems to be a useful noninvasive procedure for investigation of pancreatic sphincter of Oddi function, but evaluation in larger series is needed.

Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management

Adverse outcomes of endoscopic retrograde cholangiopancreatography (ERCP) include technical failures and complications. Complications cause significant morbidity to patients and anxiety to endoscopists. The key to preventing complications is to understand which patients and procedures are at highest risk so that appropriate decisions can be made as to whether ERCP should be performed at all, and if so, how. Patients who need ERCP the least are often the ones most likely to develop complications. For marginal indications, ERCP should be avoided. Success rates are higher and complication rates lower for endocopists performing large numbers by endoscopists with adequate experience.

Key issues in sphincter of Oddi dysfunction

SOD is a challenging condition that is difficult to diagnose and treat. The high failure rate of endoscopic and surgical treatment reflects the difficulties in establishing accurate diagnosis and the lack of specific objective criteria by which appropriate therapy could be determined. In general, sphincter ablation should be offered for type I patients. An initial trial of medical therapy is appropriate for type II patients with mild-to-moderate symptoms and for all type III patients. SOM is highly recommended for type II patients and is mandatory for all type III patients if sphincter ablation is contemplated. Other causes of abdominal pain such as chronic pancreatitis or functional disorders should be considered in patients not benefiting from sphincter ablation. All procedures on the sphincter should be undertaken with caution after meticulous investigation, and patient selection should be based on strict objective criteria.

Controversies in clinical pancreatology: should the sphincter of Oddi be measured in patients with idiopathic recurrent acute pancreatitis, and should sphincterotomy be performed if the pressure is high?

The risk benefit ratio of measuring the sphincter of Oddi pressure and performing sphincterotomy in patients with idiopathic acute pancreatitis with high sphincter pressures has not been assessed. Few healthy controls have had sphincter measurements so that the definition of an abnormal sphincter remains understudied. The procedures involved have significant risks and the benefits are hard to measure considering the variable natural history of this disorder. No prospective, randomized investigations have been performed to evaluate efficacy of these invasive procedures. It is the author's opinion that until appropriate studies prove efficacy that these interventions be considered experimental.

Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment

Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.

Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography

Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Technique-related risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient's coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.

Reduction in the incidence of pancreatitis in patients undergoing sphincter of Oddi manometry: a successful quality improvement project

OBJECTIVE

Acute pancreatitis is a recognized complication of sphincter of Oddi manometry (SOM). Its frequency of occurrence has been reported in the range of 4 to 31%. In an earlier retrospective study performed at this institution, the incidence of pancreatitis was 9.3% in patients who only had SOM compared with 26.1% in those patients who had SOM and endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy at the same session. On the basis of these data, a quality-improvement project was initiated at two university-affiliated hospitals. This involved performance of SOM without ERCP. If ERCP was required, it was performed at a different session. The purpose of this project was to decrease the incidence of pancreatitis associated with SOM.

METHODS

This study involved prospective patient identification and retrospective chart review of patients who underwent SOM without ERCP between May 1998 and December 2000. SOM was performed using a triple-lumen catheter with water perfusion at a rate of 0.25 ml/min using an Arndorfer pneumohydraulic capillary perfusion system. The data recorded included pancreatitis after SOM, pancreatitis after ERCP and sphincterotomy, average days in the hospital after pancreatitis, and time between SOM and ERCP.

RESULTS

Forty-one patients were studied. Three (7.32%) patients had pancreatitis after SOM. Five patients subsequently underwent ERCP and sphincterotomy and one (20%) patient had pancreatitis. The overall frequency of pancreatitis after SOM and any subsequent ERCP or sphincterotomy was 4 (9.78%) of 41 (95% confidence interval, 3.9-22.5%). The odds ratio for pancreatitis with ERCP and SOM at the same time compared with the SOM-only strategy was 3.26 (P = 0.05). The average stay in the hospital after pancreatitis ranged from 2 to 4 days, with a mean length of stay of 2.75 days. The time between SOM and subsequent ERCP ranged from 6 to 20 days, with a mean of 10.4 days.

CONCLUSION

By adopting a protocol to perform diagnostic SOM, separate from ERCP and sphincterotomy, we were able to decrease the incidence of pancreatitis considerably at our institutions.

Feasibility of and interest in combined endoscopic ultrasonography and biliary drainage in unexplained acute biliopancreatic disorders

Combined endoscopic ultrasonography and duodenal bile drainage for microscopic bile examination was prospectively evaluated in patients with unexplained acute biliopancreatic disorders defined as follows: isolated biliary-type pain (group 1), biliary-type pain and elevated transaminases (group 2), or acute pancreatitis (group 3). All patients had prior negative transabdominal ultrasonography. Endoscopic ultrasonography and bile drainage were combined under anesthesia during the same procedure. Combined endoscopic ultrasonography and bile drainage was feasible without any complication in the 48 patients studied. Biliary lithiasis was diagnosed in 20 patients (42%), 5 in group 1 (38%), 7 in group 2 (39%), and 8 in group 3 (47%). Endoscopic ultrasonography and microscopic bile examination were positive respectively in 17 (36%) and in 13 (27%) patients. In conclusion, combined endoscopic ultrasonography and bile drainage for microscopic bile examination is a simple procedure. Biliary lithiasis is diagnosed in a high proportion of patients with unexplained acute biliopancreatic disorders.

Effects of gabexate mesilate, a protease inhibitor, on human sphincter of Oddi motility

Gabexate mesilate is an antiprotease drug, which reduced the severity of pancreatitis and frequency of post-ERCP pancreatitis. In dogs gabexate inhibits sphincter of Oddi motility but no data are available in humans. The aim of this study was to verify by manometry the action of gabexate on human sphincter of Oddi motility. We enrolled 12 patients with idiopathic recurrent pancreatitis (eight males, five females, mean age 46 +/- 8 years). Standard preendoscopic sphincter of Oddi manometry was done in basal conditions and during infusion of gabexate 20 mg/min: basal pressure, amplitude and frequency of phasic contractions, and motility index (amplitude per frequency) were calculated before and after gabexate injection. Statistical analysis was performed by using Wilcoxon rank test for paired data. Six patients had a manometric diagnosis of stenosis (basal pressure greater than 40 mm Hg); six had normal findings. Phasic activity was not evaluable in five patients with stenosis. Basal pressure was unaffected by drug infusion, while gabexate caused a significant reduction of phasic activity, both in terms of frequency (4.5 +/- 1 vs 3.6 +/- 1; P < 0.05) and amplitude (157.4 +/- 44 vs 80.0 +/- 32; P < 0.05) of contractions. Motility index was reduced on average by 49%. In conclusion, this pilot study confirms, in patients with acute recurrent pancreatitis, the inhibitory action of gabexate on sphincter of Oddi motility already described in dogs. This action needs to be revaluated at therapeutic dosages. On the other hand, prophylactic use of the drug should be avoided during sphincter of Oddi manometry, in order to avoid false negative results.

Manometry of the gastrointestinal tract: toy or tool?

In the eyes of scientific researchers, there are various manometric techniques that are useful tools for studying the motility of the gastrointestinal tract. Clinicians, however, regard most of these techniques as toys, either because they do not lead to clinically relevant results, or because they are too cumbersome in clinical practice. Nevertheless, a number of manometric techniques have reached the status of clinically relevant diagnostic procedure in gastroenterology. Among these, oesophageal manometry is the most important. Not only has conventional oesophageal manometry been added to the diagnostic armamentarium of many hospitals, but also prolonged ambulatory recording of oesophageal pressures (usually combined with pH monitoring). Small intestinal manometry has also gained the status of a diagnostic tool, in particular in patients in whom the existence of pseudo-obstruction syndrome is suspected and in patients in whom total colectomy is considered because of intractable constipation. Sphincter of Oddi manometry is another example of a clinically relevant manometric technique to be used in particular in patients with suspected dyskinesia of the sphincter of Oddi. The value of anorectal manometry may have been overestimated in the past. The most important indication is the exclusion of Hirschsprung disease. The contribution of anorectal manometry to the diagnosis of anismus and to the work-up of patients with faecal incontinence is limited.

Comparison of sphincter of Oddi manometry, fatty meal sonography, and hepatobiliary scintigraphy in the diagnosis of sphincter of Oddi dysfunction

BACKGROUND

Sphincter of Oddi dysfunction (SOD) afflicts approximately 1% to 5% of patients after cholecystectomy. The diagnostic standard for SOD is sphincter of Oddi manometry (SOM), a technically difficult, invasive test that is frequently complicated by pancreatitis. A sensitive and accurate noninvasive imaging modality is thus needed for the diagnosis of SOD. Quantitative hepatobiliary scintigraphy (HBS) and fatty meal sonography (EMS) are frequently used for this purpose, but results vary. This study compared SOM, HBS, and EMS in the diagnosis of SOD in a large group of patients.

METHODS

Three hundred four consecutive patients after cholecystectomy (38 men, 266 women, age 17-72 years) suspected to have SOD were evaluated by SOM, FMS, and HBS. SOM was considered abnormal if any of the following were observed: (1) increased basal pressure (greater than 40 mm Hg), (2) increased phasic activity with amplitude greater than 350 mm Hg, (3) frequency of contractions greater than 8 per minute, (4) greater than 50% of propagation sequences retrograde, and (5) paradoxical response to cholecystokinin. FMS was considered abnormal if ductal dilation was greater than 2 mm at 45 minutes after fatty meal ingestion. Quantitative HBS was performed with sequential images obtained every 5 minutes for 90 minutes to monitor excretion of the radionuclide. Time-to-peak, halftime, and downslope were calculated according to predetermined ranges.

RESULTS

A diagnosis of SOD was made in 73 patients (24%) by using SOM as the reference standard. HBS was abnormal in 86 whereas EMS was abnormal in 22 patients. A true-positive result was obtained in 15 patients by EMS and 36 patients with HBS. EMS and HBS gave false-positive results, respectively, in 7 and 50 patients. Sensitivity of EMS was 21% and for HBS 49%, whereas specificities were 97% and 78%, respectively. EMS, HBS, or both were abnormal in 90% of patients with Geenen-Hogan Type I SOD, 50% with Type II, and 44% of Type III. Of the 73 patients who underwent sphincterotomy, 40 had a long-term response. Of those with SOD, 11 of 13 patients (85%) with an abnormal HBS and EMS had a good long-term response.

CONCLUSIONS

In this series, the largest reported to date, correlation of FMS and HBS with SOM in the diagnosis of SOD was poor. When HBS and EMS are used together, a slight increase in sensitivity can be expected. The accuracy of EMS and HBS in the diagnosis of SOD decreases across the spectrum from Type I to Type III SOD. EMS and HBS, nonetheless, may by of assistance in predicting long-term response to endoscopic sphincterotomy in patients with elevated sphincter of Oddi basal pressure.

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study

BACKGROUND

Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers.

METHODS

Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria.

RESULTS

Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic.

CONCLUSIONS

Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.

Influence of cholangiography on biliary sphincter of Oddi manometric parameters

BACKGROUND

When sphincter of Oddi manometry (SOM) and endoscopic retrograde cholangiopancreatography are performed at the same session, SOM is usually performed immediately before ductography because of concern about the accuracy of the manometric recording after contrast medium injection. However, it would be preferable to inject contrast medium first to identify other causes for a patient's symptoms, allowing selective use of SOM. The aim of this study was to evaluate the effect of cholangiography on sphincter of Oddi (SO) basal pressure.

METHODS

Twenty-five patients with suspected SO dysfunction were prospectively studied. Conventional station pull-through manometry of the biliary part of the sphincter was performed before and after cholangiography. The intraductal pressure and basal sphincter pressure were evaluated.

RESULTS

The mean intraductal pressure was 8+/-5.5 mm Hg before and 13.3+/-6.8 mm Hg after contrast medium injection (p< 0.01). However, the basal sphincter pressure was not significantly altered (52.9+/-42.1 mm Hg vs. 55.1+/-38.1 mm Hg, p = 0.52). Concordance (normal vs. abnormal) between the basal sphincter pressure before and after ductography was seen in 24 of 25 patients (96%).

CONCLUSIONS

Intraductal installation of contrast medium immediately before SOM infrequently alters SO basal pressure in a clinically significant manner. We therefore believe that this sequence can be utilized in clinical practice.

Dilated bile duct in patients receiving narcotic substitution: an early report

Narcotic substitution is now widely used. Morphine can induce a spasm of the sphincter of Oddi but dilation of bile duct has been reported only in an anecdotal case. In June 1995, we observed a first case of dilation of the common bile duct without organic obstacle in a hepatitis C virus (HCV)-infected patient who was under narcotic substitution, suggesting a causal relationship. We conducted a prospective study to evaluate the precise prevalence of bile duct abnormalities related to narcotic substitution in active intravenous drug or ex-intravenous drug users referred to our liver unit for histologic evaluation of HCV infection. We conducted a prospective study in a 30-month period of 334 HCV-infected patients, including 36 receiving narcotic substitution with methadone or buprenorphine. Biliary tract was analyzed by ultrasonography and by endoscopy ultrasound in cases of bile duct abnormalities. Of the 36 patients under narcotic substitution, 3 (8.3%) had asymptomatic dilated bile duct without organic obstacle--defined as a common bile duct > or =9 mm--compared to 1 of 298 (0.03%; p < 0.001) of those who did not receive substitution. Narcotic substitution may lead to bile duct dilation that does not require invasive diagnosis procedures.

Sphincter of Oddi motility in patients with hepatolithiasis and common bile duct stones

The purpose of this study was to explore a difference in sphincter of Oddi (SO) motor activity among patients with intrahepatic (I, N = 5), intra- and extrahepatic (IE, N = 15), and common bile duct (CBD, N = 6) stones. Interdigestive motility of the SO and duodenum was studied by pneumohydraulic infusion manometry via the percutaneous route. SO phasic contractions showed a cyclic change in concert with the duodenal migrating motor complex (MMC) in all these patients. There was no significant difference in the cycle length, frequency, or amplitude of the SO phasic waves among the three groups throughout the whole cycle. The SO basal pressure during duodenal phases I and II of the duodenal MMC was significantly lower in patients with the IE type of hepatolithiasis than in those with the I type (P = 0.04), but there was no significant difference during phase III between the two groups. The SO basal pressure during phases I and II of the CBD group was also significantly lower than that of the I group (P = 0.02). The significance became even more prominent (P = 0.001) when a subgroup of patients with a dilated CBD (diameter > 1 cm) was examined. Lower basal pressure in the IE group or CBD group than in the I group suggested that stones in the common duct might injure or irritate the SO and cause SO dysfunction. In the subgroup with dilated CBD, which may have resulted from repeated and severe SO injury, the statistics became more prominent.

Comparison of ultrasound-secretin test and sphincter of Oddi manometry in patients with recurrent acute pancreatitis

Manometry is considered the gold standard for evaluating sphincter of Oddi dysfunction. It has recently been demonstrated that the ultrasound (US) secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddi dysfunction yields a substantial percentage of pathological findings in patients with acute recurrent pancreatitis. The aim of this study was to compare the results of the US secretin test with sphincter of Oddi manometry findings in a consecutive series of patients with recurrent acute pancreatitis. Forty-seven patients admitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwent ultrasonographic measurement of the main pancreatic duct at baseline and for 60 min after maximal stimulation with secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects, the test results were considered to indicate pathology when the duct was still dilated after 20 min. Within three to seven days the same patients underwent perendoscopic manometry. Thirty-six patients (17 men, 19 women; mean age 41 +/- 15 years) had a successful US secretin test and sphincter of Oddi manometry. Eleven patients (30.6%) presented normal manometric findings. Two of these had an abnormal US secretin test. Twenty-five patients had abnormal manometry findings, revealing stenosis in 19 (52.7%) (17 with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test). Compared to manometry findings, the US secretin test sensitivity and specificity for sphincter of Oddi dysfunction were 88% and 82%, respectively. In conclusion, most patients with recurrent acute pancreatitis have sphincter of Oddi dysfunction documented by both at the US secretin test and sphincter of Oddi manometry; results of the US secretin test are reliable compared to sphincter of Oddi manometry, and therefore the US secretin test may offer a valid alternative to the more expensive and invasive manometric procedure for assessing sphincter of Oddi dysfunction in patients with recurrent acute pancreatitis.

Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM)

OBJECTIVE

Sphincter of Oddi manometry (SOM) is a useful diagnostic procedure when evaluating patients with unexplained biliary pain or idiopathic recurrent pancreatitis. Acute pancreatitis is a recognized complication of SOM whose pathogenesis appears to be multifactoral. We conducted this study to determine the incidence of pancreatitis in patients after SOM and to identify any variables that may lead to an increased incidence of pancreatitis.

METHODS

A retrospective review of 100 consecutive patients who underwent SOM between 1992 and 1996 at two university-affiliated hospitals was done. SOM was performed using a triple lumen catheter with each lumen perfused at a rate of 0.25 cc/min using an Arndorfer pneumohydraulic capillary perfusion system. The following data were recorded: age, gender, clinical type of sphincter of Oddi dysfunction, length of procedure, doses of medications used, duct cannulated, sphincter of Oddi pressure, whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy was performed, and the number of patients developing pancreatitis. Statistical analysis was performed using a T test, chi2, and multiple regression analysis.

RESULTS

The overall incidence of pancreatitis was 17%. Six patients with type II SO dysfunction and 11 patients with type III SO dysfunction developed pancreatitis. The incidence of pancreatitis was significantly lower in those patients who only had SOM, compared with those patients who had SOM and ERCP (9.3% vs 26.1%, p < 0.026). There was no significant correlation between age, gender, duration of procedure, dose of midazolam used, sphincter of Oddi pressure, or type of SO dysfunction with the development of SOM-induced pancreatitis. Multiple regression analysis showed that sphincterotomy added no additional risk, beyond that associated with ERCP, for the development of pancreatitis.

CONCLUSIONS

The results of this study indicate that the incidence of pancreatitis was highest when SOM was followed by ERCP. A potential method of decreasing the incidence of pancreatitis after SOM is performing ERCP with or without sphincterotomy at another session, separated from the SOM by at least 24 h. Before this can be definitely recommended, the results of this study must be validated by others or by a prospective study.

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction

BACKGROUND & AIMS

Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension.

METHODS

Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3).

CONCLUSIONS

Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.

Effects of trimebutine on sphincter of Oddi motility in patients with post-cholecystectomy pain

BACKGROUND

Trimebutine is an opiate modulator of the gastrointestinal motility that interacts with enkephalinergic receptors.

AIM

To evaluate the effects of trimebutine (50 mg intravenous injection) on the motility of the sphincter of Oddi (SO) as assessed by endoscopic manometry.

METHODS

Endoscopic manometry was performed on 15 cholecystectomized patients who presented with symptoms suggestive of SO dysfunction. Prior to the endoscopic manometry, endoscopic ultrasonography was performed in order to rule out the possible presence of a bile duct stone.

RESULTS

Injecting trimebutine resulted in a significant increase in the SO antegrade phasic contraction rate (P = 0.02). Trimebutine decreased the basal pressure of the SO (32.5 vs. 27.5 mmHg), but the difference is not statistically significant (P = 0.11). The effects of trimebutine differed depending on the basal SO motility anomalies involved, but the period of latency was similar (mean 89 s: range 30-240 s). The basal anomalies were an increased basal SO pressure of > 40 mmHg in three patients, a tachyoddia (frequency of phasic contractions (PC) > 10/min) in six patients, prolonged PC (> 10 s) in two patients and an absence of phasic contraction in one patient. The basal pressure of the SO decreased in the three patients presenting with SO hyperpressure, but returned to a normal value in one case. The frequency of the PC decreased to normal in three out of the six patients with tachyoddia. The duration of the PC returned to normal in the two patients with prolonged PC whereas their frequencies increased. Prolonged PC developed in the patient without any detectable phasic contraction.

CONCLUSIONS

Trimebutine modulates SO motility in various ways depending on the basal SO motility anomaly observed after cholecystectomy. This regulatory effect suggests the existence of encephalinergic control of SO motility.

Discordance of pressure recordings from biliary and pancreatic duct segments in patients with suspected sphincter of Oddi dysfunction

It remains controversial whether manometric parameters recorded from the pancreatic and biliary segment of the sphincter of Oddi (SO) differ. We therefore studied 48 consecutive patients (40 women, 43 +/- 11 years) with suspected SO dysfunction, in 33 of whom successful dual-duct SO manometry was obtained. Measures of concordance between the two duct segments were moderate for basal sphincter pressure (K = 0.31) and for contractile frequency (0.35), and were low for peak pressure (0.15) and for proportion of retrograde propagation (-0.19). There was also low concordance (-0.13) for the overall manometric diagnosis, and in 48% (CI 31-66%) of patients a conflicting diagnosis (normal/abnormal) was obtained from the two ducts. There was no evidence of a differential motor effect of CCK on either duct, nor were there significant differences in the rate of manometric abnormality according to the order of initial duct cannulation. These results indicate that, if technically feasible, dual-duct manometry of the sphincter of Oddi is required for diagnostic precision.

Effect of octreotide on human sphincter of Oddi motility following liver transplantation

The effect of octreotide on sphincter of Oddi motility was investigated in six liver transplant patients, employing percutaneous (through the T-tube tract) manometry. Continuous and simultaneous sphincter of Oddi and duodenal motor activities were recorded before and for 60 min after the administration of octreotide (100 micrograms subcutaneously) and after the injection of cholecystokinin (0.02 microgram/kg intravenously). With octreotide, contraction frequency and basal pressure significantly increased (P < 0.05). This effect lasted more than 60 min, long after octreotide-induced duodenal migrating motor complex phase III activity had ceased. Sphincter of Oddi contraction amplitude and duration were unaffected by octreotide. Subsequent cholecystokinin administration transiently reduced sphincter of Oddi basal pressure and contraction frequency. We conclude that octreotide significantly increases sphincter of Oddi basal pressure and contraction frequency. This effect is distinct from octreotide induction of migrating motor complex phase III activity, persists for a prolonged period, and is inhibited by cholecystokinin.

Clinical update: management of acute pancreatitis

The management of acute pancreatitis commences with confirming the diagnosis and establishing the aetiology. Improved methods of assessing the biliary tree may reduce the number of patients regarded as having idiopathic pancreatitis. Detailed clinical and laboratory protocols, designed to assess severity, have no major advantage over clinical assessment. The contrast-enhanced computed tomography scan is important to assess the degree of pancreatic necrosis and to detect local complications. The treatment of pancreatitis continues to be largely supportive. However, controlled studies support the use of antibiotics in severe acute pancreatitis and indicate a possible role for the use of octreotide and antioxidants. The place of endoscopic and surgical intervention is becoming better defined. Once an attack has passed, further investigation is often required in a bid to prevent further episodes of inflammation.