Electroacupuncture may relax the sphincter of Oddi in humans

Lipid Profile Response to Acupuncture in Obese Patients with Subjective Tinnitus: a Randomized Controlled Trial

Background

Blood lipid levels have been reported as novel biomarkers for chronic subjective tinnitus (CST), with their levels being higher in patients with CST.

Objectives

This trial aimed to determine the change in lipid profile and tinnitus-related quality of life (TR-QoL) responses to 8-week acupuncture treatment in patients with CST.

Methods

Sixty obese patients with CST were randomly assigned to group A (treatment group; n = 30; mean age = 44.10 ± 3.69 years) or group B (sham group; n = 30; mean age = 45.53 ± 3.62 years). Patients in group A (n = 30) received manual stimulation at the TE3, TE5, TE17, TE18, TE19, TE20, TE21, TE22, GB2, GB8, GB20, LI4, LI11, KI3, SP6, ST36, CV4, CV9, and CV12 acupoints through in-site acupuncture needles thrice weekly. Furthermore, the bilateral abdominal ST25 and GB28 acupoints were electrically stimulated through in-site acupuncture needles. Group B (n = 30) received the same acupuncture protocol as group A but the insertion of needles was a sham insertion. Anthropometrics such as body mass index (BMI) and waist circumference (WC), TR-QoL (assessed via tinnitus handicap inventory), blood lipid levels such as high-density lipoprotein (HDL_s), low-density lipoprotein (LDL_s), cholesterol (C), and triglycerides (TG_s), and the visual analogue scale (VAS) score for tinnitus severity, were assessed prospectively.

Results

Only group A showed significant within-group improvements. Except for HDL_s, BMI, and WC, unpaired between-group comparisons showed significantly greater improvements in other outcome measures of all patients with tinnitus (TR-QoL, LDL_s, TG_s, C, and VAS) in group A than in group B.

Conclusion

Safe acupuncture treatment not only improves anthropometrics and TR-QoL, but also helps resolve hyperlipidemia and reduces the severity of tinnitus in obese patients with CST.

Immediate acupuncture with GB34 for biliary colic: protocol for a randomised controlled neuroimaging trial

INTRODUCTION

As the main manifestation of gallstone disease, biliary colic (BC) is an episodic attack that brings patients severe pain in the right upper abdominal quadrant. Although acupuncture has been documented with significance to lead to pain relief, the immediate analgesia of acupuncture for BC still needs to be verified, and the underlying mechanism has yet to be covered. Therefore, this trial aims first to verify the immediate pain-alleviation characteristic of acupuncture for BC, then to explore its influence on the peripheral sensitised acupoint and central brain activity.

METHODS AND ANALYSIS

This is a randomised controlled, paralleled clinical trial, with patients and outcome assessors blinded. Seventy-two patients with gallbladder stone disease presenting with BC will be randomised into a verum acupuncture group and the sham acupuncture group. Both groups will receive one session of immediate acupuncture treatment. Improvements in patients' BC will be evaluated by the Numeric Rating Scale, and the pain threshold of acupoints will also be detected before and after treatment. During treatment, brain neural activity will be monitored with functional near-infrared spectroscopy (fNIRS), and the needle sensation will be rated. Clinical and fNIRS data will be analysed, respectively, to validate the acupuncture effect, and correlation analysis will be conducted to investigate the relationship between pain relief and peripheral-cerebral functional changes.

ETHICS AND DISSEMINATION

This trial has been approved by the institutional review boards and ethics committees of the First Teaching Hospital of Chengdu University of Traditional Chinese Medicine, with the ethical approval identifier 2019 KL-029, and the institutional review boards and ethics committees of the First People's Hospital of Longquanyi District, with the ethical approval identifier AF-KY-2020071. The results of this trial will be disseminated through peer-reviewed publications and conference abstracts or posters.

TRIAL REGISTRATION NUMBER

CTR2000034432.

The cerebral mechanism underlying the acupoints with specific effect for gallbladder stone disease: protocol for a randomized controlled task-fMRI trial

BACKGROUND

As it has been recorded in ancient Chinese classics, Yanglingquan (GB34) and Dannangxue (EX-LE6) are two important acupoints that can regulate the function of the gallbladder. Acupuncture at these two acupoints is considered particularly effective for gallbladder disease treatment, especially for alleviating gallbladder stone disease (GSD) symptoms that can be aggravated after intaking high-fat food. However, the superior effect between the two acupoints still needs to be further explored, as well as the underlying central mechanism has never been investigated to date.

METHODS AND DESIGN

Ninety participants diagnosed with GSD will be randomly divided into group A (acupuncture at GB34), group B (acupuncture at EX-LE6), and group C (acupuncture at non-acupoint) in a ratio of 1:1:1. All of them will receive a 30-min acupuncture treatment with fatty-food cues being presented before and after acupuncture. During the task, participants will be scanned by MRI and required to rate their desire for high-/low-fat food with an 11-point Likert scale. Additionally, the participants' pain/discomfort sensation will be evaluated using the Numeric Rating Scale (NRS) at four timepoints, including before the 1st task fMRI scan, before and after acupuncture, and after the 2nd task fMRI scan. For both behavior and fMRI data, the ANOVA analysis will be conducted among three groups to testify the immediate effect of GB34 and EX-LE6. The post hoc t-test will be employed to further explore the superiority between acupuncture with GB34 and EX-LE6. Furthermore, correlation analyses will be conducted to investigate a possible correlation between neural changes and clinical data.

DISCUSSION

In comparison to the non-acupoint, the results will firstly explore the superior effect between acupuncture with GB34 and EX-LE6 on GSD patients by observing their behavioral and neural response change to fatty-food cue, and then to investigate the underlying central mechanism.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000034368 . Registered on 3 July 2020.

Self-Administered Electroacupuncture Provides Symptomatic Relief in a Patient with Sphincter of Oddi Dysfunction: A Patient's Report

A 46-year-old woman with differentially diagnosed sphincter of Oddi dysfunction (SOD) type III is described. After two and a half years of managing the condition with a conventional medical/pharmacological approach, the patient's symptoms worsened and she sought complementary approaches, starting traditional acupuncture treatment before receiving training from a practitioner of Western medical acupuncture to self-administer electroacupuncture. The frequency and intensity of severe night-time pain attacks reduced and, additionally, self-administered manual acupuncture during pain attacks resulted in quick, lasting, complete symptomatic pain resolution. This is the first published case report using electroacupuncture in the clinical management of this condition. It shows patient-administered electroacupuncture as a low-risk well-tolerated procedure which provided effective pain relief and reduced the frequency and severity of pain attacks. Self-administered acupuncture could be considered as a potential complementary medical approach for patients with SOD type III before resorting to endoscopic SO manometry and sphincterotomy which carry significant associated risks of pancreatitis.

Synergistic immunoreaction of acupuncture-like dissolving microneedles containing thymopentin at acupoints in immune-suppressed rats

Dissolving microneedles carried drug molecules can effectively penetrate the stratum corneum of skin to improve the transdermal drug delivery. The traditional Chinese medicine acupuncture is based on the needle stimulation at a specific location (acupoint) to generate and transmit biochemical and physiological signals which alter the pathophysiological state of patients. However, the pain associated with conventional acupuncture needles and the requirement of highly trained professionals limit the development of acupuncture in non-Asian countries. The purpose of this study is to investigate whether the dissolving microneedles can be utilized as a self-administered painless replacement for acupuncture and locally released drug molecules can achieve expected therapeutic outcomes. Immunosuppressive rats were treated with acupuncture at Zusanli (ST36) acupoint using microneedles containing thymopentin. The immune functions and psychological mood of the immunosuppressed animals were examined. The proliferation of splenocytes was examined by CCK-8 assay. CD4 and CD8 expression patterns in spleen cells were detected by flow cytometry. The current study showed that use of either microneedles containing thymopentin or conventional acupuncture both resulted in immune cell proliferation, which was confirmed by flow cytometry. Furthermore, either conventional acupuncture or microneedles were able to effectively mitigate the anxiety caused by immune-suppression when applied on the ST36.

Bi-directional regulation of acupuncture on extrahepatic biliary system: An approach in guinea pigs

Clinically, acupuncture affects the motility of the extrahepatic biliary tract, but the underlining mechanisms are still unknown. We applied manual acupuncture (MA) and electrical acupuncture (EA) separately at acupoints Tianshu (ST25), Qimen (LR14), Yanglingquan (GB34), and Yidan (CO11) in forty guinea pigs (4 groups) with or without atropinization under anesthesia while Sphincter of Oddi (SO) myoelectric activities and gallbladder pressure were monitored. In both MA and EA groups, stimulation at ST25 or LR14 significantly increased the frequency and amplitude of SO myoelectrical activities and simultaneously decreased the gallbladder pressure as compared to the pre-MA and pre-EA (P < 0.05). On the contrary, stimulation at GB34 or CO11 significantly decreased SO myoelectricity and increased the gallbladder pressure (P < 0.05). Pretreatment with atropine could abolish the effect of stimulation at acupoints ST25, GB34 and LR14 (P > 0.05), although significant myoelectricity increases were still inducible with MA or EA stimulation at CO11 (P < 0.05). In summary, acupuncture has bi-directional effects to gallbladder pressure and SO function, which probably due to autonomic reflex and somatovisceral interactions.

Post-cholecystectomy syndrome and sphincter of Oddi dysfunction: past, present and future

Post-cholecystectomy syndrome and the concept of a causal relationship to sphincter of Oddi dysfunction, despite the controversy, has presented a clinically relevant conflict for decades. Historically surgeons, and now gastroenterologists have expended tremendous efforts towards trying to better understand the dilemma that is confounded by unique patient phenotypes. Areas covered: This review encompasses the literature from a century of experience on the topic of post-cholecystectomy syndrome. Relevant historical and anecdotal experiences are examined in the setting of insights from evaluation of recently available controlled data. Expert commentary: Historical observations and recent data suggest that patients with post-cholecystectomy syndrome can be categorized as follows. Patients with sphincter of Oddi stenosis will most often benefit from treatment with sphincterotomy. Patients with classic biliary pain and some objective evidence of biliary obstruction may have a sphincter of Oddi disorder and should be considered for endoscopic evaluation and therapy. Patients with atypical post-cholecystectomy pain, without any evidence consistent with biliary obstruction, and/or with evidence for another diagnosis or dysfunction should not undergo ERCP.

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.

Combination of electroacupuncture and grafted mesenchymal stem cells overexpressing TrkC improves remyelination and function in demyelinated spinal cord of rats

This study attempted to graft neurotrophin-3 (NT-3) receptor (TrkC) gene modified mesenchymal stem cells (TrkC-MSCs) into the demyelinated spinal cord and to investigate whether electroacupuncture (EA) treatment could promote NT-3 secretion in the demyelinated spinal cord as well as further enhance grafted TrkC-MSCs to differentiate into oligodendrocytes, remyelination and functional recovery. Ethidium bromide (EB) was microinjected into the spinal cord of rats at T10 to establish a demyelinated model. Six groups of animals were prepared for the experiment: the sham, PBS, MSCs, MSCs+EA, TrkC-MSCs and TrkC-MSCs+EA groups. The results showed that TrkC-MSCs graft combined with EA treatment (TrkC-MSCs+EA group) significantly increased the number of OPCs and oligodendrocyte-like cells differentiated from MSCs. Immunoelectron microscopy showed that the oligodendrocyte-like cells differentiated from TrkC-MSCs formed myelin sheaths. Immunofluorescence histochemistry and Western blot analysis indicated that TrkC-MSCs+EA treatment could promote the myelin basic protein (MBP) expression and Kv1.2 arrangement trending towards the normal level. Furthermore, behavioural test and cortical motor evoked potentials detection demonstrated a significant functional recovery in the TrkC-MSCs+EA group. In conclusion, our results suggest that EA treatment can increase NT-3 expression, promote oligodendrocyte-like cell differentiation from TrkC-MSCs, remyelination and functional improvement of demyelinated spinal cord.

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.

Influence of acupuncture on leptin, ghrelin, insulin and cholecystokinin in obese women: a randomised, sham-controlled preliminary trial

BACKGROUND

Obesity is an energy balance problem caused by overeating. Obesity treatment includes diet, exercise, behaviour treatment, pharmacotherapy and surgery; in addition, acupuncture is also an option.

OBJECTIVE

To investigate the effect of acupuncture on weight loss and whether a brief acupuncture treatment of 5 weeks can change circulating levels of leptin, ghrelin, insulin and cholecystokinin (CCK) in obese women.

METHODS

40 women with a body mass index (BMI)>30 kg/m(2) were equally randomised to either an acupuncture group or a sham (non-penetrating) acupuncture group and received treatment at LI4, HT7, ST36, ST44 and SP6 bilaterally. Both groups had two sessions of 20 min/week for a total of 10 sessions. Serum insulin, leptin, plasma ghrelin and CCK levels were measured by ELISA.

RESULTS

Acupuncture treatment decreased insulin and leptin levels and induced weight loss, together with a decrease in BMI compared with sham acupuncture. Furthermore, between-group analyses demonstrated increases in plasma ghrelin and CCK levels in subjects who received acupuncture treatment.

CONCLUSION

These findings suggest that acupuncture may help to regulate weight owing to its beneficial effects on hormones such as insulin, leptin, ghrelin and CCK in obese subjects even after a few weeks of treatment.

The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review

OBJECTIVES

Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD.

METHODS

A systematic review of articles containing relevant search terms was performed.

RESULTS

Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation's specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III.

CONCLUSIONS

Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox(TM) or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.

Medical treatment for sphincter of oddi dysfunction: Can it replace endoscopic sphincterotomy?

AIM: To report the results of a medical management of sphincter of oddi dysfunction (SOD) after an intermediate follow-up period.

METHODS: A total of 59 patients with SOD (2 men and 57 women, mean age 51 years old) were included in this prospective study. After medical treatment for one year, the patients were clinically re-evaluated after an average period of 30 mo.

RESULTS: The distribution of the patients according to the Milwaukee’s classification was the following: 11 patients were type 1, 34 were type 2 and 14 were type 3. Fourteen patients underwent an endoscopic sphincterotomy (ES) after one year of medical treatment. The median intermediate follow-up period was 29.8 ± 3 mo (3-72 mo). The initial effectiveness of the medical treatment was complete, partial and poor among 50.8%, 13.5% and 35%, respectively, of the patients. At the end of the follow-up period, 37 patients (62.7%) showed more than 50% improvement. The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively (64.2% vs 62.2%, respectively).

CONCLUSION: Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because, after an intermediate follow-up period, the two treatments show the same success rates.

Dynamic changes of echogenicity and the size of the papilla of Vater before and after cholecystectomy

This study investigated the changes in echogenicity, as measured by endoscopic ultrasound, and the surface area of the papilla of Vater (PV) and their relationship with postoperative symptoms in a group of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. After cholecystectomy, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The surface area of the PV was larger than normal prior to surgery and increased after surgery. The healthy PV is isoechogenic, but 48% of all patients were anisoechogenic preoperatively, increasing to 61% at 3 months after surgery, and decreasing to 25% at 6 months postsurgery. There was no significant difference between the two patient groups, suggesting that the changes observed in the PV do not explain the presence of the atypical symptoms of PCS.

Biliary and gallbladder dyskinesia

Gallbladder and biliary dyskinesia are conditions that are becoming increasingly recognized due to improved technology. They are motility disorders that affect the gallbladder and sphincter of Oddi (SO), respectively. Gallbladder dyskinesia presents with typical biliary pain in the absence of gallstones. Work-up includes laboratory tests and imaging to rule out gallstones. Further investigation leads to a functional radionuclide study to investigate gallbladder ejection fraction. An ejection fraction of less than 40% is considered abnormal, and patients should be referred for cholecystectomy. Symptom relief after the procedure has been seen in 94% to 98% of patients. The term sphincter of Oddi dysfunction (SOD) describes a collection of pain syndromes that are attributed to a motility disorder of the SO. SOD can be further subdivided into biliary and pancreatic SOD. Patients typically have had a prior cholecystectomy and present with episodic biliary pain. The initial work-up includes laboratory tests and imaging to rule out other structural causes of abdominal pain, such as retained gallstones. Imaging and laboratory studies further subdivide patients into types of SOD. SO manometry (SOM) is the gold standard for assessing biliary dyskinesia and can help stratify patients into one of two groups: SO stenosis versus SO dyskinesia. Those with stenosis (type I SOD) are the most likely to respond to treatment with endoscopic biliary sphincterotomy (EBS). As the vast majority of type I patients (>/= 90%) benefit from EBS, SOM is not necessary. Pancreatic SOD patients can be similarly divided into one of three groups. These patients present with recurrent bouts of abdominal pain and/or pancreatitis in the absence of gallstones or other structural abnormalities. Pancreatic sphincter manometry can help distinguish which patients would benefit from endoscopic pancreatic sphincterotomy. Recurrent stenosis of the opening after endoscopic treatment in these patients may necessitate a surgical (open) approach.

The Size of the Papilla of Vater and Its Relation to Its Height in Comparison with the Visibility of the Sphincter of Oddi before and after Cholecystectomy

This study investigated the changes in the surface area and height of the papilla of Vater (PV) and the visibility of the sphincter of Oddi complex (SOK) using endoscopic ultrasound (EUS) examinations of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. Following surgery, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The PV measurements were greater in all patients compared with normal reference values and increased significantly from before surgery to 3 months postsurgery. At 6 months postsurgery, both the surface area and height of the PV had significantly decreased to preoperative values but remained higher than normal. The proportion of patients with a visible SOK had increased by 3 months postsurgery but had reduced again by 6 months. There were no significant differences between symptomatic and asymptomatic patients, suggesting that the changes observed in the PV and SOK do not explain the presence of the atypical symptoms of PCS.

An experimental electro-acupuncture study in treatment of the rat demyelinated spinal cord injury induced by ethidium bromide

Oligodendrocyte precursor cells (OPCs) are one of the potential treating tools for multiple sclerosis (MS). Therefore, the cell number and differentiation of OPCs in a demyelinated spinal cord are crucial for improvement of reparative process. In the present study, we investigated whether "Governor Vessel (GV)" electro-acupuncture (EA) could efficiently promote increase in cell number and differentiation of OPCs into oligodendrocytes, remyelination and functional recovery in the demyelinated spinal cord. The spinal cord of adult Sprague-Dawley rats was microinjected with ethidium bromide (EB) at T10, to establish a demyelinated model. Six groups of animals were performed for the experiment. After 15 days EA treatment, neurotrophin-3 (NT-3) level and number of NG2-positive OPCs were significantly increased. Compared with the sham group, more NG2-positive OPCs were distributed between neurofilament (NF)-positive nerve fibres or closely associated with them in the lesion site and nearby tissue. In rats given longer EA treatment for 30 days, the number of adenomatous polyposis coli (APC)-positive oligodendrocytes was increased. Concomitantly, the number of newly formed myelins was increased. This was coupled by increase in endogenous oligodendrocyte involved in myelin formation. Furthermore, behavioural test and spinal cord evoked potential detection demonstrated a significant functional recovery in the EA+EB day 30 group. Our results suggest EA treatment can promote NT-3 expression, increase the cell number and differentiation of endogenous OPCs, and remyelination in the demyelinated spinal cord as well as the functional improvement of demyelinated spinal cord.

Electroacupuncture induces Fos expression in the nucleus tractus solitarius via cholecystokinin A receptor signaling in rats

OBJECTIVES

Cholecystokinin, a satiety hormone, acts on cholecystokinin A receptor on vagal afferent neurons that project to the nucleus tractus solitarius, resulting in inhibition of feeding. Cholecystokinin is known to be released by electroacupuncture stimulation at certain body sites which elicits profound psychophysiological responses. Our previous study has revealed the involvement of cholecystokinin and cholecystokinin A receptor in the electroacupuncture stimulation-induced modulation of feeding. The aim of the present study was to examine whether electroacupuncture stimulation at the acupuncture point ST36 (Joksamni) activates the nucleus tractus solitarius neurons and whether such effect is mediated by cholecystokinin A receptor.

METHODS

Using an immunofluorescent analysis of Fos, a neuronal activation marker, we compared the Fos immunoreactivity of the nucleus tractus solitarius among three groups of Sprague-Dawley rats: (1) control (48 hour fasting + saline pre-treatment + no electroacupuncture stimulation); (2) SalEA (48 hour fasting + saline pre-treatment + ST36 electroacupuncture stimulation); (3) LorEA (48 hour fasting + pre-treatment of cholecystokinin A receptor antagonist, lorglumide + ST36 electroacupuncture stimulation).

RESULTS

ST36 electroacupuncture stimulation significantly reduced 30 minute food intake (p<0.05, SalEA versus control) and increased Fos expression in the nucleus tractus solitarius (p<0.01, SalEA versus control). The effects of electroacupuncture on food intake and Fos were blocked by a lorglumide pre-treatment (p>0.05, LorEA versus control).

DISCUSSION

Our finding suggests that ST36 electroacupuncture stimulation activates the nucleus tractus solitarius neurons via cholecystokinin A receptor signaling pathway, which may be the underlying central mechanism of electroacupuncture-induced satiety effect.

The effect of electroacupuncture on T cell responses in rats with experimental autoimmune encephalitis

Successive electroacupuncture (EA) stimulation on Zusanli ST36 acupoints of rats with experimental autoimmune encephalitis (EAE), which is an inflammatory disease mediated by autoreactive T cells, relieved disease severity, inhibited specific T cell proliferation and rebuilt the CD4+ T cell subset balance. In addition, EA-treated rats had significantly higher ACTH concentrations in vivo compared to untreated EAE rats. These results indicated that EA stimulation could relieve the severity of EAE by restoring balance to the Th1/Th2/Th17/Treg Th cell subset responses by stimulating the hypothalamus to increase ACTH secretion.

The endogenous CCK mediation of electroacupuncture stimulation-induced satiety in rats

A major satiety hormone, cholecystokinin (CCK) is well known to be released by electroacupuncture (EA) stimulation at certain body sites which elicits profound psychophysiological responses. Previous clinical and animal studies have shown that EA stimulation reduces food intake and body weight in both normal and obese subjects. The aim of the present study was to elucidate the satiety effect of EA stimulation and its mechanism related to CCK in rats. Here we show that EA stimulation at "Zusanli" (ST36) acupoint significantly reduced 30-min and 60-min food intake in 48-h fasted Sprague-Dawley rats, and such effect was reversed by a lorglumide (CCK-1 receptor antagonist, 10mg/kg, i.p.) pretreatment. The ST36 EA stimulation-induced satiety was not observed in CCK-1 receptor knockout, Otsuka Long-Evans Tokushima Fatty rats, but in their controls, Long-Evans Tokushima Otsuka rats. Subdiaphragmatic vagotomy also blocked the satiety effect of ST36 EA stimulation in Sprague-Dawley rats. These results suggest that ST36 EA stimulation elicits satiety in rats and this is mediated by the endogenous CCK signaling pathway.

Functional hepatobiliary disease: chronic acalculous gallbladder and chronic acalculous biliary disease

Chronic acalculous gallbladder and chronic acalculous biliary disease are considered functional hepatobiliary diseases. Cholescintigraphy provides physiologic imaging of biliary drainage, making it ideally suited for their noninvasive diagnosis. For chronic acalculous gallbladder disease, calculation of a gallbladder ejection fraction during sincalide cholescintigraphy can confirm the clinical diagnosis and has become a common routine procedure in many nuclear medicine clinics. Published data generally confirm a high overall accuracy for predicting relief of symptoms with cholecystectomy. However, data also exist suggesting it is not useful. The discrepant results probably are caused by the various different methodologies that have been used for sincalide infusion. Proper methodology of sincalide infusion is critical for providing accurate reproducible results, minimizing false positive studies, and preventing adverse side effects. The most common causes for the postcholecystectomy pain syndrome are partial biliary obstruction secondary to stones or tumor and sphincter of Oddi dysfunction. The latter is a partial biliary obstruction at the level of the sphincter. This has long been considered a functional hepatobiliary disease because of the lack of anatomical abnormalities. Sphincterotomy is the present treatment; however, diagnosis requires invasive procedures, such as endoscopic retrograde cholangiopancreatography and sphincter of Oddi manometry, which has a high complication rate and is not widely available. The unique ability of cholescintigraphy to image biliary drainage allows noninvasive diagnosis. Different methodologies have been reported, many with good overall accuracy. Various pharmacologic interventions and quantitative methodologies have been used in conjunction with cholescintigraphy to enhance its diagnostic capability. Further investigations are needed determine the optimal methodology; however, cholescintigraphic methods have already a clinical role in the diagnosis of sphincter of Oddi dysfunction and will be used increasingly in the future.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction: managing the patient with chronic biliary pain

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to functional obstruction of pancreaticobiliary flow at the level of the sphincter of Oddi. The Milwaukee classification stratifies patients according to their clinical picture based on elevated liver enzymes, dilated common bile duct and presence of abdominal pain. Type I patients have pain as well as abnormal liver enzymes and a dilated common bile duct. Type II SOD consists of pain and only one objective finding, and Type III consists of biliary pain only. This classification is useful to guide diagnosis and management of sphincter of Oddi dysfunction. The current gold standard for diagnosis is manometry to detect elevated sphincter pressure, which correlates with outcome to sphincterotomy. However, manometry is not widely available and is an invasive procedure with a risk of pancreatitis. Non-invasive testing methods, including fatty meal ultrasonography and scintigraphy, have shown limited correlation with manometric findings but may be useful in predicting outcome to sphincterotomy. Endoscopic injection of botulinum toxin appears to predict subsequent outcome to sphincterotomy, and could be useful in selection of patients for therapy, especially in the setting where manometry is unavailable.

Effects of abdominal electroacupuncture on parameters related to obesity in obese women: a pilot study

The aim of this study was to elucidate the effects of electroacupuncture at abdominal meridian points on various obesity-related parameters: body weight (BW), body fat (BF) percentage, body mass index (BMI), percent ideal body weight (PIBW), and waist (WC) and hip (HC) circumferences. All of these parameters changed significantly compared to pretreatment in this pilot uncontrolled study involving 31 women with obesity. The percent reductions were 5.3% in BW, 1.3% in BF, 4.7% in BMI, 6.0% in PIBW, 4.6% in WC, 6.2% in HC, and 2.1% in the WC/HC ratio. The most affected variable was WC (effect size=0.58). Since this was a pilot study with several limitations, such as a small sample size and absence of a control treatment and appropriate follow-up, further studies that include a randomized design, larger sample sizes, and more detailed data about the subjects are needed to convincingly show the effects of electroacupuncture at abdominal meridian points on overweight and obese patients.

Electroacupuncture in obese women: a randomized, controlled pilot study

OBJECTIVE

To compare the effects of electroacupuncture and sit-up exercise on reducing body weight (BW) and waist circumference (WC) among obese women.

METHODS

A randomized, controlled clinical trial was conducted from July 1, 2002, to June 30, 2003, in the outpatient department of Taipei Hospital, Taiwan. The subjects were 72 obese women, with WC>90 cm and body mass index (BMI)>30 kg/m2 and who had not received any other weight control maneuver within the prior 3 months. The subjects were randomly divided into groups A, B, and C. Group A (n=22) received electroacupuncture, group B (n=20) was assigned sit-up exercises, and group C (n=21) received no intervention. All three treatments lasted for 6 weeks. The measurements of BW, BMI, and WC were performed in the beginning and after 6 weeks. The data were compared and expressed as percent reductions.

RESULTS

Electroacupuncture showed significantly greater percent reductions in BW (p=0.009, 0.004), BMI (p=0.008, 0.016), and WC (p=0.013, 0.006) compared with sit-up exercises or no intervention.

CONCLUSIONS

In this pilot study, electroacupuncture treatment was more effective than situp exercise or no intervention in reducing BW, BMI, and WC.

The sphincter of Oddi: understanding its control and function

The most common functional disorders of the biliary tract and pancreas are associated with disordered motility of the sphincter of Oddi (SO). The SO is a neuromuscular structure located at the junction of the bile and pancreatic ducts with the duodenum. The primary functions of the SO are to regulate the delivery of bile and pancreatic juice into the duodenum, and to prevent the reflux of duodenal contents into the biliary and pancreatic systems. Disordered motility of the SO leads to the common and painful clinical conditions of SO dysfunction and acute pancreatitis. In order to understand normal SO motility, studies have been performed addressing SO function, control of spontaneous SO activity, responses to bioactive agents, SO innervation, and reflexes with other gastrointestinal organs. These studies have led to the current understanding of how the SO functions and may permit the development of targeted therapy for SO dysfunction and acute pancreatitis. This review summarizes the current knowledge regarding the control and regulation of SO motility, highlighting laboratory based and clinical research performed over the last 5 years.

Sphincter of oddi dysfunction

Sphincter of Oddi dysfunction (SOD) is a benign noncalculous obstruction of bile or pancreatic drainage at the level of the sphincter of Oddi. The disorder is clinically associated with either biliary pain or idiopathic pancreatitis, depending on the portion of the sphincter affected. Patients with suspected SOD are subdivided into three categories: these are type I, II, and III, depending on associated clinical evidence for the diagnosis. Multiple noninvasive tests have been utilized to aid in the diagnosis but have been complicated by poor sensitivity and specificity. Sphincter of Oddi manometry is the gold standard for confirming the diagnosis, although questions remain about its sensitivity and specificity. Sphincterotomy of the affected portion of the sphincter is the treatment of choice and has been shown effective for palliation of symptoms in two sham-controlled studies of patients with suspected type II biliary SOD.

Suppression of IgE production and modulation of Th1/Th2 cell response by electroacupuncture in DNP-KLH immunized mice

Effects of electroacupuncture (EA) on Th1/Th2 cell response were investigated in BALB/c mice immunized intraperitoneally with 2,4-dinitrophenylated keyhole limpet protein (DNP-KLH). Successive electroacupuncture stimulation on the ST36 acupoint was performed just after immunization. Serum levels of antigen-specific IgE and total IgE were significantly decreased compared with non-acupunctured controls. Production of the Th2-specific cytokines IL-4 and IL-13 in the anti-CD3 mAb-activated splenocytes was significantly suppressed in ST36 electroacupunctured mice compared with non-acupunctured mice. These results imply that successive electroacupuncture on ST36 can decrease the serum level of antigen-specific IgE and total IgE by suppression of the Th2 lineage development.

Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation

Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.

Determination of sphincter of Oddi dysfunction in patients with prior normal manometry

BACKGROUND

Assessment of sphincter of Oddi motility by manometry is limited to a finite time period, and the presence of a motor disorder that is intermittent may not be documented. This study evaluated the frequency of sphincter of Oddi dysfunction in persistently symptomatic patients with previously normal sphincter of Oddi manometry studies.

METHODS

A total of 177 patients underwent ERCP for suspected sphincter of Oddi dysfunction and had a normal sphincter of Oddi manometry study (both biliary and pancreatic) over a 5-year period (1996-2001). All patients referred for a second ERCP with sphincter of Oddi manometry for evaluation of persistent symptoms were included in this study.

RESULTS

Of the 177 patients, 12 (mean age 37.6 years, range 19-59 years) met criteria for inclusion. The mean time interval between the first and second ERCP was 337 days (range 43-792 days). Sphincter of Oddi dysfunction was diagnosed at a second sphincter of Oddi manometry in 5 (42%) patients; 4 had pancreatic sphincter hypertension; one had elevation of both pancreatic and biliary sphincter pressures. All 5 patients underwent endoscopic sphincter ablation therapy; 4 were symptom-free on follow-up at, respectively, 26, 40, 48, and 72 months; one patient had persistent symptoms from pancreatic sphincter restenosis and required multiple endoscopic interventions. Five of the 12 (42%) patients with normal manometric studies were found to have pancreatographic changes of chronic pancreatitis; the two remaining patients had a normal ERCP and manometry.

CONCLUSIONS

A single negative manometry study does not rule out sphincter of Oddi dysfunction. Repeat ERCP with manometry may be warranted for patients with persistent symptoms in whom the clinical suspicion for sphincter of Oddi dysfunction remains high.

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.

The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog

AIM: To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regulatory effect of gallbladder.

METHODS: Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed.

RESULTS: According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0 ± 2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8 ± 0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P < 0.01) in the interval period of bile draining, but significant difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8 ± 0.5 mmHg) and the bile flowing period (15.9 ± 0.9 mmHg) (P > 0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling.

CONCLUSION: During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.

Effects of bioactive agents on biliary motor function

Our understanding of biliary motility under normal and pathophysiologic conditions is still incomplete, but there have been recent advances. Of particular interest are the mechanisms involved in gallbladder filling and emptying, with a focus on understanding the processes underlying impaired gallbladder emptying leading to gallbladder dyskinesia and the formation of gallstones or cholecystitis. The sphincter of Oddi (SO) is a complex neuromuscular structure. Recent studies have attempted to unravel the specific neural or hormonal mechanisms operating under normal physiologic conditions and those that may lead to SO dysfunction. Furthermore, new research fronts are emerging, including the role of leptin in obese patients with impaired biliary motility and the action of electroacupuncture for possible treatment of SO dysfunction. This review illustrates the broad front of current research regarding the effects of bioactive agents on biliary motility, including enteric hormones, nitric oxide, opioids, inflammatory mediators, leptin, protease inhibitors, neurotransmitters, and electroacupuncture.

The effect of transcutaneous nerve stimulation on intraductal biliary pressure in post-cholecystectomy patients with T-drainage

OBJECTIVE

To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) on intraductal biliary pressure (IDP) in basal conditions and after intravenous morphine and oral meal stimulation.

DESIGN AND METHODS

Fifteen patients (5 male, 10 female) aged 31-83 years (mean 61.5 +/- 13.7 years) with prior cholecystectomy and residual in situ T-tube were examined. Final radiographs excluded any organic abnormalities. The study consisted of three sessions. On the first day (session 1), after the initial manometric intraductal pressure was measured for 15 min, TENS (using a PRO-TENS pocket stimulator) was applied for 15 min. Measurement was continued for 15 min after termination of TENS. The measurement was performed using a water-perfused manometry system (Synectics Medical, Stockholm, Sweden) by a triple-channel manometric catheter inserted into the common bile duct through a T-drain. On the following day (session 2), the protocol was similar except that, after basal IDP measurement, morphine hydrochloride 0.08 mg/kg was injected intravenously 10 min before TENS. On the third day (session 3), after basal measurements were taken, patients were given a standard test meal and the IDP was recorded continuously for 45 min. To estimate the effects of the stimuli applied, absolute intraductal pressure changes were analysed.

RESULTS

In session 1, TENS reduced basal IDP in all patients by a mean of 3.95 +/- 1.6 mmHg. In 13 patients, 15 min after cessation of TENS a further decrease in IDP was observed. In two patients, termination of TENS was followed by a rebound increase in IDP; however, it did not reach the initial value (mean total decrease 5.05 +/- 2.25 mmHg). In session 2, administration of morphine produced an evident increase in IDP in all subjects by 6.9 +/- 2.7 mmHg. TENS decreased IDP in 13 patients. In two patients, TENS initially failed to lower elevated pressure, but it appeared several minutes after the end of stimulation. In 13 patients, the final IDP values were lower than the baseline pressures. In session 3, after administration of a test meal, IDP decreased within 30-40 min by a mean of 4.89 +/- 1.29 mmHg.

CONCLUSIONS

TENS decreased basal as well as elevated IDP in the majority of the T-drain patients studied. The effect of TENS persisted after its termination. Elevated IDP is believed to be responsible for pain in patients with sphincter of Oddi dysfunction (SOD). Therefore, we think that TENS can be used effectively and safely as an optional therapeutic method in the treatment of biliary dyskinesia.