Periarticular Morphine-Induced Sphincter of Oddi Spasm Causing Severe Pain and Bradycardia in an Awake Patient Under Spinal Anesthesia: An Important Diagnostic Consideration

Sphincter of Oddi spasm from opioids has been documented, presenting as severe epigastric pain and potentially overlooked in a differential diagnosis. We present a case of sphincter of Oddi spasm from periarticular morphine in a patient under spinal anesthesia, causing severe distress and treated effectively with glucagon. It is important for anesthesiologists using opioids to consider it as a cause of perioperative pain and be familiar with treatment as it may be refractory by conventional use of opioids for pain relief. It is also important to consider the systemic effects of periarticular absorption, as evident by our case.

ENDOSCOPIC METHODS OF DIAGNOSTICS AND TREATMENT OF PAPILLOSTENOSIS

Differential diagnostics of papillospasm and papillostenosis should be based on the complex of clinical and instrumental researches with the priority to endoscopic technologies. Conservative therapy should be considered as optimal option of treatment for the patients with papillospasm. Preference of endoscopic operations have to be in case of revealed papillostenosis of different degree. Similar differentiated diagnostics and treatment management justified in 90% of cases and led to improvement of patient’s conditions and their recovery.

[Periampullar diverticulum--related to bilio-pancreatic disorders]

Periampullar diverticulum (PAD) represent a particular type of duodenal diverticulum, with important pathological effect on the functionality of both the billiary tree and the pancreas. In our retrospective, randomised study, we analised 204 patients who underwent ERCP. We diagnosed 34 PAD (17%). We performed the endoscopic procedure for several pathological conditions of the biliary tract (cholestasis, jaundice, angiocolitis). Most DPA were identified in patients over 60 years (80%), beeing slightly more frequent in males (59%). We found in 25% of patients (over 65 years) with bile duct stones at least one PAD. Over 50% of patients with PAD had bile duct stones. Fibrous, obstructive papillo-odditis was found in 37% of patients with PAD.

CONCLUSIONS

1. PAD are related to bilio-pancreatic disorders, especially to bile duct stones. 2. The most common physio-pathological mechanism is a alteration of the bile flow, due to angulation, compression and/or obstruction of the final part of the bile duct and Wirsung duct, followed by secondary upper stasis. 3. Papillosphincterotomy has technical particularities, because of difficulties in incision orientation (a deformed papilla, with modified anatomical relationships, being situated profound inside the diverticulum cavity). Sphincterotomy depth was limited, which lead to less succesfull extraction of bile stones (89%, compared to the control group 92%). 4. We did not encounter major accidents. Secondary acute pancreatitis after ERCP was similar in both study groups. There was no significant difference in morbidity and mortality rates in both groups.

Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation

PURPOSE

There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data.

PATIENTS AND METHODS

Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections.

RESULTS

Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%.

CONCLUSIONS

EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

Effect of native somatostatin on Sphincter of Oddi motility in patients with acute recurrent pancreatitis. A pilot study with Ultrasound-Secretin test

BACKGROUND

The effect of native somatostatin on Sphincter of Oddi motility still remains controversial. Sphincter of Oddi inhibition was demonstrated at manometry in patients in the acute phase of alcoholic pancreatitis. Other investigators showed marked somatostatin-induced impairment of bile flow by hepato-biliary scintigraphy.

AIM

Aim of the study was to determine the effects of therapeutical doses of exogenous somatostatin on Sphincter of Oddi motility.

PATIENTS AND METHODS

We studied eight patients (two men, six women, age 18-42), in the quiescent phase of idiopathic recurrent pancreatitis. We directly studied Sphincter of Oddi motility by perendoscopic manometry and, indirectly, secretin-stimulated pancreatic juice outflow by Ultrasound-Secretin test. The two tests were repeated before and after somatostatin infusion.

RESULTS

Manometry was performed in two patients. After 250 microg somatostatin bolus the sphincter showed an increase of motor activity. At Ultrasound-Secretin test mean diameters were significantly larger at 40-60 min evaluation intervals during 250 microg/h somatostatin infusion as compared to saline infusion, showing a delayed pancreatic duct emptying.

CONCLUSIONS

Acute administration of somatostatin seems to induce an excitatory effect on Sphincter of Oddi motility, with impaired pancreatic outflow in patients in the quiescent phase of recurrent pancreatitis.

[Immediate and long-term effects of endoscopic papillosphincterotomy in patients with cholelithiasis]

The subjects of the study were 164 patients, divided into two groups. Group I included 76 patients at the physicochemical stage of cholelithiasis, and 38 patients after cholecystectomy, who underwent endoscopic papillosphincterotomy (EPST). Group II (control) included 30 patients at the physicochemical stage of cholelithiasis, and 20 patients after cholecystectomy, who did not undergo EPST. Endoscopic retrograde pancreatocholangiography revealed type II Oddi's sphincter dysfunction in all the patients. Evaluation of the chemical composition of bile in Group I, performed 6, 12, 18, and 24 months after EPST, revealed its graduate stabilization. In Group II the dynamics of bile composition was negative--in 8 patients bile became more lithogenic. Long-term observations showed that 6 years after EPST bile was lithogenic only in 4 Group I patients, while at the same moment in 25 Group I patients bile lithogenicity did not disappear, but even worsened. Biliferous tract ultrasonography, performed long after EPST, found biliary sludge in 4 Group I patients. 6-year observation of Group Il patients, including ultrasonography, demonstrated that during the 4th year of observation biliary sludge occurred in as many as 28 patients, in 15 of whom small concrements on the bottom of the gall bladder were found during the 5-6th year of observation, and in 3 of whom a solitary concrement of 4 to 5 mm in diameter was found in the choledoch. The results demonstrate that it is appropriate to perform EPST as early as at the physicochemical stage of cholelithiasis, because this procedure results in stabilization of biliary colloid balance and thus prevents biliary sludge and forming of gall bladder concrements. At the same time, 36% of patients with cholelithiasis at various stages who did not undergo EPST, formed gall bladder concrements. EPST is also appropriate in some patients after cholecystectomy, in order to prevent repeating gall bladder concrement formation.

[Biliary tract in patients with chronic viral hepatitides]

AIM

To characterize motor-kinetic and inflammatory changes in extrahepatic biliary tracts and gallbladder in patients with chronic viral hepatitis (CVH). To ascertain whether there is a pathogenetic correlation between affection of the biliary system and viral infection.

MATERIAL AND METHODS

The condition of the biliary tract was examined in 183 patients with CVH using fractionated duodenal tubing with biochemical tests and bacteriological investigation of bile, dynamic ultrasonic investigation.

RESULTS

69.9% patients were diagnosed to have dysfunction of the Oddi's sphyncter caused by its hypertonicity, 4.4% patients had hypotonic sphyncter. Hyper- and hypotonicity of the gallbladder were observed in 45.8 and 20.8% patients, respectively. Biliary dysfunction was associated with the process activity but not with a nosological form of the disease. Chronic acalculous cholecystitis was verified in 21.2% patients.

CONCLUSION

Chronic HBV and HCV infections are accompanied with biliary dysfunctions associated with activity of inflammation in the liver. Oddi's sphincter dysfunction in CVH is a risk factor of gallbladder inflammation.

Abnormal bile flow in patients with achalasia

BACKGROUND

It has been reported that esophageal achalasia is frequently associated with the dysmotility of other digestive organs. However, the prevalence of extraesophageal complications in patients with achalasia still remains poorly understood. We performed cholescintigraphy, using (99m)Tc-pyridoxyl-5-methyl-tryptophan, in patients with esophageal achalasia to assess any possible dysfunction of the sphincter of Oddi associated with achalasia.

METHODS

Eight patients (two men and six women) were examined to determine the time required for bile to flow from the bile duct to the duodenum.

RESULTS

Excretion time of bile was markedly prolonged in five of the eight patients with achalasia. Scintigraphic findings were not correlated with the radiographic classification of achalasia or with the grading of achalasia.

CONCLUSIONS

The present results suggest that a considerable number of patients with achalasia have dysfunction of the sphincter of Oddi, irrespective of the morphological type of achalasia and the grade of esophageal dilatation.

Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver, sphincter, and gallbladder in patients with sphincter of Oddi spasm

The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111-185 MBq (3-5 mCi) technetium-99m mebrofenin after 6-8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (+/-SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%+/-31%) than in controls (61%+/-36%) and the opioid group (61%+/-25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%+/-4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%+/-18%) and the SOS group (48%+/-29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (+/-193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the sphincter and gallbladder in response to CCK-8, most of the bile emptied from the gallbladder refluxes into intrahepatic ducts, and reenters the gallbladder immediately after cessation of hormone infusion. The characteristic features of gallbladder filling, emptying, and paradoxical refilling with cholecystokinin provide objective parameters for noninvasive diagnosis of SOS by quantitative cholescintigraphy.

Preserved function of the Oddi sphincter after endoscopic papillary balloon dilation

BACKGROUND/AIMS

Endoscopic papillary balloon dilation (EPBD) is a safe and effective procedure for the treatment of bile duct stones that appears to be less hazardous to the sphincter of Oddi than endoscopic sphincterotomy. However, little is known about the function of Oddi muscle after EPBD. The aim of the present study is to evaluate Oddi muscle function using quantitative cholescintigraphy.

METHODOLOGY

This study was conducted using 12 patients treated for bile duct stones by EPBD, and 8 patients treated by endoscopic sphincterotomy, followed by laparoscopic cholecystectomy thereafter. For the controls, 10 asymptomatic cholecystectomized patients were used. From 1-3 years after the interventional procedures, patients received a quantitative cholescintigraphy examination using 185 MBq of technetium-99m-N-pyridoxyl-5-methyl-tryptophan. The hepatic hilum-duodenum transit time on quantitative cholescintigraphy was measured as the time interval between the initial appearance of isotope activity at the hepatic hilum and that at the duodenum.

RESULTS

Mean hilum-duodenum transit time in patients after EPBD (6.3 min, 95%CI 4.5-8.0) was not different from that in control patients (6.5 min, 95%CI 4.3-8.7), whereas mean hilum-duodenum transit time in endoscopic sphincterotomy patients (3.2 min, 95%CI 2.4-4.0) was markedly shorter than both the control and EPBD groups (p = 0.0053).

CONCLUSIONS

The function of the sphincter of Oddi may be preserved after endoscopic papillary balloon dilation.

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.

Gastrointestinal imaging update: swallowing disorders and sphincter of Oddi dysfunction

This update focuses on swallowing disorders and sphincter of Oddi dysfunction. Anatomy and physiology of swallowing are described, as are the signs, symptoms, and etiology of swallowing disorders. The imaging of these patients, particularly with videofluoroscopic swallowing study and fiberoptic endoscopic examination of swallowing, is then discussed. Sphincter of Oddi dysfunction as a cause of postcholecystectomy syndrome as well as its classification is described. This is followed by an explanation of the roles of fatty meal sonography and hepatobiliary scintigraphy in patients with sphincter of Oddi dysfunction, particularly type II and type III.

Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction

INTRODUCTION

Sphincter of Oddi (SO) manometry is at present the "gold standard" investigation for patients with suspected biliary SO dysfunction. Non-invasive scintigraphy in cholecystectomised patients using a complex scoring system or the transit time from the hepatic hilum to the duodenum (HDTT) have been promoted as sensitive and specific alternatives.

AIM

To evaluate the scintigraphic scoring system and HDTT in patients with suspected biliary SO dysfunction undergoing SO manometry.

METHODS

Cholecystectomised patients undergoing SO manometry for persistent biliary-type pain, as defined by the Rome II criteria, for which all other causes had been excluded, were prospectively studied. Scintigraphy with cholecystokinin octapeptide infusion was performed within a month prior to manometry. Scoring of the scans and measurement of HDTT was performed by independent blinded observers. Manometry of the biliary sphincter was performed per-endoscopically and defined as abnormal if basal pressure was > or = 40 mm Hg.

RESULTS

Thirty two patients were enrolled (30 females, mean age 45.1 years). Three patients were excluded from analysis because manometry from the bile duct was not technically possible. Eight patients had abnormal manometry. Scintigraphic scoring had a sensitivity of 25-38%, a specificity of 86-89%, positive predictive value (PPV) of 40-60%, and a negative predictive value (NPV) of 75-79%. The coefficient of variation for interobserver variation in scores was 0.72. HDTT sensitivity was 13%, specificity 95%, PPV 50%, and NPV 74%.

CONCLUSIONS

Our findings indicate that scintigraphy using these methods of analysis correlates poorly with manometry in post cholecystectomy patients with suspected biliary SO dysfunction.

[Sphincter of Oddi dysfunction--prolonged medical therapy or early endoscopic sphincter ablation]

INTRODUCTION

Sphincter of Oddi dysfunction is a real challenge from both diagnostic and therapeutic point of view.

PATIENTS AND METHODS

In the last two years the authors have performed ERCP and EST in 29 patients with positive evocative test results, who had important enzyme elevations and/or did not respond to prolonged medical treatment.

RESULTS

Endoscopic findings were positive in 25/29 patients (86.2%): 8 adenoma of p. Vateri, 17 papillitis were identified, and in 4 cases the papilla was intact. Histopathology obtained in 12 patients supported the diagnosis. In 6 patients, who underwent a postpapillotomy evocative test, after an average of 10 months follow up the results have been converted from positive to negative response in all but two cases. The two patients continued to have abdominal symptoms with persistent positive provocation tests because of restenosis, were treated with repapillotomy.

CONCLUSIONS

The Debray and Nardi tests are useful screening tests for hypertonic biliary or pancreatic dyskinesia. Structural endoscopic and histological findings are frequent already in the functional cases. Early sphincter ablation should be considered in failure of medical therapy for preventing the transformation of this functional disorder into an organic, potentially precancerous state.

Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy

BACKGROUND

Sphincter of Oddi dysfunction is diagnosed at manometry and, after cholecystectomy, non-invasively at quantitative choledochoscintigraphy. Patients may benefit from endoscopic sphincterotomy.

AIMS

The aim of this study was to assess the usefulness of choledochoscintigraphy compared with manometry in predicting outcome of sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction.

PATIENTS AND METHODS

Thirty patients with biliary-type pain complying with the Rome diagnostic criteria of sphincter of Oddi dysfunction and belonging to biliary group I and II were subjected to clinical evaluation, choledochoscintigraphic assessment of the hepatic hilum-duodenum transit time, endoscopic retrograde cholangiopancreatography, and perendoscopic manometry. Twenty two biliary group I and II patients with prolonged hepatic hilum-duodenum transit times were invited to undergo sphincterotomy. Fourteen patients underwent sphincterotomy; eight refused. Clinical and scintigraphic assessments were performed at follow up.

RESULTS

Hepatic hilum-duodenum transit time was delayed in all patients with manometric evidence of sphincter of Oddi dysfunction, in all biliary group I patients and in 64% of biliary group II patients. At follow up, all patients who underwent sphincterotomy were symptom free and hepatic hilum-duodenum transit time had either normalised or significantly improved. A favourable post sphincterotomy outcome was predicted in 93% of cases at choledochoscintigraphy and in 57% at manometry.

CONCLUSIONS

Quantitative choledochoscintigraphy is a useful and non-invasive test to diagnose sphincter of Oddi dysfunction as well as a reliable predictor of sphincterotomy outcome in post cholecystectomy biliary group I and II patients, irrespective of clinical classification and manometric findings.

[Secretin stimulated magnetic resonance cholangiopancreatography in diseases of the biliary and pancreatic ducts]

BACKGROUND

MRCP has replaced ERCP as the diagnostic tool in diseases in the biliary and pancreatic ducts. Secretin increases the secretion to ducts, and this has been reported to improve MRCP image quality.

MATERIAL AND METHODS

We report our experience with S-MRCP in our first 20 patients. Secretin was given intravenously and images were obtained every minute for 10 minutes. These images were compared with MRCP images taken before and after secretin stimulation.

RESULTS

New information was yielded in 18 cases, i.e. information not observed in previous radiological examinations.

INTERPRETATION

In diagnostics of dysfunction of the sphincter of Oddi, the method may be useful, given the functional aspect of the procedure where increased pressure in the ducts may lead to pain. It may further improve the diagnostics of pancreatic cancer versus pancreatitis, in pancreas divisum and sclerosing cholangitis. The method is also valuable for clarifying whether there is injury to the pancreatic duct after blunt abdominal trauma. Surgical common bile duct injuries may be better assessed than with any other method. In difficult pancreatic and biliary investigations, S-MRCP seems to be a useful and complication-free supplement to existing diagnostic methods.

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.

Cholecystokinin-Stimulated mebrofenin (99mTc-Choletec) hepatobiliary scintigraphy in asymptomatic postcholecystectomy individuals: assessment of specificity, interobserver reliability, and reproducibility

OBJECTIVES

Cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS) is a noninvasive method reported to be highly accurate in the diagnosis of sphincter of Oddi dysfunction. Our primary aim was to assess the specificity of CCK-HBS by evaluating its ability to exclude disease in 20 asymptomatic postcholecystectomy individuals. Secondary aims were to assess the interobserver reliability in scoring the CCK-HBS examinations between three blinded observers and to assess reproducibility of CCK-HBS repeated in the same individuals.

METHODS

Twenty asymptomatic postcholecystectomy individuals with normal liver serum chemistries underwent CCK-HBS on two separate occasions. Three nuclear medicine specialists read each CCK-HBS study in a blinded fashion.

RESULTS

There was good agreement between the three observers reading the same scans for both the first scan (kappa = 0.554) and the second scan (kappa = 0.507). There was poor agreement between the first and second scans on the same patient, read by the same nuclear medicine specialist (kappa = 0.062-0.385). The overall specificity of the CCK-HBS score was 77.5%; however, the specificity was only 60% when a true negative was defined as two negative CCK-HBS examinations.

CONCLUSIONS

Quantitative CCK-HBS is of poor specificity in asymptomatic postcholecystectomy individuals. Hence, it is of questionable value in excluding sphincter of Oddi dysfunction in patients suspected to suffer from this disorder.

Correlation between sphincter of Oddi manometry and intraductal ultrasound morphology in patients with suspected sphincter of Oddi dysfunction

BACKGROUND AND STUDY AIMS

Intraductal ultrasonography (IDUS) makes it possible to study sphincter of Oddi morphology during endoscopy. Two recent IDUS studies have described the sphincter of Oddi as a circumferential hypoechoic layer in the papilla, but there have as yet been few published data from patients with suspected sphincter of Oddi pathology.

PATIENTS AND METHODS

Twenty-one consecutive patients with suspected biliary sphincter of Oddi dysfunction (seven men, 14 women; age 54 +/- 17 years) were enrolled in the study. Endoscopic sphincter of Oddi manometry was carried out using a 4-Fr electronic microtransducer device. After this, a wire-guided 6-Fr ultrasound catheter was placed in the common bile duct (CBD), and IDUS was carried out while the ultrasound catheter was being withdrawn from the CBD toward the duodenum.

RESULTS

Sphincter of Oddi manometry and IDUS were carried out successfully in 18 of the 21 patients. Sphincter of Oddi manometry revealed sphincter of Oddi hypertension (baseline pressure > 35 mmHg) in eight patients. The mean sphincter of Oddi baseline pressure was 32 +/- 17 mmHg, and the mean phasic sphincter of Oddi pressure was 132 +/- 31 mmHg. During IDUS, a circumferential hypoechoic layer was clearly delineated in all patients. There was a significant correlation between the manometrically determined length of the sphincter of Oddi (8 +/- 2 mm) and the thickness of the hypoechoic layer (6 +/- 2 mm) as assessed by IDUS (r = 0.66, P < 0.001). However, no correlation was found between the baseline or phasic sphincter of Oddi pressures and the thickness of the hypoechoic layer. Accordingly, IDUS did not allow identification of patients with sphincter of Oddi hypertension. Mild pancreatitis was observed in one of the 18 patients (6 %).

CONCLUSIONS

The circumferential hypoechoic layer of the papilla visualized by IDUS is the ultrasonographic correlate of the sphincter of Oddi. IDUS of the papilla is technically feasible and safe in patients with suspected sphincter of Oddi dysfunction. IDUS may provide additional information at the sphincter of Oddi level, but cannot be used as a substitute for sphincter of Oddi manometry.

Efficacy of biliary scintigraphy in suspected sphincter of Oddi dysfunction

Sphincter of Oddi dysfunction (SOD) can pose diagnostic challenges for the physician. SOD is classified into types I, II, and III, but clinical outcome after sphincterotomy for suspected types II and III SOD has been unpredictable. Therefore, accurate diagnosis of types II and III SOD is important because of the increased risk of sphincterotomy in patients with SOD. Endoscopic sphincter of Oddi manometry (ESOM) is the gold standard for diagnosis of SOD; however, it is associated with significant morbidity and is not an appropriate screening test. Quantitative hepatobiliary scintigraphy (QHBS) has demonstrated good sensitivity as a screening test for SOD in patients following cholecystectomy; however, studies using this methodology are criticized for poor design and patient selection. Recent publications address these criticisms and provide evidence that QHBS and ESOM are comparable diagnostic tools after exclusion of organic biliary obstruction. QHBS can effectively replace invasive ESOM in the diagnostic algorithm of SOD.

Pneumoperitoneum caused by transhepatic air leak after metallic biliary stent placement

A self-expanding metallic biliary stent was placed for palliation of a common bile duct obstruction in a 68-year-old male with unresectable pancreatic head cancer 3 days after initial percutaneous right transhepatic catheter decompression. The stent crossed the ampulla of Vater. Three days later, the stent was balloon-dilated and the percutaneous access was removed. At removal, a small contrast leak from the transhepatic tract was seen. Three days later, pneumoperitoneum was found with symptoms of peritoneal irritation and fever. A widely open sphincter of Oddi caused by the metallic stent, accompanied by delayed sealing of the transhepatic tract, may have caused the air and bile leakage into the peritoneal space. This case shows that pneumoperitoneum may occur without ductal tear or bowel injury, with a biliary stent crossing the ampulla of Vater.

Sphincter of Oddi dysfunction: two case reports and a review of the literature

Sphincter of Oddi dysfunction is an underdiagnosed but important clinical condition. It should be considered in the differential diagnosis of biliary pain when the gallbladder sonogram shows no evidence of gallbladder disease. Hepatobiliary scanning (Tc-99m dimethyl iminodiacetic acid) may provide valuable information in the evaluation of these patients and may be helpful in monitoring response to treatment.

Quantitative hepatobiliary scintigraphy and endoscopic sphincter of Oddi manometry in patients with suspected sphincter of Oddi dysfunction: assessment of flow-pressure relationship in the biliary tract

OBJECTIVE

In the present study, the diagnostic efficacy of quantitative hepatobiliary scintigraphy (QHBS) was compared with that of endoscopic sphincter of Oddi (SO) manometry (ESOM) in patients with a suspected SO dysfunction (SOD) of biliary type II or III.

METHODS

Twenty cholecystectomized patients with SOD biliary types II and III were investigated by QHBS and by ESOM. Twenty asymptomatic cholecystectomized patients served as controls for scintigraphy. ESOM was performed by applying the station pull-through method. Then SO basal pressure and phasic contraction characteristics were determined. During QHBS, time-activity curves were generated, and the time-to-peak (Tmax), the half-time of excretion (T(1/2)), the duodenal appearance time (DAT) and the hilum-to-duodenum transit time (HDTT) were then calculated. At the 60th minute of QHBS, 5 ng/kg body weight/min caerulein was administered.

RESULTS

In patients with SOD and elevated SO basal pressure (> 40 mmHg), QHBS parameters, such as Tmax and T(1/2) calculated from regions of interest over the hepatic hilum and common bile duct, HDTT and DAT proved to be significantly increased compared to controls: 28.7 +/- 4.3 versus 21.1 +/- 4.6 min, 39.7 +/- 15.4 versus 18.8 +/- 2.6 min, 9.0 +/- 3.6 versus 2.3 +/- 1.3 min and 27.1 +/- 4.9 versus 16.6 +/- 3.0 min, respectively. In contrast, in patients with SOD and normal SO basal pressure, QHBS parameters did not differ significantly from the controls. For the pooled data on the symptomatic patients with SOD, a statistically significant linear correlation was found between the SO basal pressure and the QHBS parameters. Although HDTT was the most sensitive scintigraphic parameter (89%), the combined sensitivity and specificity of Tmax and T(1/2) of the common bile duct reached 100%. No scintigraphic sign of a paradoxical response to cholecystokinin was detected.

CONCLUSIONS

QHBS is a useful non-invasive diagnostic method for the selection of SOD patients with an elevated SO basal pressure. A significant correlation has been established between the trans-papillary bile flow measured by QHBS and the SO basal pressure determined by ESOM.

Use of (99m)Tc-DISIDA biliary scanning with morphine provocation for the detection of elevated sphincter of Oddi basal pressure

BACKGROUND

Endoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive.

AIM

To investigate the role of (99m)Tc-DISIDA scanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with endoscopic biliary manometry.

SUBJECTS AND METHODS

A total of 34 patients with a clinical diagnosis of type II (n = 21) or III (n = 13) sphincter of Oddi dysfunction were studied. Biliary scintigraphy with 100 MBq of (99m)Tc-DISIDA was carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent endoscopic biliary manometry.

RESULTS

Eighteen (nine type II, nine type III) of the 34 (53%) patients had sphincter of Oddi basal pressures above the upper limit of normal (40 mm Hg). In the standard DISIDA scan without morphine, no significant differences were observed in time to maximal activity (Tmax) or percentage excretion at 45 or 60 minutes between those with normal and those with abnormal biliary manometry. However, following morphine provocation, median percentage excretion at 60 minutes was 4.9% in those with abnormal manometry and 28.2% in the normal manometry group (p = 0.002). Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated sphincter of Oddi basal pressure by the morphine augmented DISIDA scan was 83% and specificity was 81%. Also, 14 of the 18 patients with abnormal manometry complained of biliary-type pain after morphine infusion compared with only two of 16 patients in the normal manometry group (p = 0.001).

CONCLUSIONS

(99m)Tc-DISIDA with morphine provocation is a useful non-invasive investigation for types II and III sphincter of Oddi dysfunction to detect those with elevated sphincter basal pressures who may respond to endoscopic sphincterotomy.

Biliary complications of orthotopic liver transplantation

Biliary complications are a common cause of morbidity following orthotopic liver transplantation. Complications involving the biliary tree occur after 6-34% of all liver transplants performed, usually within the first 3 months after transplantation. Bile leaks and biliary strictures are the most common biliary complications, but sphincter of Oddi dysfunction, hemobilia, and biliary obstruction from stones, sludge, or casts have also been described. The risk of specific biliary complications is related to the type of biliary reconstruction performed at the time of transplantation. In this article, we review the major types of biliary reconstruction and their associated biliary complications. Specific risk factors for the development of biliary complications are outlined. Finally, the management of biliary complications is discussed, with an emphasis on the role of endoscopic therapy.

Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction

BACKGROUND

Sphincter of Oddi manometry as performed at ERCP is the most accepted method to evaluate for sphincter of Oddi dysfunction. To fully assess for sphincter of Oddi dysfunction, both the pancreatic and the bile ducts must be evaluated. We assessed the frequency of pancreatic and biliary sphincter abnormalities in a large series of patients.

METHODS

A total of 593 patients underwent manometry of the biliary and pancreatic ducts at one endoscopic retrograde cholangiopancreatography session. Basal sphincter pressure greater than or equal to 40 mm Hg was considered abnormal. Phasic waves were not evaluated. Manometric abnormalities were correlated with the clinical presentation as categorized using a modified Geenen/Hogan classification.

RESULTS

Of 360 patients with intact sphincters, 18.9% had abnormal pancreatic sphincter basal pressure alone, 11.4% had abnormal biliary basal sphincter pressure alone, and in 31.4% the basal pressure was abnormal for both sphincters; thus, 60.1% of the patients had sphincter dysfunction. The frequency of sphincter of Oddi dysfunction did not differ whether typed by biliary or pancreatic criteria: approximately 65% type II and 59% type III. Of patients without pancreatitis, 55.9% had an abnormal basal sphincter pressure, whereas sphincter dysfunction was present in 72.3% of those with idiopathic pancreatitis and 53.9% of patients with chronic pancreatitis. Of patients with an ablated biliary sphincter, 45.9% had abnormal basal pancreatic sphincter pressure and only 0.6% had an abnormal biliary sphincter pressure alone. Abnormal pressure in both sphincters was found in 9.3%.

CONCLUSION

If both portions of the sphincter of Oddi are studied simultaneously, abnormalities are found very commonly (55% to 72%). Assessment of both sides of the sphincter is necessary. Classifying patients according to both pancreatic and biliary sphincter segments is cumbersome, and may be replaced by an overall type. Using this modified classification, the frequency of sphincter of Oddi dysfunction is similar in both type II and type III patients (59% to 67%).

Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy

BACKGROUND

The transpancreatic duct pre-cut to gain access to the bile duct for diagnostic and therapeutic maneuvers has been described as useful, but questions of efficacy and safety remain to be resolved.

METHODS

To further evaluate this technique, we performed a review on 200 consecutive endoscopic sphincterotomies. Standard direct biliary sphincterotomy was performed in 143 patients and transpancreatic duct pre-cut in 51 patients.

RESULTS

The overall complication rate for the standard sphincterotomy was 2.1%; that for the transpancreatic approach was 1.96%. There were no cases of post-ERCP pancreatitis after transpancreatic duct pre-cut sphincterotomy. The length of hospital stay was 1 day or less for 192 patients, 2 days for 5 patients, 4 days for 1 patient and 7 days for 2 patients. In 2 patients there was failure to enter the bile duct despite the pre-cut. In one, the procedure was successful at a second attempt 48 hours later.

CONCLUSIONS

Transpancreatic duct pre-cut is a safe and effective method for gaining quick access to the bile duct in patients in whom cannulation is difficult.

The effects of somatostatin and octreotide on the human sphincter of Oddi

OBJECTIVE

Somatostatin acts at different sites in the human gastrointestinal tract and generally inhibits the release and effects of many gastrointestinal hormones and neuropeptides. Together with its long-acting analogue octreotide, somatostatin is widely used in the treatment of hormone-producing tumours, variceal bleeding, etc., but multi-centre trials have failed to prove a beneficial effect in the treatment of acute pancreatitis or in the prevention of post-ERCP pancreatitis (pancreatitis following endoscopic retrograde cholangiopancreatography). The aim of the present work was to study the effects of somatostatin and octreotide on the human sphincter of Oddi by means of quantitative hepatobiliary scintigraphy (QHBS).

METHOD

Fifteen cholecystectomized patients were enrolled in the study, six in the somatostatin group and nine in the octreotide group. QHBS was performed initially with a standard protocol (baseline data), then repeated after 0.1 mg octreotide or a 250 microg bolus + 250 microg/h somatostatin administration. In the 60th min of QHBS, 0.5 mg glyceryl trinitrate (GTN) was administered sublingually.

RESULTS

QHBS demonstrated that both somatostatin and octreotide caused a marked impairment in the bile flow: the half-time of excretion (T1/2) over the common bile duct was significantly prolonged compared with baseline data (somatostatin group: common bile duct T1/2 180 min versus 59.7+/-31 min; octreotide group: common bile duct T1/2 140.9+/-60.5 min versus 30.7+/-11.7 min). Glyceryl trinitrate administration accelerated the transpapillary bile flow, with significant decreases in the elevated T1/2 in both groups.

CONCLUSION

Increased transpapillary flow induced by glyceryl trinitrate may be beneficial in the treatment of acute or post-ERCP pancreatitis.

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept

BACKGROUND

The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition.

METHODS

We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians.

RESULTS

An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis.

CONCLUSIONS

Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.

Biliary sphincter balloon dilation; who, when and how?

Biliary sphincter balloon dilation for biliary stone removal was introduced in 1983. In the early 1990s, several groups studied this technique further. The success rate of stone removal is comparable with that of endoscopic sphincterotomy in patients with fewer than three stones that are less then 1 cm in diameter. Fewer complications after balloon dilation than after endoscopic sphincterotomy have been noted in most studies. One study, however, showed a higher incidence of pancreatitis and, in particular, severe pancreatitis. Therefore, there is still some reluctance among endoscopists to promote balloon dilation as a routine first choice treatment. The technique, however, is accepted as the treatment of choice in patients with a bleeding tendency and those in whom the local anatomy is associated with an increased risk of complications with endoscopic sphincterotomy, such as patients with periampullary diverticula or Billroth II gastrectomy.

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.

[The tonus of Oddi's sphincter and gallbladder contractility in patients with chronic cholecystitis]

As many as 163 young male patients with chronic noncalculous cholecystitis were studied for motility of the biliary tract. Normal findings were in 15.9% of cases. Hypocontractility of the gallbladder, hypermyotonia of the Oddi sphincter (with 33.7% and 44.2% respectively), and concurrent presence thereof were the most commonly seen types of dyskinesia. The results obtained suggest that the above abnormalities in motility of the biliary tract may have a part in the origination and/or progression of chronic cholecystitis.

Effect of glyceryl trinitrate on the sphincter of Oddi spasm evoked by prostigmine-morphine administration

OBJECTIVE

In this study the effect of glyceryl trinitrate on the prostigmine-morphine-induced sphincter of Oddi spasm was evaluated in nine female patients with sphincter of Oddi dyskinesia.

METHOD

Sphincter of Oddi spasm was induced by prostigmine-morphine administration (0.5 mg prostigmine intramuscularly and 10 mg morphine subcutaneously) and visualized by quantitative hepatobiliary scintigraphy. The entire procedure was repeated during glyceryl trinitrate infusion (Nitrolingual 1 microg/kg/min for 120 min).

RESULTS

Prostigmine-morphine provocation caused significant increases in the time to peak activity (Tmax) over the hepatic hilum (HH: 34.33 +/- 5.05 vs. 22.77 +/- 3.26) and the common bile duct (CBD: 60.44 +/- 5.99 vs. 40.0 +/- 2.88) and in the half-time of excretion (T1/2) over the liver parenchyma (LP: 120.04 +/- 16.01 vs. 27.37 +/- 2.19), HH (117.61 +/- 14.71 vs. 31.85 +/- 3.99) and CBD (158.11 +/- 9.18 vs. 40.1 +/- 6.24), indicating a complete spasm at the level of the sphincter of Oddi. Glyceryl trinitrate infusion completely normalized the prostigmine-morphine-induced alterations in these quantitative parameters (TmaX over the LP: 11.33 +/- 1.13; over the HH: 18.88 +/- 1.48; and over the CBD: 36.22 +/- 1.92; and T1/2 over the LP: 28.21 +/- 1.83; over the HH: 33.42 +/- 3.10; and over the CBD: 41.66 +/- 6.33), suggesting an effective sphincter-relaxing effect of glyceryl trinitrate.

CONCLUSION

These results provide the first evidence of the effectiveness of glyceryl trinitrate on the morphine-induced sphincter of Oddi spasm in humans. Since glyceryl trinitrate is able to overcome even the drastic effect of morphine, it might be of relevance in the treatment of sphincter of Oddi dyskinesia.

Sphincter of Oddi dysfunction is associated with chronic pancreatitis

OBJECTIVES

Chronic pancreatitis can be caused by ductal obstruction resulting from cicatricial papillary stenosis, but sphincter of Oddi motility studies have been inconclusive in patients with established chronic pancreatitis. We sought to determine whether there is an association between papillary sphincter dysfunction and changes of early chronic pancreatitis.

METHODS

Consecutive patients who underwent sphincter of Oddi manometry to investigate unexplained upper abdominal pain (n = 104) were assessed for evidence of chronic pancreatitis by pancreatic ductography, endoscopic ultrasound, and pancreatic fluid bicarbonate concentration.

RESULTS

Sphincter of Oddi dysfunction patients were four times more likely (odds ratio = 4.6) to have evidence of chronic pancreatitis than were those without sphincter dysfunction (p = 0.01). Of 68 patients with sphincter of Oddi dysfunction, 20 (29%) had structural evidence of chronic pancreatitis. Twenty of 23 (87%) patients with chronic pancreatitis had sphincter of Oddi dysfunction.

CONCLUSIONS

Sphincter of Oddi dysfunction is associated with changes of chronic pancreatitis in patients with unexplained pancreaticobiliary pain. Longitudinal follow-up is required to confirm these preliminary findings.

[Do ultrasound parameters allow diagnosis of biliary sphincter of Oddi dysfunction?]

A noninvasive test to prove sphincter of Oddi dysfunction is desired, because endoscopic manometry is technically demanding and not without risks.

METHODS

40 consecutive patients (n = 20 patients with, and n = 20 patients without enzymatic cholestasis) with suspected SOD were investigated both by ultrasonography (US; 3.5 MHz) and by endoscopic manometry. SOD was suspected at US if the extrahepatic bile duct diameter was > or = 9 mm and a further increase (at least > 0.5 mm) was observed after intravenous ceruletide (0.3 micrograms/kg b.w.). SOD was verified manometrically by a sphincter of Oddi basal pressure > or = 40 mmHg. Endoscopic sphincterotomy was performed if SOD was diagnosed by manometry. Thereafter, all patients were enrolled in a prospective follow-up (median: one year).

RESULTS

At US SOD was suspected in eleven of 20 patients with cholestasis. SOD was confirmed manometrically in all of them but also in two further patients (13 of 20 patients with proven SOD). After EST twelve of 13 patients remained free from biliary symptoms. In the 20 patients without cholestasis SOD was suspected at US in five patients only. However, endoscopic manometry revealed SOD in eleven of 20 patients and proved sonographically presumed SOD in only three of five patients. After EST only three of eleven patients remained asymptomatic during follow-up (p < 0.05 vs. patients with cholestasis). Clinically important side effects were not observed after ceruletide administration, whereas postmanometry pancreatitis was observed in three of 40 patients.

CONCLUSION

In patients with recurrent symptoms after cholecystectomy and enzymatic cholestasis SOD was reliably diagnosed by ultrasonography (sensitivity: 85%, specificity: 100%), and this finding may guide endoscopic sphincterotomy.