Manometric study of the sphincter of Oddi in patients with and without common bile duct stones

Understanding bacterial infiltration of the pancreas through a deformable pancreatic duct

Tiny amount of bacteria are found in the pancreas in pancreatitis and cancer, which seemed involved in inflammation and carcinogenesis. However, bacterial infiltration from the duodenum is inhibited by the physical defense mechanisms such as bile flow and the sphincter of Oddi. To understand how the bacteria possibly infiltrate the pancreas through a deformable pancreatic duct, influenced by the periodic contractions of the sphincter of Oddi, a mathematical model of bacterial infiltration is developed that considered large deformation, fluid flow, and bacterial transport in a deformable pancreatic duct. In addition, the sphincter's contraction wave is modeled by including its propagation from the pancreas toward the duodenum. Simulated structure of the deformed duct with the relaxed sphincter and simulated bile distribution agreed reasonably well with the literature, validating the model. Bacterial infiltration from the duodenum in a deformable pancreatic duct, following the sphincter's contraction, is counteracted by a gradual peristalsis-like deformation of the pancreatic duct, due to an antegrade contraction wave propagation from the pancreas to the duodenum, Parametric sensitivity analysis demonstrated that bacterial infiltration is increased with lower bile and pancreatic juice flow rate, greater contraction amplitude and frequency, thinner wall thickness, and retrograde contraction wave propagation. Since contraction waves following retrograde propagation are increased in patients with common bile duct stones and pancreatitis, they may possibly be factors for continuum inflammation of pancreas. (224 words).

Sphincter of Oddi Dysfunction Induces Gallstone by Inhibiting the Expression of ABCB11 via PKC-α

The abnormal increase of Oddi sphincter pressure and total bile duct pressure may play an important role in the formation of cholesterol stones, but the specific molecular mechanism is still unclear. This study aims to investigate it through in vitro and in vivo experiments. A mouse model of Oddi sphincter dysfunction was constructed by stone-inducing diet. We compared the two groups with PKC-α inhibitor GÖ6976 and PKC-α agonist thymeleatoxin. Oddi sphincter pressure and total bile duct pressure were measured. Biochemical analysis of total cholesterol, bile acid and bilirubin was then conducted. The histopathologic changes of bile duct were observed by HE staining and the ultrastructure of liver cells and surrounding tissues was observed by transmission electron microscopy. Through the above experiments, we found that the change of PKC-α expression may affect the formation process of gallstones. The relationship between PKC-α and ABCB11 was further verified by in vitro and in vivo experiments. Our results suggest that ABCB11 and PKC-α are co-expressed in the tubule membrane of hepatocytes and interact with each other in hepatocytes. The high cholesterol diet further enhances the activation of PKC-α and thus reduces the expression of ABCB11. The formation of cholesterol stones is associated with the down-regulation of ABCB11 expression in the tubule membrane of hepatocytes due to kinase signaling. This is the first study to demonstrate that sphincter of Oddi dysfunction induces gallstones through PKC-α inhibition of ABCB11 expression.

Manometric Measurement of the Sphincter of Oddi in Patients with Common Bile Duct Stones: A Consecutive Study of the Han Population of China

Objective. Role of dysfunction of the sphincter of Oddi (SO) in choledocholithiasis is controversial. This study was to evaluate SO motor activity in patients with common bile duct (CBD) stones in the Han population of China. Patients and Methods. In this study, 76 patients with CBD stones were enrolled in a single tertiary endoscopy center. Data of SO motor activities was prospectively evaluated by endoscopic manometry. Mean basal SO pressure, amplitude, and frequency were collected and analyzed. Results. The mean basal SO pressure, amplitude, and frequency were 52.7 ± 40.0 (1.60–171.1) mmHg, 39.9 ± 19.7 (14.9–115.5) mmHg, and 5.7 ± 3.2 (1.3–13.8)/min, respectively. The basal SO pressure was higher in patients with CBD stones < 10 mm in diameter than that in those with CBD stones larger than 10 mm in diameter (60.7 ± 41.0 mmHg versus 36.8 ± 29.4 mmHg, P = 0.043). There was no significant difference in the basal SO pressure, amplitude, and frequency when compared with the CBD diameter, CBD stone number, prior cholecystectomy, periampullary diverticula, and symptoms. Levels of alanine aminotransferase, aspartate transaminase, γ-glutamyl transpeptidase, and alkaline phosphatase showed no significant difference in patients with normal or elevated basal SO pressure. Conclusion. These results identify that, in Chinese Han population, abnormalities of SO motor activity are associated with CBD stones.

Endoscopic papillary balloon dilation causes transient pancreatobiliary and duodenobiliary reflux

BACKGROUND

Endoscopic papillary balloon dilation reduces sphincter function at least transiently or partially, which may allow pancreatobiliary and duodenobiliary reflux to occur. This study prospectively evaluated pancreatobiliary and duodenobiliary reflux after endoscopic papillary balloon dilation.

METHODS

In 12 patients with choledocholithiasis, ductal bile was sampled for amylase concentration and bacterial culture during ERCP, before and at 7 days to 5 years after endoscopic papillary balloon dilation. To provide comparative and control data, ductal bile was sampled in 12 patients with gallbladder cholesterol polyps and 6 with anomalous pancreaticobiliary junction who did not undergo endoscopic papillary balloon dilation.

RESULTS

Amylase concentrations in ductal bile from patients with choledocholithiasis before endoscopic papillary balloon dilation were marginally significantly higher (before Bonferroni correction) compared with concentrations in bile from patients with gallbladder polyps. The concentration of amylase in bile was significantly increased at 7 days after endoscopic papillary balloon dilation compared with that before endoscopic papillary balloon dilation; the level was comparable with that of patients with an anomalous pancreaticobiliary junction. Subsequently, the amylase concentration gradually decreased and was approximately equal to the pre-endoscopic papillary balloon dilation level at 1 year. Bacteriocholia was frequent (67%-92%) for up to 3 months after endoscopic papillary balloon dilation but was rare thereafter.

CONCLUSIONS

Endoscopic papillary balloon dilation causes transient pancreatobiliary and duodenobiliary reflux. However, reflux is no longer present at 1 year after endoscopic papillary balloon dilation.

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.

Endoscopic papillary balloon dilatation may preserve sphincter of Oddi function after common bile duct stone management: evaluation from the viewpoint of endoscopic manometry

BACKGROUND

Endoscopic papillary balloon dilatation (EPBD) has been reported as a safe and effective alternative to endoscopic sphincterotomy in the management of common bile duct (CBD) stones; its effect on papillary function has yet to be elucidated.

AIM

To investigate sphincter of Oddi (SO) motility before and after EPBD to determine its effect on SO function.

PATIENTS AND METHODS

The papillary function of 10 patients with CBD stones was studied using endoscopic manometry before and one week after EPBD. The manometric studies were repeated one month after EPBD in seven patients.

RESULTS

One week after EPBD, CBD pressure, SO peak pressure, SO basal pressure, and SO frequency decreased significantly. One month after EPBD, however, all parameters increased although the increases in SO basal pressure and CBD pressure were not significant. There was no significant difference in values of any parameter before and one month after EPBD. No serious complications occurred.

CONCLUSION

These data suggest at least partial recovery of papillary function one month after the procedure. EPBD seems to preserve papillary function in treatment of CBD stones; a longer term follow up study with SO manometry should be performed to clarify the effect of EPBD on SO function.

Sphincter of Oddi motility

BACKGROUND

Technical improvement in endoscopic and manometric technique has allowed direct manometry of the human sphincter of Oddi (SO). The aim of the present review is to describe the present status of physiologic and clinical knowledge of the SO, with emphasis on contributions from Danish Gastroenterology.

RESULTS

The SO is a zone with an elevated basal pressure with superimposed phasic contractions. It acts mainly as a resistor in the regulation of bile flow. Neurohormonal regulation influences the motility pattern. The contractions are under the control of slow waves. Clinical subgroups show abnormalcy in SO manometric pattern especially in patients with biliary or pancreatic pain without demonstrable organic substrate. Evidence suggests that endoscopic sphincterotomy may be of benefit in these patients.

Hepatoduodenal bile transit in cholecystectomized subjects. Relationship with sphincter of Oddi function and diagnostic value

The hepatic hilum-duodenum transit time (HHDT) was evaluated in cholecystectomized subjects to assess its relationship with the motor function of the sphincter of Oddi (SO) and its diagnostic accuracy in the detection of SO dysfunction. The study was performed in asymptomatic controls and symptomatic patients with SO dysfunction before and after sphincterotomy. HHDT showed a direct correlation with manometric SO maximal basal pressure (r = 0.77; P < 0.001) but not with SO phasic activity. In sphincterotomized subjects HHDT did not differ from that of the asymptomatic subjects, and HHDT, which was prolonged before sphincterotomy, normalized after sphincterotomy. HHDT had a 100% specificity and an 83% sensitivity in diagnosing SO dysfunction when compared to SO manometry. In conclusion, the cholescintigraphic HHDT is mainly related to the SO maximal basal pressure, presenting an elevated specificity and a satisfactory sensitivity in the diagnosis of SO dysfunction in cholecystectomized subjects.

Biliary motility. Changes in detailed characteristics correlated to duodenal migrating motor complex and effects of morphine and motilin in dogs

The temporal relationship of biliary motility to the duodenal migrating motor complex and effects of morphine and motilin were studied in five dogs prepared with a duodenal cannula. Common bile duct, sphincter of Oddi, and duodenal manometry were performed awake. Sphincter of Oddi phasic contractions occurred even during the quiescent period of duodenal phase I and its activity increased from phase II to III. Minimum basal pressure of sphincter of Oddi and common bile duct pressure decreased from phase I to phase III. Both morphine and motilin induced premature phase III in the sphincter of Oddi and duodenum. Latencies of the effect were 0.2 min for morphine and 3.2 min for motilin (P < 0.01). After morphine, vigorous continuous contractions with high basal pressure occurred, being interrupted by brief and repeated inactive periods, similar to spontaneous phase III. Motilin-induced phase III appeared indistinguishable from spontaneous phase III. Although both agents induced phase III in the sphincter of Oddi, differences in the latency and contraction pattern suggest different mechanisms of action of these agents on the sphincter of Oddi.

Sphincter of Oddi function studied by radioimmunoassay of biliary trypsin in patients with bile duct stones and in controls

The trypsin level in bile was studied by radioimmunoassay in a prospective series of 63 patients with gallstone disease but without signs or symptoms of cholecystitis or pancreatitis in order to find indirect evidence of a retrograde flow of pancreatic juice. Mobile duct stones were present in 18 patients and impacted stones in 12. The remaining 33 patients had stones only in the gallbladder and served as controls. The average intraoperative trypsin level of the ductal bile was normal, both in the control group and in the group with stones occluding a potential retrograde reflux of pancreatic juice. After removal of the impacted stones, the bile showed a significantly higher trypsin level. The average intraoperative trypsin level for the group with mobile stones was significantly higher than that of the control group, and was further increased 10 days postoperatively. The trypsin level of ductal bile from 23 of the 30 patients (77%) with bile duct stones exceeded that of the 33 patients with stone-free bile ducts, indicating an inflow of pancreatic juice to the bile ducts of patients with bile duct stones. The present results correspond well to those in a previous report on retrograde phasic contractions of the sphincter of Oddi in the majority of patients with bile duct stones. This dysfunction of the sphincter, which persisted for 10 days after surgical stone removal, may be the primary disorder, probably consisting of a retrograde propulsive activity of the sphincter of Oddi.

Sphincter of Oddi motility in patients with bile duct stones. A comparative study using percutaneous transhepatic manometry

The motility of the sphincter of Oddi was measured by percutaneous transhepatic manometry of the sphincter of Oddi (PTMSO) in three groups of 57 patients with bile duct stones. The three groups were: (1) cholecystectomy group (N = 10)--patients with common bile duct stones (CBDS) who had already undergone cholecystectomy; (2) noncholecystectomy group (N = 37)--patients with CBDS who had not undergone cholecystectomy; and (3) intrahepatic stone (IHS) group (N = 10). The basal pressure, amplitude, frequency, and propagation direction of contraction waves and the response to cerulein injection or dried egg yolk ingestion were analyzed and compared among these groups. No significant differences in the basal pressure, amplitude, frequency, and propagation direction of the contraction waves were found among the three groups. There were also no differences in the response to cerulein or dried egg yolk ingestion. The frequency and duration of the burst contractions occurring in duodenal phase III of the migrating motor complex were significantly higher (P < 0.05) in the cholecystectomy group than in the other two groups. These two differences in the burst contractions may be ascribed to the absence of the gallbladder.

Bacterial biofilm, brown pigment stone and blockage of biliary stents

Bacterial pathogens gain access into the biliary system by descending via the portal venous circulation or ascending through the sphincter of Oddi in duodenal-biliary reflux. Bacteria thrive as glycocalyx-enclosed microcolonies, coalescing to form an adherent biofilm. The establishment of biofilm is a key event in the formation of biliary sludge and pigment gallstones, and the blockage of biliary stents. The biofilm mode of growth is very effective because it provides bacteria with a measure of protection from antibacterial agents and phagocytic leucocytes. Calcification of the matrix confers further protection for the micro-organisms living inside the biofilm. To date, attempts to prevent blockage of biliary stent have employed physical methods by using large self-expandable stents and stents without side hole. Incorporation of antibiotics within stents has not been successful presumably because bacteria once living in their biofilm are quite resistant to antimicrobial agents. Even the most toxic bile salts have no effect on the biofilm bacteria. Yet, hydrophobic bile salts reduce bacterial adhesion on biomaterial, suggesting that incorporation of such bile salts might prevent the formation of bacterial biofilm.

Controlled study of the effect of nicardipine and ceruletide on the sphincter of Oddi

Although sphincter of Oddi dysfunction is a recognised cause of post cholecystectomy pain, the control mechanisms involved in sphincter of Oddi function are poorly understood. Pharmacological relaxation of the sphincter of Oddi may have a beneficial effect particularly in sphincter of Oddi dysfunction where basal sphincter pressure is high. The aim of this study was to investigate the effects of calcium channel blockade (nicardipine) and synthetic cholecystokinin (ceruletide) on sphincter of Oddi pressures. Nineteen patients (median age 49 years; range 21-75) attending for routine endoscopic retrograde cholangiopancreatographic (ERCP) examination were studied. No patients with evidence of sphincter of Oddi dysfunction were included in the study. Each patient was randomly allocated to receive a three minute intravenous infusion of nicardipine 3 mg (six) ceruletide 5 ng/kg (seven) or placebo (six). Endoscopic biliary manometry was done with recording of basal sphincter of Oddi pressures, sphincter of Oddi phasic wave amplitude and frequency before and after intravenous infusions. In the nicardipine group patients showed a decrease in both basal and phasic amplitude sphincter of Oddi pressure (mm Hg) from the preinfusion values (mean (SEM)) of 24.7 (3.6) and 112.3 (13.4) to 12.9 (2.9) (p less than 0.01) and 89.9 (12.4) (p less than 0.03) after infusion respectively. Ceruletide produced a decrease in sphincter of Oddi phasic wave frequency (c/min) from 3.4 (0.3) before infusion to 2.6 (0.5) after infusion (p less than 0.05). We conclude that nicardipine effectively decreases sphincter of Oddi pressure. This drug may therefore be of value in the treatment of sphincter of Oddi dysfunction where raised sphincter pressures are thought to be the primary pathogenic feature.

Monitoring the pressure of the sphincter of Oddi by percutaneous transhepatic choledochoscopy: new method for evaluating motor function

The pressure of the sphincter of Oddi was measured in 40 patients using a thin microtransducer introduced via percutaneous transhepatic choledochoscopy. Choledochograms of the Vaterian bile duct were classified into four types: N (normal), I, II and III. Judging from the length of the Vaterian bile duct and the degree of fibrosis observed in the biopsy specimens, duodenal papillitis was found to be more severe in Type III than in Type II. Nevertheless the systolic pressure was significantly lower in Type III. We considered that when duodenal papillitis is considerably advanced, the force of contraction of the sphincter is reduced. In addition, based on choledochoscopic observations, as duodenal papillitis increased in severity, the incidence of an irregular shape at the end of the common bile duct during diastole increased. The indications for endoscopic sphincterotomy were determined based on the pressure of the sphincter of Oddi in patients with normal duodenal papilla. In the 26 patients in whom the procedure was not indicated, no gallstones developed. In the 3 patients in whom the procedure was indicated and performed, gallstones have not developed. However, 3 of the 6 patients in whom the procedure was indicated but not performed developed gallstones. This method is useful in evaluating the motor function of the sphincter of Oddi under relatively physiological conditions.

Pathogenesis of gallstones

The many developments in nonoperative methods for the treatment of gallstone disease underscore the importance of understanding the pathogenesis of these stones. Elucidation of the factors responsible for nucleation of crystals and the mechanism by which it occurs would appear to be the challenge if we are to define the cascade of events that results in gallstone formation.

Pharmacokinetics and clinical application of technetium 99m-labeled hepatobiliary agents

Hepatobiliary imaging, introduced first in late 1950s with iodine 131 rose bengal, has undergone major changes since the introduction of technetium 99m-labeled agents in the late 1970s. 99mTc-labeled iminodiacetic acid (IDA) agents, with their high hepatic uptake and fast biliary excretion, provide superior image resolution in addition to supplying simultaneous physiologic parameters quantitatively. The measurement of hepatic extraction fraction by deconvolutional analysis aids in separating hepatocyte from biliary disease. Excretion half-time calculation by nonlinear least square fit provides a quantitative method of analyzing hepatobiliary function and correlates directly with the severity of disease. The measurement of gallbladder ejection fraction, ejection rate, and common bile duct bile reflux index following cholecystokinin, enables quantification of the degree of obstruction to bile flow through the common bile duct. The combined application of morphologic and physiologic parameters enables diagnosis of various hepatobiliary disease, especially in early stages. Quantitative functional parameters not only provide criteria for diagnosis, but also assist in monitoring the therapeutic benefit from drugs and interventional techniques such as endoscopic sphincterotomy or balloon dilation of the obstruction. Biliary dynamic studies with cholecystokinin assist in distinguishing common bile duct dilation without obstruction from dilation with obstruction. Methods of application of 99mTc-IDA agents in quantitative physiologic studies are reviewed and future direction of their use is proposed.

Clinical and scintigraphic assessment of the role of endoscopic sphincterotomy in the treatment of sphincter of Oddi dysfunction

Postcholecystectomy pain caused by sphincter of Oddi dysfunction remains a difficult condition to treat. Endoscopic sphincterotomy has been recommended for those patients with confirmed sphincter of Oddi motor abnormalities. We have studied sphincter of Oddi dysfunction patients to evaluate the effects of endoscopic sphincterotomy on both clinical symptoms and previously reported scintigraphic parameters to determine the efficacy of this method of treatment. Nine postcholecystectomy patients (seven women: two men, median age 59 years) with clinical and manometric evidence of sphincter of Oddi dysfunction underwent endoscopic sphincterotomy for persisting biliary type pain. Each patient had scintigraphy before and eight weeks after endoscopic sphincterotomy. The patients symptomatic response was assessed independently at three monthly intervals after endoscopic sphincterotomy. Scintigraphic analysis showed that the TMAX (time in minutes to maximum counts) was significantly reduced from 25.0 (20-36) (median [range]) before endoscopic sphincterotomy to 15.0 (13-25) after endoscopic sphincterotomy (p less than 0.01). Seven of nine (78%) sphincter of Oddi dysfunction patients had significant improvement in their symptoms after a mean follow up period of 12 months (range 6-19) although only six of nine were totally pain free. These results suggest that endoscopic sphincterotomy in manometrically confirmed sphincter of Oddi dysfunction improves bile drainage as measured by quantitative cholescintigraphy and is associated with at least short term symptom relief in the majority of patients.

Sphincter of Oddi manometry in healthy volunteers

In this study we describe in detail the characteristics of sphincter of Oddi motor function in a large group of healthy subjects. Studies were obtained in 50 healthy volunteers. The findings showed a sphincter of Oddi segment that had a basal pressure of 14.8 +/- 6.3 mm Hg (X +/- SD). Phasic contractions were superimposed on the basal pressure. They had an amplitude of 119.7 +/- 32 mm Hg, a duration of 4.7 +/- 1 sec, and a frequency of 5.7 +/- 1.2 contractions/min. In 40 subjects the propagation sequence of phasic contractions could be evaluated and were simultaneous in 53%, antegrade in 35%, and retrograde in 11% of the waves. In 20 subjects, pressure measurements done at the common bile duct sphincter waves. In 20 subjects, pressure measurements done at the common bile duct sphincter were similar to those obtained at the pancreatic duct sphincter. In 10 subjects, pressure values obtained at the common bile duct sphincter within a week were similar. Our study should help to establish standards for normal manometric values of the sphincter of Oddi and emphasizes the importance of having a healthy volunteer group from which to obtain the normal values of sphincter of Oddi motor function.

Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

We studied the motility of the sphincter of Oddi in 12 patients with suspected sphincter of Oddi dysfunction, in four patients with cystic dilatation of the bile ducts (two Caroli's cases and two fusiform choledochal cyst cases), and in 33 patients with retained common duct stones. In these last 33 patients, the motor activity of the sphincter of Oddi was similar to that recorded in nine control subjects without pancreatic or biliary diseases. In the suspected Oddi dysfunction cases, both the basal sphincteric pressure and the frequency of the phasic contractions were significantly elevated (P less than 0.001). Patients with biliary cystic dilatation showed an increased basal pressure, but the frequency of the contractions was elevated in only those with choledochal cysts and the amplitude in only one of the two patients with Caroli's disease. Motor disorders of the sphincter of Oddi provide a basis for an alternative etiopathogenesis of cystic disease of the biliary system and a possible explanation for pain and dilatation of the bile duct in patients with suspected sphincter of Oddi dysfunction.

Effects of buprenorphine on motor activity of the sphincter of Oddi in man

Buprenorphine, (Temgesic), a N-cyclopropylmethyl derivative of oripavine, is both an agonist and antagonist of morphine. Its effect on the motility of the sphincter of Oddi (SO) in humans have been investigated by endoscopic manometry (EM). Buprenorphine leads to a significant decrease in the amplitude of SO contraction waves without altering other parameters. Thus, it has no morphine-like effect on SO motility, but it does act like a partial antagonist of morphine in reducing the amplitude of SO contraction waves.

Technetium-99m-iminodiacetic acid organic anions: review of biokinetics and clinical application in hepatology

Technetium-99m-labeled iminodiacetic acid analogs are a new class of organic anions, taken up and secreted by hepatocyte into hepatic bile by a carrier-mediated organic anion pathway. They provide a new dimension in the assessment of pathophysiology and morphology of the hepatobiliary system. The amount of uptake and the rapidity of its elimination from the liver is dependent upon the structural configuration of the agent as well as the functional integrity of the hepatocyte and the patency of the biliary system. The clinical areas for application are wide and include most of the hepatobiliary diseases. Technetium-99m-iminodiacetic acid, an agent well suited for both planar and single photon tomographic scintigraphy, is ideal for early diagnosis prior to anatomical changes in the hepatobiliary system. The data collection directly from the liver provides quantitation of both regional and global liver diseases. The count-based method for measuring gallbladder emptying overcomes the theoretical disadvantages of geometric tests. Biokinetics and current clinical application of six of the 99mTc-iminodiacetic acid agents are reviewed, and the potential future clinical and research areas of application are indicated.

Quantitative 99mTc-DISIDA scanning and endoscopic biliary manometry in sphincter of Oddi dysfunction

Sphincter of Oddi (SO) dysfunction is a recognised cause of postcholecystectomy pain, but a difficult condition to diagnose, requiring endoscopic biliary manometry (EBM) to confirm sphincter motor abnormalities. We have assessed quantitative cholescintigraphy in 10 postcholecystectomy (PC) patients with clinical and manometric evidence of SO dysfunction, 10 PC patients with non-biliary type abdominal pain and 10 asymptomatic PC volunteers acting as controls to determine its value as a non-invasive screening test. Quantitative 99mTc-DISIDA scans lasted 60 minutes, activity/time curves being created by computer analysis using the entire hepatobiliary system as region-of-interest (ROI). Scintigraphic analysis demonstrated that the time in minutes to maximum counts (Tmax) was significantly increased in the SO dysfunction group compared with the non-biliary pain group and the asymptomatic volunteers (p less than 0.001). The per cent of biliary tracer emptied was also significantly less in the SO dysfunction group than either of the other groups at both 45 minutes (p less than 0.01) and 60 minutes (p less than 0.02). We conclude that quantitative cholescintigraphy may be a valuable non-invasive screening test in clinically suspected SO dysfunction.

Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.

Manometric measurement of human sphincter of Oddi length

Length of biliary (CBD) and/or pancreatic (PD) sphincter of Oddi (SO) was measured during perendoscopic or intraoperative manometry in 21 control subjects and in 46 patients with biliary disease. When the high resting pressure (HPZ) and the phasic wave zone (PAZ) were considered, SO length was, in the control group, 9.5 +/- 0.5 mm (M +/- SE) and 9.4 +/- 0.6 mm at the level of the CBD-SO, and 7.7 +/- 0.6 mm and 6.9 +/- 0.5 mm at the level of the PD-SO. The physiological sphincter length appeared substantially shorter than the anatomical one, as reported in the literature. No significant differences were found between controls and patients with CBD stones. Endoscopic sphincterotomy without manometry reduced mean sphincter length length of the sphincterotomy was tailored to the manometric findings. Surgical partial sphincterotomy reduced sphincter length by only 46.7 +/- 10.3%.

Certain aspects of normal and abnormal motility of sphincter of Oddi

Applications of electromyographic and endoscopic manometric techniques in experimental and clinical studies have enhanced our knowledge of the normal physiology and motility disturbances of the sphincter of Oddi. The sphincter of Oddi has an active role in coordinating the time and rate of secretion of biliopancreatic juice into the duodenum. In the opossum, the sphincter of Oddi exhibits spontaneous contractions that migrate distally along the sphincter and expels its contents into the duodenum. Although the motor activity of the sphincter of Oddi is independent from that of the duodenum, there is a correlation between the frequency of bursts of spike potentials in the sphincter of Oddi and the migrating motor complex phases in the duodenum. Abnormal motility of the sphincter of Oddi has been reported during endoscopic manometric evaluation of patients with choledocholithiasis and sphincter of Oddi dyskinesia. Patients with common bile duct stones have an increase in the frequency of retrograde propagation of phasic waves. Elevation of basal pressure as well as an increase in the frequency and amplitude of sphincter of Oddi phasic waves and the common bile duct-duodenum gradient pressure may occur in patients with sphincter of Oddi dyskinesia. Endoscopic manometric studies of the sphincter of Oddi may become an important method to diagnose sphincter of Oddi dyskinesia.

Frequencies and cyclical pattern of the human sphincter of Oddi phasic activity

Basal frequency of sphincter of Oddi phasic contractility has been repeatedly measured during endoscopic manometry and reported to range, in control subjects, from (M +/- SE) 3.0 +/- 0.6 to 7.5 +/- 0.7 c/min. Recently, high frequency (greater than 8 c/min) phasic contractions or absence of phasic activity were recorded in patients with postcholecystectomy or pancreatic complaints, possibly suggesting a sphincter of Oddi dysfunction. In the present study, sphincter of Oddi (biliary tract) phasic contractility was measured by perendoscopic manometry in 13 subjects without specific clinical symptoms of biliopancreatic disease and with a normal common bile and pancreatic duct at ERCP. Four T-tube patients with no evidence of common bile duct stones or papillary stenosis were studied for comparison (transductal sphincter of Oddi manometry). Basal frequency was found to range from 0 to 7 c/min (M +/- SE: 2.99 +/- 0.46) in perendoscopic manometry (85 min of recording time) and from 0 to 12 c/min (2.0 +/- 0.3) in transductal manometry (2546 min of recording time). Long lasting transductal recordings also showed that frequency of activity derived from the sphincter area varied cyclically in close relation with the duodenal migrating motor complex. It is concluded that the sphincter of Oddi in man is likely to participate in the interdigestive gastrointestinal motor activity and that short perendoscopic recordings may not be representative of the overall sphincter of Oddi activity.