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PubMed2006

Down regulated expression of the beta1 subunit of the big-conductance Ca2+ sensitive K+ channel in sphincter of Oddi cells from rabbits fed with a high cholesterol diet.

Hypercholesterolemia, which is closely related to gallbladder bile stasis, can cause sphincter of Oddi dysfunction (SOD) by increasing the tension of sphincter of Oddi (SO). Intracellular calcium ion concentration ([Ca(2+)](i)) could influence the tension of SO. The beta1 subunit of the big-conductance Ca(2+) sensitive K(+) channel (BK(Ca)) can enhance the sensitivity of the BK(Ca) channel to [Ca(2+)](i). Absence and decline of the BKCa channel subunit beta1 could lead to many diseases. However, the relationship between hypercholesterolemia and the expression of beta1 subunit is not well understood. In this study, we successfully expressed and purified the rabbit BK(Ca) beta1 subunit protein and prepared its polyclonal antibody. The specificity of the prepared antibody was determined by Western blotting. A SOD rabbit model induced by a high cholesterol diet was established and the expression of the beta1 subunit of SO was determined by immunohistochemical staining and western blotting. Compared with the controls, our results demonstrated that hypercholesterolemia could decrease the expression of the beta1 subunit in the SO cells from rabbits. This indicates that lower expression of BKCa channel beta1 subunit might induce SOD.

Animals↗

PubMed2000

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.

Adult↗

PubMed1991

[Quantitative hepato-biliary scintigraphy in the diagnosis of duodenogastric reflux and dysfunction of the Oddi's sphincter in post-cholecystectomy syndrome].

Qualitative indicators of dynamic hepato-biliary scintigraphy+ were studied before and after administration of cerucal in postcholecystectomy syndrome, determined by duodenogastric reflux (24 patients), dysfunction (21 patients) and stenosis of Oddi sphincter (17 patients) and in a control group (28 volunteers) without any complaints after cholecystectomy. A conclusion was made that dynamic hepato-biliary scintigraphy+ allowed quantitative estimation of duodenal reflux to be made and the dynamics of excretion of radiopharmagent before and after administration of cerucal may be an indicator of the functional state of the Oddi sphincter.

Adult↗

PubMed2006

Recent developments in gastrointestinal motility.

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

Constipation↗

PubMed1998

Dynamic imaging of the pancreas using real-time endoscopic ultrasonography with secretin stimulation.

BACKGROUND: Obstructive disorders of the pancreas, including strictures, stones, sphincter of Oddi dysfunction, and pancreas divisum, are diagnostic and therapeutic challenges. Conventional extracorporeal ultrasound with secretin stimulation has been used as a noninvasive study to detect obstruction and predict outcome of therapy. Inconsistent results have been obtained because of the inherent limitations of standard ultrasonography. The aim of this study was to evaluate the behavior of the main pancreatic duct by endoscopic ultrasonography during secretin stimulation and to diagnose obstructive disorders of the pancreas. METHODS: Secretin-stimulated endoscopic ultrasound (SSEUS, 1 IU/kg secretin) was performed in 20 control subjects (no pancreatic or biliary disease), 40 patients with symptomatic chronic pancreatitis, 40 patients with symptomatic pancreas divisum, 20 patients with suspected sphincter of Oddi dysfunction, and 20 patients with suspected occlusion of pancreatic duct stents. Ductal diameter was measured by endoscopic ultrasonography at baseline and at 1-minute intervals, after administration of secretin, for 15 minutes. A result was determined to be abnormal when a 1 mm or greater dilation of the pancreatic duct was observed from baseline after secretin administration. RESULTS: Of the 40 patients with symptomatic chronic pancreatitis, SSEUS correctly predicted obstructive pathology (stones, strictures) in 12 of 13 patients (92%). Of the 40 patients with symptomatic pancreas divisum, 22 underwent stent therapy (16 of 22 with resolution of symptoms). SSEUS accurately predicted response to stent therapy in 13 patients (81%). Seven of twenty patients with suspected sphincter of Oddi dysfunction had abnormal sphincter manometry. SSEUS accurately predicted sphincter dysfunction in only 4 of 7 patients (57%). Finally, 20 patients with suspected occlusion of pancreatic duct stents were studied. Of the 14 stent occlusions confirmed at ERCP, SSEUS correctly predicted premature occlusion in 12 patients (86%). CONCLUSIONS: SSEUS appears to be a useful diagnostic modality in the evaluation of patients with suspected obstructive disorders of the pancreas and it can predict which patients may respond to endoscopic therapy.

Case-Control Studies↗

PubMed2005

Surgical sphincteroplasty in 446 patients.

HYPOTHESIS: Pancreaticobiliary sphincter disease is reliably diagnosed by endoscopic and intraoperative manometry. DESIGN: Retrospective review of prospectively collected data. SETTING: A 400-bed urban university hospital. PATIENTS: Between May 1, 1978, and March 27, 2002, 446 patients were treated surgically for dysfunction of the pancreaticobiliary sphincters. There were 376 females and 70 males (mean +/- SD age, 41.6 +/- 12.5 years). There were 372 patients with sphincter of Oddi dysfunction, and 74 with pancreas divisum. Symptoms included abdominal pain (100.0%), nausea/vomiting (80.5%), back pain (57.2%), and pancreatitis (22.4%). INTERVENTIONS: Perfusion manometry has evolved as the gold standard for diagnosis, and intraoperative manometry was done in 214 patients. All patients underwent transduodenal sphincteroplasty and biopsies of the ampullae and transampullar septa. RESULTS: Excellent or good results were seen in 86.8% of the patients with sphincter of Oddi dysfunction and in 63.5% of the patients with pancreas divisum. Common duct and sphincter of Oddi pressures were 0 mm Hg in all patients after sphincteroplasty. Pancreatic duct and pancreatic sphincter manometry results were improved in 82.4% of the patients. Biopsy results of the main and accessory sphincters demonstrated inflammation and/or fibrosis in 33.9% of ampullae and 43.5% of transampullar septa, but this did not correlate with outcome. There was 1 death from a duodenal leak. Complications occurred in 34.8% of patients, with pancreatitis (8.8%), asymptomatic hyperamylasemia (6.0%), and wound/abdominal infection (7.1%) the most common. Predictive factors for good outcome were reduction in pancreatic duct and sphincter pressures following sphincteroplasty. CONCLUSION: Good to excellent results may be achieved by surgical sphincteroplasty when careful patient selection by manometry is used.

Adult↗

PubMed1997

Pancreatic sphincter hypertension increases the risk of post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: The reason for the increased risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in patients with sphincter of Oddi dysfunction is not known. This study sought to determine whether pancreatic sphincter hypertension might explain some of the increased risk. PATIENTS AND METHODS: The incidence of pancreatitis was determined from a cohort of patients who underwent pancreatic sphincter manometry. Additional data collected included: pancreatic and biliary sphincter manometry results, distal bile duct diameter, chronic pancreatitis grade by pancreatography, and endoscopic treatments. RESULTS: Ten of 32 patients (31%) with pancreatic sphincter hypertension developed post-ERCP pancreatitis, compared to one of 33 (3%) with normal pancreatic manometry (P = 0.002). Patients with pancreatic sphincter hypertension were more likely to undergo endoscopic treatments (88%) compared to those with normal manometry (27%) (P = 0.001). The distal bile duct diameter was significantly smaller (4.5 +/- 0.5 mm) in patients who developed post-ERCP pancreatitis than in those who did not (6.2 +/- 0.3) (P = 0.025). Patients with small distal bile duct diameters (< 5 mm) were three times more likely to develop post-ERCP pancreatitis than those with larger ducts (relative risk [RR] 3.1, 95% confidence interval [CI] 0.9, 10.7). Patients with pancreatic sphincter hypertension were ten times more likely to develop post-ERCP pancreatitis than those with normal pancreatic manometry (RR 10.3, 95% CI 1.5, 76.0). In patients with a small bile duct size, pancreatic sphincter hypertension substantially increased the risk compared to those with normal manometry (RR 18.1, 95% CI 1.1, 287.6). CONCLUSIONS: Pancreatic sphincter hypertension greatly increases the risk of post-ERCP pancreatitis in patients undergoing treatment or evaluation, or both, for sphincter of Oddi dysfunction.

Acute Disease↗

PubMed1989

A case of the pathogenesis of choledochocele in relation to dysfunction of the sphincter of Oddi.

A 47-year-old woman was admitted for evaluation of pain in the right upper quadrant of the abdomen. Seventeen years previously, she had undergone cholecystectomy for cholelithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a cystic dilatation of the terminal portion of the common bile duct (CBD) protruding into the duodenal lumen and delaying the drainage of contrast medium. In this patient the CBD and the pancreatic duct appeared to be unimportant in the formation of the cyst. Repeated changes in the radius of the cyst suggested dysfunction of the ampullary component of the sphincter of Oddi, with maintenance of normal function of the common duct component. The pathogenesis of the choledochocele in this patient is discussed in relation to dysfunction of the sphincter of Oddi. In addition, 2 criteria for the diagnosis of choledochocele by ERCP are proposed: [1] cystic dilatation of the terminal portion of the CBD protruding into the duodenal lumen, and [2] absence of the narrow segment of the CBD.

Ampulla of Vater↗

PubMed1999

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

OBJECTIVE: Sphincter of Oddi manometry (SOM) is a useful diagnostic procedure when evaluating patients with unexplained biliary pain or idiopathic recurrent pancreatitis. Acute pancreatitis is a recognized complication of SOM whose pathogenesis appears to be multifactoral. We conducted this study to determine the incidence of pancreatitis in patients after SOM and to identify any variables that may lead to an increased incidence of pancreatitis. METHODS: A retrospective review of 100 consecutive patients who underwent SOM between 1992 and 1996 at two university-affiliated hospitals was done. SOM was performed using a triple lumen catheter with each lumen perfused at a rate of 0.25 cc/min using an Arndorfer pneumohydraulic capillary perfusion system. The following data were recorded: age, gender, clinical type of sphincter of Oddi dysfunction, length of procedure, doses of medications used, duct cannulated, sphincter of Oddi pressure, whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy was performed, and the number of patients developing pancreatitis. Statistical analysis was performed using a T test, chi2, and multiple regression analysis. RESULTS: The overall incidence of pancreatitis was 17%. Six patients with type II SO dysfunction and 11 patients with type III SO dysfunction developed pancreatitis. The incidence of pancreatitis was significantly lower in those patients who only had SOM, compared with those patients who had SOM and ERCP (9.3% vs 26.1%, p < 0.026). There was no significant correlation between age, gender, duration of procedure, dose of midazolam used, sphincter of Oddi pressure, or type of SO dysfunction with the development of SOM-induced pancreatitis. Multiple regression analysis showed that sphincterotomy added no additional risk, beyond that associated with ERCP, for the development of pancreatitis. CONCLUSIONS: The results of this study indicate that the incidence of pancreatitis was highest when SOM was followed by ERCP. A potential method of decreasing the incidence of pancreatitis after SOM is performing ERCP with or without sphincterotomy at another session, separated from the SOM by at least 24 h. Before this can be definitely recommended, the results of this study must be validated by others or by a prospective study.

Acute Disease↗

PubMed1991

[Dysfunction of the sphincter of Oddi as a cause of so-called postcholecystectomy syndrome].

In up to 30% of cases of the so-called postcholecystectomy syndrome functional disturbances of the sphincter of Oddi are responsible for the clinical picture. These pathological changes in pressure and motility at the sphincter can be identified by means of endoscopic manometry. We found dysfunction of the sphincter of Oddi in 4 out of 10 patients with so-called postcholecystectomy syndrome. In 2 patients in whom the basal pressure was higher than 40 mmHg endoscopic papillotomy was performed, after which the patients remained symptom-free. In one case tachyoddi was diagnosed and in another case the proportion of retrograde sphincter contractions exceeded 50%. Endoscopic manometry at the sphincter of Oddi enables many of the as yet unclarified postcholecystectomy symptoms to be identified.

Biliary Dyskinesia↗

PubMed1997

Causes and management of recurrent biliary pain after successful nonoperative gallstone treatment.

OBJECTIVE: To evaluate the frequency and causes of recurrent biliary colic after successful extracorporeal shock wave lithotripsy of gallstones. METHODS: Follow-up of 77 patients for 2 yr (median) after complete gallstone clearance by lithotripsy and adjuvant oral litholysis. All patients with recurrent biliary colic were examined thoroughly (laboratory data, ultrasonography, gastroscopy); the examination included gallbladder motility testing. If the patients suffered from additional gastrointestinal complaints, further symptom-guided investigations (pH-metry, lactose absorption study, enteroclysis, colonic transit time, colonoscopy) were performed. Patients without documented gallstone recurrence underwent ERCP and sphincter of Oddi manometry. Cholecystectomy was advised for patients in whom gallstones recurred, and patients with sphincter of Oddi dysfunction underwent endoscopic sphincterotomy. If other gastrointestinal disorders were diagnosed, appropriate treatment was initiated. RESULTS: Twenty-seven patients (35%) experienced biliary colic during follow-up. Gallstone recurrence was documented in 17 patients, and 16 of the patients who underwent cholecystectomy became symptom-free again (follow-up: 12 months). Gallbladder hypomotility was revealed in seven of the 17 patients with gallstone recurrence compared to none of the 10 patients without gallstone recurrence (p < 0.05). Microlithiasis was not detected in bile samples from the patients whose gallstones did not recur. Sphincter of Oddi dysfunction was found in four patients, and sphincterotomy cured all of them (follow-up: 9 months). Two of the remaining six patients had functional gastrointestinal disorders (reflux, constipation) and became asymptomatic after specific treatment. CONCLUSIONS: Biliary colic often recurs after successful gallstone lithotripsy. Recurrent gallbladder stones are the main cause, but another cause is sphincter of Oddi dysfunction. Neither gallbladder hypomotility nor microlithiasis seems to cause biliary symptoms in patients without recurrence of gallstones.

Adult↗

PubMed1996

Division of the sphincter of Oddi for treatment of dysfunction associated with recurrent pancreatitis.

Increasing evidence suggests that motility disorders of the sphincter of Oddi may lead to episodes of recurrent pancreatitis in a small proportion of patients with the diagnosis of idiopathic recurrent pancreatitis. Over 10 years, 35 patients have been identified and treated for this condition. The aim of the study was to assess symptomatic outcome in these patients. Following the exclusion of common causes of pancreatitis the patients underwent sphincter of Oddi manometry. Patients with manometric abnormalities and three with normal manometric findings underwent treatment. Twenty-six patients with persistent symptoms underwent total division of the sphincter via open sphincteroplasty and septectomy. Patients were followed up according to symptoms and classed as having a cure, mild symptoms or no change. At a median follow-up of 24 (range 9-105) months, 15 of the 26 patients were cured, eight had only mild symptoms and three remained unchanged. In the majority of patients with a good clinical outcome, manometry had demonstrated sphincter of Oddi stenosis. Total division of the sphincter of Oddi is associated with good symptomatic outcome in patients with recurrent episodes of pancreatitis and documented sphincter of Oddi stenosis.

Adult↗

PubMed1997

Tilidine does not affect human sphincter of Oddi motility--a randomized, controlled study.

AIM: To investigate the effects of intravenous pentazocine and tilidine on sphincter of Oddi motility. METHODS: Twenty patients with suspected sphincter of Oddi dysfunction were enrolled in a prospective, double-blind study. Sphincter of Oddi motility was assessed by means of endoscopic manometry after injection of 0.9% saline, as well as after randomized dosing with either 30 mg pentazocine i.v. (n = 10) or 50 mg tilidine i.v. (n = 10). RESULTS: Pentazocine significantly increased the sphincter of Oddi baseline pressure from 32 +/- 21 mmHg (saline) to 41 +/- 19 mmHg (P = 0.002), whereas tilidine did not alter the sphincter baseline pressure (34 +/- 15 mmHg saline vs. 36 +/- 16 mmHg tilidine, P = 0.16). Furthermore, pentazocine increased the phasic sphincter contraction amplitude (108 +/- 16 mmHg saline vs. 121 +/- 18 mmHg pentazocine, P = 0.004), but tilidine was without any effect (125 +/- 24 mmHg saline vs. 125 +/- 21 mmHg tilidine, P = 0.93). The phasic sphincter of Oddi contraction frequency and duration were not influenced either by pentazocine or by tilidine. CONCLUSION: In contrast to 30 mg of pentazocine, 50 mg of tilidine does not affect sphincter of Oddi motility. Therefore, tilidine can be used during endoscopic manometry and for analgesia in pancreatobiliary disease.

Adult↗

PubMed2002

Complications of endoscopic sphincterotomy: results from a single tertiary referral center.

BACKGROUND AND STUDY AIMS: Complications of endoscopic sphincterotomy (ES) have been assessed in recent multicenter studies. The aim of this series was to report and identify risk factors for complications of ES at a single tertiary referral center. PATIENTS AND METHODS: Between 1996 and 2000, 1159 consecutive endoscopic retrograde cholangiopancreatographies (ERCP) procedures were performed and their related complications were assessed. A total of 658 patients (57 %) underwent ES. All the clinical, radiological and biological data were carefully recorded within the 30 days following the procedure. Multivariate analysis was performed using a stepwise logistic model. RESULTS: The morbidity rate for ES was 7.7 %, being moderate to severe in 5 %. Morbidity included acute pancreatitis (3.5 %), perforations (1.8 %), sepsis (1.2 %) and bleeding (1.2 %). The 30-day mortality was 0.9 %. In the 1159 ERCP procedures, 231 patients underwent precut papillotomy (20 %) followed by sphincterotomy in 174 cases. Using logistic regression analysis, the risk factors for ES were precut papillotomy (relative risk, RR 2.76), confidence interval, (CI 1.39 - 5.49) and the presence of sphincter of Oddi dysfunction (RR, 7.72, CI 3.2 - 18.4). CONCLUSIONS: In this single-center series, we found a complication rate of ES in about 7 %, comparable to that in multicenter series. Precut papillotomy and sphincter of Oddi dysfunction were the main independent risk factors for ES.

Female↗

PubMed2002

ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.

BACKGROUND: ERCP by means of long-limb Roux-en-Y surgical anastomoses has been reported primarily in patients with biliary or pancreatic anastamoses, but rarely in patients with an intact papilla. METHODS: All ERCP procedures attempted over a 6-year interval in patients with Roux-en-Y gastrojejunostomies and an intact papilla were reviewed. Patients with a prior Billroth II operation or alteration of the major papilla were excluded. Cannulation and therapy were primarily performed with a duodenoscope after exploration and placement of a guidewire in the afferent limb with a forward-viewing colonoscope. In some cases the duodenoscope was pulled into the afferent limb with a wire-guided balloon passed retrograde into the afferent limb. A follow-up of 30 days was obtained for all patients as part of a prospective ERCP outcome study. RESULTS: Of 15 patients in whom ERCP was attempted, the papilla was reached in 10 patients (67%), the bile duct being accessed in all 10. Needle-knife precut papillotomy after placement of a pancreatic duct stent was performed in 3 patients. Biliary sphincterotomy with a variety of techniques was successful in all 9 patients in whom it was attempted. Other maneuvers included stone extraction, sphincter of Oddi manometry, and biliary stent placement. Final diagnoses were sphincter of Oddi dysfunction (6), malignant biliary stricture (2), choledocholithiasis plus tumor (1), and choledocholithiasis (1). Complications occurred after 3 (12%) of 25 ERCP procedures including pancreatitis (1 mild, 1 moderate) and bleeding (1 mild), all in patients with sphincter of Oddi dysfunction. CONCLUSIONS: Diagnostic and therapeutic ERCP was ultimately successful in two thirds of patients with long-limb gastrojejunostomies and an intact papilla. The success of the ERCP is determined primarily by ability to advance a duodenoscope through the afferent limb. Once the major papilla was accessed with a duodenoscope, advanced biliary and pancreatic therapeutic techniques were feasible.

Adult↗

PubMed1990

Biliary manometry.

The purpose of the paper is to introduce the reader to sphincter of Oddi dysfunction and the technique of biliary manometry. This paper will review sphincter of Oddi anatomy and physiology, abnormalities, patient selection, equipment and technique used in testing, interpretation and scoring.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1991

Innervation of the sphincter of Oddi: physiology and considerations of pharmacological intervention in biliary dyskinesia.

The sphincter of Oddi is a small sphincter which is strategically placed at the junction of the bile duct and pancreatic duct with the duodenum. It regulates the flow of bile and pancreatic juice into the duodenum and prevents reflux of duodenal contents into the ducts. The structure of the sphincter of Oddi differs from species to species and consequently its physiological action varies in different species. Anatomical and immunohistochemical investigations have demonstrated that the sphincter of Oddi is richly innervated by cholinergic, adrenergic and peptidergic neurons. In addition, neural connections exist between the sphincter, gallbladder and proximal gastrointestinal tract. These nerves in addition to hormones are important in the control of sphincter of Oddi motility and function. The normal human sphincter of Oddi is characterized by prominent phasic contractions which are superimposed on a modest basal pressure. These contractions are present throughout the interdigestive period. The contractions and basal pressure are inhibited by ingestion of a meal or infusion of cholecystokinin octapeptide, thus enhancing the flow of bile and pancreatic juice into the duodenum. Sphincter of Oddi dysfunction has been described in patients who present with recurrent biliary type pain and no evidence of a structural cause for the pain. Motility disorders characterized as an elevated basal pressure, rapid contraction frequency, paradoxical response to cholecystokinin octapeptide or excess of retrograde contractions have been identified. A number of pharmacologically active substances have been used in an attempt to treat these patients. Such pharmaceuticals include nitrites, Ca2+ channel blockers and smooth muscle relaxants. Their effect is transient and side effects relating to cardiovascular actions preclude their longterm use. Division of the sphincter either endoscopically or by open operation has been demonstrated by prospective clinical trials to be the most efficacious treatment for patients with a stenosed sphincter manometrically demonstrated by a high basal pressure. Improved understanding of the controlling mechanisms of sphincter of Oddi motility and the pathophysiology of sphincter of Oddi dysfunction should assist in the development of effective pharmacotherapy for these disorders.

Animals↗

PubMed2003

Acalculous biliary pain: new concepts for an old entity.

Biliary pain is commonly reported in household surveys with the presumed cause being gallstones. When gallstones are absent or other abnormalities as a potential cause of similar pain do not exist, a different approach is necessary. Although trans-abdominal ultrasound can detect stones down to 3-5 mm, the advent of endoscopic ultrasound provides an even better definition for microlithiasis of < 3 mm. Duodenal aspiration of bile can further detect cholesterol microlithiasis or bilirubin granules, another potential source of biliary-type pain and perhaps even pancreatitis. Only in this way can acalculous gallbladder disease be clearly defined. The percentage of cholecystokinin-stimulated gallbladder emptying has been reputed to be the most sensitive diagnostic test for 'biliary dyskinesia', but abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi. The value of surgical intervention has not been clearly established. The advent of laparoscopic cholecystectomy, however, has increased the number of patients with acalculous biliary disease who undergo surgery. Surgery is best done using impaired gallbladder emptying as the criterion for operation with improved outcome. Often, following cholecystectomy, biliary pain does not resolve the so-called 'post cholecystectomy syndrome'. Absence of the gallbladder as a pressure reservoir leaves the sphincter of Oddi as the prime determinant of bile duct pressure. Sphincter of Oddi dysfunction also exists in patients with an intact biliary tract and may become evident following cholecystectomy. Biliary manometry has clarified who might benefit from sphincterotomy. Choledochoscintigraphy is a non-invasive preliminary test. Advent of visceral hypersensitivity and better definition of this entity has shown, that in some of these patients with type III sphincter of Oddi, dysfunction appears to reside in duodenal hyperalgesia. It is clear that improved criteria are required to perform gallbladder emptying and better techniques to detect visceral hypersensitivity. Nonetheless, functional biliary pain in the absence of gallstone disease is a definite entity and a challenge for clinicians.

Acalculous Cholecystitis↗