[Dysfunction of the Oddi's sphincter].
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Common Bile Duct Diseases↗
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Results for “Sphincter of Oddi Dysfunction”
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Dysfunction of the sphincter of Oddi in a postcholecystectomy patient.
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Adult↗
[Sphincter of Oddi disfunction in "idiopathic" recurrent pancreatitis].
OBJECTIVE: As the pathogenesis of acute recurrent pancreatitis remains unclear in 30% of patients, it was the aim of this study to find out whether and how often changes in sphincter of Oddi motility is present in these patients and whether endoscopic treatment promises success. PATIENTS AND METHODS: 18 patients (three men, 15 women; mean age 41.5 [30-56] years) with "idiopathic" acute recurrent pancreatitis seen consecutively between April 1991 and November 1995, were included in the study. In none had laboratory examinations, sonography, computed tomography and endosonography (n = 11) demonstrated any unusual findings. Neither exocrine (pancreaolauryl test in 8, secretin-pancreozymin test in 10 patients), nor endocrine (oral glucose tolerance test) pancreatic insufficiency had been found. Endoscopic retrograde cholangiopancreatography had excluded morphological changes in the biliary-pancreatic system. All patients underwent endoscopic manometry. When a basal sphincter of Oddi pressure > or = 40 mm Hg was demonstrated in the pancreatic sphincter segment, combined endoscopic sphincterotomy was done of both the biliary and the pancreatic component. RESULTS: Nine patients had a raised basal sphincter pressure in the pancreatic segment of the sphincter, but in only four in the biliary one as well. The phasic sphincter motility was normal in all patients. In four patients iatrogenic pancreatitis developed after the procedure (mild in three, moderately severe in one). Eight of the nine patients who had a sphincterotomy remained symptom-free during a mean follow-up period of 21 months, but only three of the nine with normal manometric findings. CONCLUSION: Half of the patients with acute recurrent pancreatitis of unknown cause have sphincter of Oddi dysfunction, usually limited to the pancreatic segment of the sphincter, Endoscopic sphincterotomy can prevent recurrent pancreatitis in most of the patients.
Acute Disease↗
Sphincter of Oddi.
It has been more than 100 years since Rugero Oddi described the sphincter that bears his name. In that time, investigators have determined its precise anatomy and they have demonstrated its independence from the duodenal muscle wall. Modern manometric techniques have defined the motor activity of the sphincter and motility abnormalities in patients presenting with either recurrent biliary-type pain or idiopathic recurrent pancreatitis. The term Sphincter of Oddi dysfunction is used to describe motility disorders of the sphincter. Clinical studies have shown that in patients with manometrically determined stenosis, division of the sphincter is associated with cure of the symptoms in more than 70%. For patients with biliary-type pain, division of the bile duct sphincter is all that is required, whereas in patients with idiopathic recurrent pancreatitis, division of the septum between the bile duct and the pancreatic duct is mandatory.
Biliary Dyskinesia↗
Sphincter of oddi manometry: is it necessary to measure both biliary and pancreatic sphincter pressures?
BACKGROUND: Data are scant on the miss rate of sphincter of Oddi dysfunction if basal pressure in both biliary and pancreatic sphincter segments is not measured during manometry. METHODS: Motility tracings with basal pressure measurements of both sphincter segments were retrospectively analyzed. Basal sphincter pressure greater than 40 mm Hg was considered abnormal in either sphincter segment. RESULTS: The study population consisted of 73 subjects (64 women, 9 men; age 45.3 +/- 1.6 yr). The basal pressures in the 2 sphincter segments were highly discordant (correlation coefficient = 0.2, p = 0.04). Basal pressures were normal in both segments in 19%, abnormal in both segments in 40%, and abnormal in 1 segment but normal in the other in 41%. The negative predictive value of normal biliary sphincter pressure in excluding sphincter dysfunction was 0. 42; when the pancreatic sphincter pressure was normal, the negative predictive value was 0.58. The incidence of pancreatitis with dual duct manometry was comparable to the institutional experience with all sphincter studies. CONCLUSIONS: Although the clinical relevance of individually elevated sphincter pressures remains uncertain, there is significant discordance of basal pressures between the biliary and pancreatic sphincter segments. If only the biliary sphincter pressure were to be measured, one fourth of abnormal sphincter pressures would be missed. Therefore, if the first sphincter segment has a normal basal pressure, the other segment should also be evaluated.
Adult↗
Recurrent Acute Pancreatitis.
Patients with recurrent acute pancreatitis should be treated with the same supportive and symptom-oriented measures as those with acute pancreatitis. The need for specific treatment depends on the cause of the pancreatitis. Patients should discontinue alcohol use, putative causative medications, and exposure to toxins or helminths in endemic areas. Metabolic abnormalities need to be corrected, and appropriate treatment should be initiated for associated infections, autoimmune diseases, vasculitis, and hypercoagulable states. For patients with gallstone pancreatitis, endoscopic retrograde cholangiopancreatography is indicated if biliary obstruction persists or if cholangitis is present. Elective cholecystectomy may be performed in appropriate patients; otherwise, consider biliary sphincterotomy and ursodeoxycholic acid for prevention of recurrent attacks. Transpapillary stenting or sphincterotomy of the minor papilla benefits some patients with pancreas divisum and no other explanation for recurrent pancreatitis. Surgical sphincteroplasty is reserved for those failing endoscopic treatment. Biliary sphincterotomy benefits more than 50% of patients with sphincter of Oddi dysfunction and recurrent acute pancreatitis. Some authors advocate pancreatic sphincter manometry and sphincterotomy for persistent pancreatic segment hypertension in patients who have recurrent pancreatitis after biliary sphincterotomy. In patients with pancreatic duct strictures, transpapillary stent placement serves as a short-term measure; most patients ultimately require surgery.
Journal Article↗
The empty gallbladder syndrome--results of operation for noncalculous biliary disorders.
Based on results of long-term follow-up and pathophysiologic considerations in 38 consecutive patients, it was possible to speculate on the frequencies of the various causes of the empty gallbladder syndrome. In approximate percentages, these are as follows: bile stasis causing chronic acalculous cholecystitis, 47%; physiologic dysfunction of the gallbladder, 24%; psychogenic illness, 16%; sphincter of Oddi dysfunction, 13%; ulcerative colitis, 3%. Because as many as 30% to 35% of these patients will not benefit from cholecystectomy, I feel that it should be undertaken with caution in cases of this syndrome.
Adolescent↗
A brief commentary: electroacupuncture may relax the contraction of sphincter of Oddi.
Animal studies have shown that acupuncture can affect the function of the sphincter of Oddi, a smooth muscle encircling major papilla located at the second portion of the duodenum that regulates the flow of bile and pancreatic juice. This study of thirteen patients was the first to observe the effects of acupuncture on sphincter of Oddi motility in humans. Stimulation of the acupuncture point GB-34, which is known to Oriental medicine as an acupoint with effect on the biliary system, showed reversible inhibition of sphincter of Oddi contractions. In contrast, stimulation of a nonspecific control acupoint did not induce significant change. This study suggests that acupuncture may be one alternative treatment for patients with sphincter of Oddi dysfunction.
Common Bile Duct Diseases↗
Diagnostic endoscopic retrograde cholangiopancreatography.
Although diagnostic endoscopic retrograde cholangiopancreatography (ERCP) has been replaced in many fields by magnetic resonance cholangiopancreatography (MRCP), considerable amounts of research are still ongoing. Major fields of interest include ways of reducing the incidence of post-ERCP pancreatitis, new ways of improving the yield of tissue sampling, and the diagnosis of sphincter of Oddi dysfunction. In addition, there are new data comparing the diagnostic accuracy of ERCP with that of MRCP and endoscopic ultrasonography.
Cholangiopancreatography, Endoscopic Retrograde↗
NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.
OBJECTIVE: To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the use of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. PARTICIPANTS: A non-Federal, non-advocate, 13-member panel representing the fields of gastroenterology, hepatology, clinical epidemiology, oncology, biostatistics, surgery, health services research, radiology, internal medicine, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300. EVIDENCE: Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of ERCP research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience. CONFERENCE PROCESS: Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. CONCLUSIONS: In the diagnosis of choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and ERCP have comparable sensitivity and specificity. Patients undergoing cholecystectomy do not require ERCP preoperatively if there is low probability of having choledocholithiasis. Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones. ERCP with endoscopic sphincterotomy (ES) and stone removal is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. In patients with pancreatic or biliary cancer, the principal advantage of ERCP is palliation of biliary obstruction when surgery is not elected. In patients who have pancreatic or biliary cancer and who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. ERCP is the best means to diagnose ampullary cancers. ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts. Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures. With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.
Acute Disease↗
Division of the sphincter of Oddi for treatment of dysfunction associated with recurrent pancreatitis.
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Acute Disease↗
Differentiation between organic stenosis and functional dyskinesia of the sphincter of Oddi with amyl nitrite-augmented quantitative hepatobiliary scintigraphy.
Recurrent biliary pain after cholecystectomy is presumably due to sphincter of Oddi dysfunction (SOD). There is no ideal non-invasive test for SOD, and the diagnosis often relies on invasive procedures such as sphincter of Oddi (SO) manometry. Amyl nitrite-augmented quantitative hepatobiliary scintigraphy (QHBS) was performed on nine asymptomatic volunteers and 22 patients with SOD of biliary types I and II. Normal QHBS parameters were established in the asymptomatic volunteers. QHBS revealed a partial obstructive pattern in nine patients in whom SO stenosis was suspected and in 13 patients in whom SO dyskinesia was suspected. This obstructive pattern remained unchanged in the former group, but was completely relieved in the latter group of patients on amyl nitrite administration. In conclusion, amyl nitrite-augmented QHBS proved to be a useful non-invasive method in the diagnosis of SOD of biliary types I and II and permitted differentiation between organic stenosis and functional motor abnormalities of the SO.
Adult↗
Periampullary diverticula cause pancreatobiliary reflux.
BACKGROUND: Periampullary diverticula are associated with dysfunction of the sphincter of Oddi. Papillary dysfunction may allow reflux of pancreatic juice as well as intestinal contents into the common bile duct. We prospectively investigated pancreatobiliary reflux in patients with and without periampullary diverticula. METHODS: The ductal bile was sampled for amylase concentration during endoscopic retrograde cholangiopancreatography in 47 patients with choledocholithiasis (n = 29; with (n = 14) or without (n = 15) periampullary diverticula) or gallbladder cholesterol polyps (n = 18; with (n = 6) or without (n = 12) diverticula). RESULTS: The amylase concentration within the ductal bile was significantly higher in choledocholithiasis patients with periampullary diverticula (1621 +/- 587 IU/l) than in those without diverticula (1155 +/- 418 IU/l). The amylase concentration tended to be higher in gallbladder polyp patients with diverticula (1087 +/- 275 IU/l) than in those without diverticula (833 +/- 272 IU/l). Irrespective of the presence or absence of diverticula, patients with bile duct stones had significantly higher amylase concentrations than those with gallbladder polyps. CONCLUSIONS: Periampullary diverticula cause pancreatobiliary reflux. Further investigation is required to determine the clinical implication of pancreatobiliary reflux.
Ampulla of Vater↗
Ampulla of Vater/duodenal wall spasm diagnosed by antroduodenal manometry.
Patients with chronic epigastric to right upper quadrant pain are often considered to have gallbladder of sphincter of Oddi dysfunction, but standard tests are nondiagnostic. In 62 consecutive patients with this compliant undergoing antroduodenal manometry, we correlated a change on duodenal motility with spasm of the ampulla of Vater/duodenal wall. This distinctive motility pattern occurred and was analyzed in 35% of patients. It is characterized by increased duodenal wall tone with phasic contractions of 19-22 or 41-44 contractions/min or by phasic activity alone. The subjects with spasm also underwent cholecystokinin cholescintigraphy, and 50% showed either significantly delayed gallbladder emptying of hilum to small intestine emptying, or both. The disorder appears to be secondary to a loss of neural inhibitory control and a dysfunctional small-bowel pacemaker. Antroduodenal manometry is an essential diagnostic procedure that complements sphincter of Oddi manometry in evaluation of unexplained right upper quadrant pain.
Abdominal Pain↗
Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain.
Acalculous biliary-type abdominal pain is a commonly encountered clinical problem whose pathophysiology is unclear and evaluation and management are controversial. Cholecystokinin cholescintigraphy to measure the gallbladder ejection fraction (GEF) has been advocated as a criterion for cholecystectomy. However, there is no consensus regarding the dose and rate of infusion of cholecystokinin, both of which can alter the GEF, and the definition of an abnormal ejection fraction varies among studies. Many but not all studies have concluded that a low GEF predicts good outcomes after cholecystectomy, but most studies suffer from poor methodology and there is only one prospective randomized controlled trial. Also, some patients with a normal GEF have responded to cholecystectomy. Another controversial area has been the role of sphincter of Oddi dysfunction (SOD) in patients with biliary-type pain and gallbladder in situ. Some reports suggest an overlap between SOD and low GEF, although a causal relationship has not been established. Yet another subject of interest is the role of visceral hyperalgesia in patients with acalculous biliary-type pain. We have reviewed the relevant literature relating to these issues and have highlighted the controversial aspects. In the absence of high-quality studies, an evidence-based treatment algorithm is difficult to design but will be proposed. More prospective controlled trials are warranted to better define the appropriate evaluation and management of patients with this syndrome.
Abdominal Pain↗
Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.
BACKGROUND: Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers. METHODS: Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria. RESULTS: Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic. CONCLUSIONS: Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.
Cholangiopancreatography, Endoscopic Retrograde↗
The diagnosis of hypertonic Oddi's sphincter dyskinesia.
The diagnostic possibility of hypertonic Oddi's sphincter dysfunction was evaluated in 100 cholecystectomized and 28 noncholecystectomized patients. An organic lesion interfering with free bile flow was ruled out in every case. The existence of the syndrome, i.e., the dysfunction of the Oddi's musculature, was verified using the morphine-choleretic test combined with either dynamic hepatobiliary scintigraphy or (in selected cases) percutaneous transhepatic cholangiography. Hypertonic Oddi's sphincter dyskinesia can be regarded as an independent clinical syndrome.
Ampulla of Vater↗
Why the incidence of post-ERCP pancreatitis varies considerably? Factors affecting the diagnosis and the incidence of this complication.
The reported incidence of post-ERCP/sphincterotomy pancreatitis ranges between 1.3 and 24.4% in non-selected series. This varying incidence likely reflects on the one hand difference in patient populations, indications and endoscopic expertise and, on the other hand, different definitions of pancreatitis and methods of data collection. Among a number of patient-related factors recognized at risk for post-ERCP pancreatitis in four recent large prospective studies, the combination of female gender, normal serum bilirubin levels and recurrent abdominal pain suggesting sphincter of Oddi dysfunction and previous post-ERCP pancreatitis placed patients at an increasingly higher risk of pancreatitis. Among the technique-related risk factors for post-ERCP pancreatitis, biliary sphincter balloon dilation, difficult cannulation, sphincter of Oddi manometry and pancreatic sphincterotomy have also been recognized as significant risk factors. However, since the case mix in non-selected series does not significantly differ in the different studies, it is logical to assume that the different criteria adopted for defining the post-ERCP pancreatitis play a key role in the reported wide variation of incidence reported for this complication. The occurrence and duration of pain and the amplitude of serum amylase after ERCP are critical points in the definition of post-ERCP pancreatitis. Although a consensus conference identified 24-hour persisting pain associated with hyperamylasemia greater than 3 times the upper reference limit as an indicator of pancreatitis, these two parameters are however considered in a different manner in the studies available up to now. In a prospective study where we calculated the incidence of post-ERCP pancreatitis by using the most widely used criteria, for both occurrence and duration of pancreatic pain and serum amylase amplitude, the incidence of post-procedure pancreatitis ranged from 1.9 to 11.7% depending on the criteria adopted.
Cholangiopancreatography, Endoscopic Retrograde↗