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PubMed2003

Therapeutic biliary endoscopy.

Some steps of progress have been seen in the area of biliary therapeutic endoscopy, in the understanding and management of primary sclerosing cholangitis, problems relating to liver transplantation, malignant biliary strictures, complications after endoscopic retrograde cholangiopancreatography, sphincter of Oddi dysfunction, and tissue sampling. The benefits (or lack thereof) of preoperative biliary drainage in the setting of malignant obstructive jaundice have received an extensive review.

Biliary Tract Diseases↗

PubMedDate not supplied

Status evaluation: sphincter of Oddi manometry. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee.

SO manometry appears to be helpful in defining a group of patients with biliary pain or idiopathic recurrent pancreatitis who may benefit from endoscopic or surgical treatment. It is a procedure that requires considerable time and endoscopic expertise along with knowledge of the manometric interpretation of sphincter of Oddi dysfunction. The diagnostic accuracy of SO manometry and criteria for basing therapeutic decisions on manometric findings need further study and verification.

Biliary Tract Diseases↗

PubMed1996

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in patients with chronic pancreatitis.

CONCLUSION: Endoscopic manometry in patients with chronic pancreatitis has demonstrated some manometric abnormalities in the sphincter of Oddi, but these abnormalities have no significant role in the pathogenesis of chronic pancreatitis. BACKGROUND: The study was undertaken to determine whether the sphincter of Oddi dysfunction plays a significant role in the pathogenesis of chronic pancreatitis. METHODS: Manometric investigation was performed in 32 patients with chronic pancreatitis. Twenty-three of them had alcohol-induced chronic pancreatitis, seven had biliary pancreatitis, and two patients had annular pancreas with chronic pancreatitis. Fifteen of them had dilated main pancreatic duct. Twenty-one cholecystectomized patients with no abnormality of the pancreas and biliary system served as controls. RESULTS: This study showed no significant difference in the mean pressures in the pancreatic duct, sphincter of Oddi (basal and phasic), and frequency of the sphincter of Oddi phasic contractions when comparing patients and controls. Sphincter of Oddi basal pressure (26-44 mmHg) was markedly increased in seven patients, whereas three patients (two of them had increased sphincter of Oddi basal pressure) had increased pancreatic duct pressure (20-24 mmHg). Increased numbers of retrograde contractions were found in seven patients.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1994

Dynamic endoscopic manometry of the response to secretin in patients with chronic pancreatitis.

Endoscopic manometry of the sphincter of Oddi and the main pancreatic duct (MPD) was performed before and after intravenous injection of secretin (1 CU/kg) in 15 control subjects and 19 patients with chronic pancreatitis. Secretin significantly but transiently enhanced the MPD pressure in the controls, whereas chronic pancreatitis patients had an elevated basal MPD pressure and a manometric pattern of sphincter of Oddi dyskinesia. The secretin-induced MPD pressure was also elevated and more sustained in chronic pancreatitis patients compared to controls. No influence of the etiology or MPD ductal diameter was found, but the duration of the disease correlated significantly to the pressure response to secretin in patients. The pressure enhancement was most impressive in chronic pancreatitis of recent onset (less than four years), whereas it was minimal or normal in later stages of the disease. This dynamic manometric test reliably demonstrates sphincter of Oddi dysfunction and an altered response to secretin. The test could have a role to play in the explanation of progressive MPD dilatation as well as in the early diagnosis of chronic pancreatitis.

Adolescent↗

PubMed1995

Biliary manometry in swine: a unique endoscopic model for teaching and research.

Biliary manometry, the "gold standard" for the diagnosis of sphincter of Oddi dysfunction, is associated with technical and methodological problems. The lack of a suitable experimental model has hindered efforts to solve these problems. We report here on the first practical animal model for endoscopic biliary manometry, similar in technique to the procedure in humans. Piglets were sedated and intubated with a standard human duodenoscope. A standard water-perfused manometry catheter was inserted into the bile duct. The biliary sphincter was identified by a zone of high-pressure activity with superimposed phasic contractions. The sphincter responded normally to the administration of cholecystokinin and morphine by relaxation and contraction, respectively. This model should be useful for training in biliary manometry, and facilitate technical innovations in the field. Since it is relatively atraumatic, it may also be better than existing surgical models for studying the normal physiology and pharmacology of the sphincter of Oddi.

Animals↗

PubMed2000

A new source of drug-induced acute pancreatitis: codeine.

A variety of drugs have been reported to cause acute pancreatitis during the past 40 years. We report the first series of four cases of acute pancreatitis related to codeine ingestion. Four patients (three female, mean age 50.2 yr) presented with clinical, biochemical, and radiological evidence of acute pancreatitis. All four had ingested a therapeutic dose of codeine 1-3 h before the onset of abdominal symptoms. Unintentional rechallenge occurred in three cases and was followed by recurrence of acute pancreatitis in all three. All patients made a full recovery. All four patients had had a previous cholecystectomy. The likely underlying pathophysiological mechanism is codeine-induced spasm of the sphincter of Oddi combined with sphincter of Oddi dysfunction related to a previous cholecystectomy. Codeine ingestion leads to acute pancreatitis in some individuals. Previous cholecystectomy seems to predispose to codeine-induced pancreatitis.

Acute Disease↗

PubMed1993

Pathophysiology of the sphincter of Oddi.

Pathophysiology of the sphincter of Oddi--or sphincter of Oddi dysfunction--manifests as either a biliary-type pain syndrome or recurrent pancreatitis. Imaging studies are unreliable, and direct endoscopic manometry is used to diagnose this entity. Milwaukee biliary classification, in addition to manometry, helps guide therapy. Endoscopic sphincterotomy in selected patients achieves permanent relief of symptoms. Endoscopic therapy for recurrent pancreatitis is still experimental.

Gastrointestinal Motility↗

PubMedDate not supplied

Pancreatitis due to codeine.

Pancreatitis is a rare adverse effect of codeine. We report the case of a 42-year-old man who suffered from epigastric pain 1 hour after taking a tablet containing amoxicillin plus clavulanic acid (500/125 mg) and another tablet containing acetaminophen plus codeine (500/30 mg) for a respiratory infection. He was admitted to the emergency room and was treated with metamizol and pantoprazole. A few minutes after receiving intravenous doses of both drugs he developed a maculopapular and itching eruption with facial angioedema. Laboratory tests showed high levels of serum amylase, GOT, GPT and total bilirubin. Serological tests for several viruses showed no evidence of recent infection. Ultrasonography was negative for biliary lithiasis and showed only cholecystectomy performed in 2000. The patient was sent to our department where skin prick and oral challenge tests were performed with negative results. For ethical reasons, oral challenge with codeine was not carried out. We believe that our patient had codeine-induced pancreatitis. The most likely underlying pathophysiological mechanism was probably codeine-induced spasm of the sphincter of Oddi combined with sphincter of Oddi dysfunction related to a previous cholecystectomy. Allergy departments should be aware of possible non-immunological adverse.

2-Pyridinylmethylsulfinylbenzimidazoles↗

PubMed2001

Idiopathic acute recurrent pancreatitis.

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Acute Disease↗

PubMed2001

Chronic Visceral Right Upper Quadrant Pain Without Gallstones.

Patients with chronic visceral right upper quadrant pain without gallstones can be broadly categorized into two groups: patients with gallbladder dyskinesia, and patients with sphincter of Oddi dysfunction (SOD). Treating patients with these disorders is often challenging to clinicians due to the difficulty at arriving at a definite diagnosis, and the lack of efficacy of various treatment modalities. The only real treatment option for patients with gallbladder dyskinesia is cholecystectomy; however, the results are difficult to predict in an individual patient. Patients with SOD can be approached according to a classification that at least partially reflects the underlying pathophysiology. Patients with type I SOD have underlying papillary stenosis, and benefit from empiric sphincterotomy. Patients with type II SOD may have muscle spasm as predominant pathophysiology; this group of patients benefit from sphincterotomy only if increased sphincter pressure is demonstrated by sphincter of Oddi manometry. Patients with type III SOD may have visceral hyperalgesia; a trial of antidepressants or a therapeutic trial with botulinum toxin injection into the ampulla should be considered prior to more invasive endoscopic therapy.

Journal Article↗

PubMed2005

A new mechanism for diverticular diseases: aging-related vagal withdrawal.

It is widely believed that diverticulosis, a common condition among the elderly, results from repeated colonic barotrauma related to low dietary fiber and low stool bulk. Recent evidence has challenged the dietary-barotrauma hypothesis. We propose an alternative hypothesis that diverticulosis may be attributable to colonic smooth muscle dysfunction that results from vagal attrition associated with aging. We previously proposed that broad aging-related attrition of autonomic nerves may unmask intrinsic sympathetic bias of end-organs, leading to the compendium of familiar conditions associated with senility. Unexplained cholinergic hypersensitivity and receptor over-expression in bowel affected by diverticulosis have recently been observed. These findings are highly suggestive of a compensatory response to loss of vagal innervation. The resulting autonomic dysregulation may induce bowel smooth muscle dysfunction, setting the stage for diverticula formation. Thus, diverticular bowel disease may be a manifestation of the aging-related systemic vagal withdrawal. The framework may extend to diverticula formation in other parts of the gastrointestinal and genitourinary tracts. For instance, aging-related vagal attrition may represent the common upstream mechanism that induces both sphincter of Oddi dysfunction and peri-ampullary duodenal diverticula, conditions that frequently occur together. Novel approaches to preventing and treating diverticular diseases by promoting vagal activity are proposed including the electrical or pharmacologic modulation of the autonomic system.

Aging↗

PubMed2000

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of pancreatic diseases.

Endoscopic retrograde cholangiopancreatography (ERCP) has been used for diagnosis and treatment of pancreatic diseases for over 20 years. ERCP has been most intensely investigated for acute biliary pancreatitis. Randomized trials have proven that its use will decrease morbidity and have suggested a decrease in mortality for patients with severe gallstone pancreatitis. ERCP is also valuable in detecting and treating main pancreatic duct leaks with transpapillary stenting. Symptomatic pseudocysts, which may be seen in either acute or chronic pancreatitis, can be drained via the papilla or through creation of a cystogastrostomy or cystoduodenostomy with a needle-knife sphincterotome. Endoscopic treatment of patients with recurrent acute pancreatitis presumed due to pancreas divisum and sphincter of Oddi dysfunction remains controversial. Dominant pancreatic strictures or calculi in the setting of chronic pancreatitis may be treated with stenting and removal of calculi to improve abdominal pain. Finally, diagnosis of pancreatic cancer by brush cytology and palliative management of biliary obstruction with various plastic and expandable metal sents have simplified management of this difficult problem.

Biopsy↗

PubMed1989

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and biliary drainage.

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and endoscopic biliary drainage have dramatically changed the diagnosis and management of disorders of the pancreas and hepatobiliary tract. Endoscopic retrograde cholangiopancreatography will provide a high-resolution study that will define accurately the nature and location of the disease process involving the pancreas or bile ducts. Although sonography, CT, and, recently, MRI may provide clues to the diagnosis, it often remains for endoscopic retrograde cholangiopancreatography to establish the diagnosis with certainty. Endoscopic sphincterotomy has been invaluable in the management of common bile-duct stones. In patients who have had their gallbladders removed, sphincterotomy has avoided reoperation in the same field and the risk of general anesthesia. Sphincterotomy also is assuming an increasingly important role in the management of common-duct stones in patients with their gallbladders in situ who are poor operative candidates. In these patients, sphincterotomy likewise avoids the risk of general anesthesia and the surgical stress of opening a major body cavity. The technique has also proved to be helpful in the palliative treatment of ampullary and distal common bile-duct carcinomas in those patients who are poor operative candidates. Finally, sphincterotomy has found a role in the treatment of choledochal cysts and may provide relief of pain in those patients with the elusive diagnoses of postcholecystectomy syndromes, biliary dyskinesias, and sphincter of Oddi dysfunction. Endoscopic biliary drainage is becoming an increasingly popular option for the palliation of malignant biliary obstruction. In those patients who are poor operative candidates, the risk of general anesthesia and major surgery is avoided. In those patients with obviously incurable tumors, endoscopic drainage allows for a brief hospitalization without surgery in the face of a short life expectancy.

Adult↗

PubMed2006

Bio-sensor system discriminating between the biliary and pancreatic ductal systems.

Sphincter of Oddi manometry is the "gold standard" to evaluate the ductal anatomy of patients with suspected sphincter of Oddi dysfunction. During such procedure it can be unclear which duct is being investigated without radiographs. Bilirubin and other pigments in bile strongly absorb blue light, whereas pancreatic fluid is clear and does not absorb blue light. The bio-sensor system incorporates fibre-optic technology to measure blue light absorbance in the ducts. Bench tests and animal tests were conducted utilising possums. In bench and animal experiments the bio-sensor correctly discriminated between bile and pancreatic juice, based on the absorbance of blue light. The mean absorbance of the bile was 3.57+/-1.74 and that of the pancreatic duct fluid was 0.53+/-0.34 (P<0.01) in the animal models. The optical sensing system could be incorporated into a manometry catheter to aid sphincter of Oddi manometry shortening procedure time and reduce radiography exposure.

Animals↗

PubMed1982

New diagnostic and treatment modalities involving endoscopic retrograde cholangiopancreatography and esophagogastroduodenoscopy.

Within the past several years, there has been dramatic advances in diagnostic and therapeutic modalities involving EGD and ERCP. Endoscopic sclerotherapy of esophageal varices is effective in controlling acute variceal bleeding in approximately 90% of the patients. Once bleeding is controlled, sclerotherapy may be a useful, long term treatment to prevent recurrent hemorrhage and to improve survival. In the treatment of patients with nonvariceal upper Gl bleeding, endoscopic electrocoagulation and laser photocoagulation does not significantly alter the operative rate or mortality rate. However, a subset of patients with either a visible vessel or angiodysplasia may benefit from endoscopic therapy of upper Gl bleeding. Another innovation, the ultrasonic endoscope has many potential applications, but instrumentation needs to be improved significantly before this diagnostic modality will be of clinical value. In the treatment of biliary tract disease, endoscopic sphincterotomy has revolutionized the therapy of patients with common bile duct stones and sphincter of Oddi disorders. Although sphincter of Oddi manometry is in its infancy, pressure measurements in the sphincter segment appear useful in identifying patients with sphincter of Oddi dysfunction who will benefit from sphincterotomy. Following endoscopic sphincterotomy, transpapillary biliary catheters, endoprosthesis and Gruntzig's balloons can be placed endoscopically into the common bile duct. These techniques are beneficial in the therapy of patients with large common bile duct stones as well as in short or long term management of patients with benign or malignant strictures of the biliary tree.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1999

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.

Anastomosis, Surgical↗

PubMed2001

Endoscopic sphincterotomy for stenosis of the sphincter of Oddi.

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis). METHODS: Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed. RESULTS: EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months. CONCLUSIONS: SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.

Abdominal Pain↗

PubMed2004

Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success.

BACKGROUND: Increasingly, pancreatic stents are being placed to prevent post-ERCP pancreatitis. However, guidewire and stent placement may fail if the duct is small or tortuous, potentially exacerbating the risk. This study assessed the impact of unsuccessful pancreatic stent placement on complications and the efficacy of a modified technique for stent insertion when pancreatic ductal anatomy makes stent insertion technically difficult. METHODS: Technical variables and 30-day complications of consecutive therapeutic ERCPs, including attempted major papilla pancreatic stent insertion were prospectively studied. Success rates for pancreatic stent placement were compared for a 1-year period during which conventional deep guidewire insertion was used and another 1-year period in which a modified technique was used as needed in patients with ductal anatomy that made stent placement technically difficult. In the modified technique, a short (2-3 cm) small diameter (3F-5F) stent was placed over a 0.018-in nitinol-tipped guidewire, passed as little as 1 to 2 cm beyond the pancreatic sphincter. RESULTS: In 225 high-risk therapeutic ERCPs, pancreatitis occurred after the procedure in two of 3 (66.7%) patients in whom pancreatic stent insertion failed vs. 32 of 222 (14.4%) patients with successful insertion (p=0.06). Severe pancreatitis occurred only after unsuccessful stent insertion. Significant multivariate risk factors for post-ERCP pancreatitis were unsuccessful pancreatic stent insertion (odds ratio 16.1: 95% CI[1.3, 200]), sphincter of Oddi dysfunction (odds ratio 3.2: 95% CI[1.4, 7.5]), and prior post-ERCP pancreatitis (odds ratio 3.2: 95% CI[1.4, 7.1]). The following were not risk factors: performance of pancreatic, biliary, or needle-knife pre-cut sphincterotomy; number of pancreatic contrast injections; and difficult cannulation. Stent placement was unsuccessful in 3 (3.2%) of 93 attempts during the 1-year period in which a conventional technique was used vs. none of 132 attempts in a subsequent year in which the modified technique was used. CONCLUSIONS: Failed attempts at pancreatic stent placement are associated with an extremely high risk of post-ERCP pancreatitis. Success can be consistently achieved by use of a modified technique.

Adult↗