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PubMed1998

[Post-cholecystectomy syndrome: hepatobiliary scintigraphy and cholangiopancreatography with magnetic resonance in 5 consecutive patients. Comparison of results and integrated diagnosis].

PURPOSE: To investigate the clinical effectiveness of combined hepatobiliary scintigraphy (HBS) and MR-cholangiopancreatography (MRCP) studies in the postcholecystectomy syndrome. MATERIAL AND METHODS: June 1997, to February 1998, we examined with HBS and MRCP five women, three of them submitted to surgical and two to laparoscopic cholecystectomy. All patients had biliary pain but no changes in cholestasis and liver function blood parameters. After at least 4 hours' fasting HBS was performed dynamically, for one hour, injecting a 185 MBq 99mTc-mebrofenin bolus i.v. A fatty meal was given at the end of the basal test and serial static images were acquired till complete biliary washout. RESULTS: MRCP was normal in one case while in the others it showed biliary tree dilation, severe stricture of the distal common bile duct (CBD) and marked enlargement of the remnant cystic duct (RCD), which lodged a 6-mm stone in one patient. Pancreatic ducts were regular. HBS showed delayed biliary transit in all patients, which was however completed within 3 hours of injection, favored by the fatty meal. The RCD was not injected in three cases. Finally, HBS detected an early liver dysfunction in three cases. DISCUSSION: HBS and MRCP allow to evaluate the biliary tree function and anatomy, respectively, adding further data on liver function and pancreatic duct morphology. We detected associated functional and organic biliary alterations which were the likely cause of postcholecystectomy pain, such as severe spasm in Oddi's sphincter, nonpatent enlarged RCD and RCD stones. Moreover, HBS detected an early liver dysfunction in three cases. In conclusion, combined HBS and MRCP studies make a noninvasive, simple and accurate diagnostic approach in postcholecystectomy syndrome and for the screening of patients needing prompt surgical treatment.

Aged↗
PubMed1986

Diagnosis and treatment of diseases of the papilla.

The papilla of Vater, diminutive as it may be, forms the nidus for a variety of clinical disorders. Owing to its crucial location at the confluence of the bile and pancreatic ducts, many of these clinical disorders lead to an impedance to the flow of secretions from the liver and pancreas. Thus, most symptomatic papillary disorders present with a rather predictable and monotonous conglomeration of symptoms. The common clinical presentations of papillary disorders include abdominal pain, jaundice, fever, pruritus and pancreatitis. Rarely, gastrointestinal bleeding leading to anaemia and weight loss may also be observed. The advent of ERCP rekindled interest in diseases of the papilla. The major duodenal papilla is more accessible now than ever before. The endoscopist can visualize the papilla within minutes and take an appropriate tissue sample using different biopsy techniques. Definitive diagnosis is thus possible in most patients with papillary tumours. Along with ERCP, the miniaturization of a perfusion system with minimal compliance enabled us to accurately evaluate sphincter of Oddi (SO) dynamics. This in turn gave us a wealth of information on the physiology of the sphincter of Oddi. In addition, ERCP manometry led to a resurgence of interest in SO dysfunction, especially papillary stenosis. Several characteristic manometric abnormalities have been identified recently. Finally, the introduction of endoscopic sphincterotomy (ES), nearly a decade ago, opened a new chapter in the therapeutic approach towards papillary disorders. While the technique was initially applied in the management of common bile duct stones in postcholecystectomy patients who were high operative risks, the indications for ES steadily increased during the past decade. Experience over the years led us to be convinced that ES is equally effective in the management of a variety of papillary disorders, including choledochoduodenal fistula, choledochocele, papillary tumours and SO dysfunction. Most recently, other ancillary procedures such as endoprosthesis insertion have emerged as yet another useful therapeutic modality. Such internal biliary stents have been shown to be suitable in establishing biliary drainage in ampullary neoplasms when the operative approach is considered risky.

Ampulla of Vater↗
PubMed2006

Functional gallbladder and sphincter of oddi disorders.

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1991

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in patients with papillary stenosis.

The function of the sphincter of Oddi (SO) in patients with papillary stenosis was evaluated using endoscopic manometry to determine its possible contribution to pancreatic dysfunction. A total of 30 patients with papillary stenosis were divided into two groups according to the pattern of narrowing of the sphincter zone observed in ERCP studies: group A, a mild form, and group B, a severe form. Group C (control) comprised 12 subjects with no abnormality of the pancreas or biliary system. The SO contraction pressure was significantly higher in group A (115.1 mmHg) than in groups B (79.2) and C (91.1). The SO basal pressure in groups A (11.5 mmHg) and B (10.3) was significantly higher than in group C (5.8). The pancreatic duct pressure in group A (15.5 mmHg) was significantly higher than in group C (9.7), while group B (11.1) showed an intermediate value. The increase in pancreatic duct pressure following intravenous secretin was significantly greater in groups A and C than in B. The BT-PABA test in groups A and C revealed a normal value in contrast to group B. A significant correlation was observed between these two factors. The function of both the SO and the pancreas thus appears to be abnormal in patients with severe narrowing of the SO and papillary stenosis.

Adult↗
PubMedDate not supplied

[The correction of functional disorders of the bile-secreting system by using laser radiation].

He-Ne laser irradiation of biologically active points and infrared laser irradiation of the liver were employed to improve gallbladder and sphincter functions, bile production and biochemistry, respectively, in a total of 57 patients with biliary dyskinesia presenting as hypokinetic dyskinesia of the gallbladder, hyperkinetic dyskinesia of the sphincter of Oddi or the combination of the two affections. Simultaneous use of the two kinds of laser irradiation appreciably shortens treatment duration, abolishes biliferous dysfunction, reestablishes physiological balance of bile components in case of its initial lithogenic potential.

Acupuncture Points↗
PubMed1983

Pathogenesis of alcoholic pancreatitis.

The pathogenesis of alcoholic pancreatitis continues to be a puzzle. Of the many theories as to how alcohol might cause pancreatic damage, none satisfactorily explains why only a minority of alcoholics develop clinical pancreatitis. Hypertriglyceridemia and inherited factors could be important antecedents in some individuals, and high fat and protein diets may favour the development of the disease. Disturbances of the sphincter of Oddi have been postulated, but there are experimental and theoretical objections to the view that alcoholic pancreatitis generally results from sphincter dysfunction (obstruction-hypersecretion, biliary-pancreatic reflux and duodeno-pancreatic reflux). Biochemical studies of the effect of alcohol on pancreatic tissue have so far been relatively unrewarding. The most widely held view is that alcohol causes the deposition of protein in peripheral ducts leading to obstruction, inflammation and degeneration. However, it remains to be shown that these deposits are the cause rather than a result of pancreatic inflammation. Research might be facilitated by the development of a suitable animal model of the disease.

Adult↗
PubMed1981

Myoelectric control of gastrointestinal and biliary motility: a review.

The movement of ingested food and secretions through the gastrointestinal and its appendages depends on a highly integrated and coordinated response of the smooth muscle contained within the wall of the gut. This review will consider, in detail, the various myogenic factors that contribute to the usual aboral propulsion of the gastrointestinal contents. The role of myoelectrical complexes as represented by slow waves and spike potentials are emphasized, for they appear to play a central role in the initiation of sphincter function and gastrointestinal peristalsis. The myoelectric control of the sphincter of Oddi is discussed in relationship to gastroduodenal motility, since disturbances in this finely modulated sphincter may lead to biliary-pancreatic dysfunction and symptoms of upper gastrointestinal disease.

Animals↗
PubMed2005

[Functional status of the bile ducts and their sphincters in short- and long-term period after resection of the stomach].

Morphofunctional state of the gall bladder and Oddi's sphincter was studied in 188 patients with stomach ulcer treated surgically for different complications of this disease. It is demonstrated that patients with stomach ulcer have dysfunction of the gall bladder before surgery, and in long-term period after stomach resection (especially by Bilrot-II technique) functional disorders transform in organic ones.

Adult↗
PubMed1998

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.

Adult↗
PubMed1984

Evidence for sphincter dysfunction in patients with gallstone associated pancreatitis: effect of ceruletide in patients undergoing cholecystectomy for gallbladder disease and gallstone associated pancreatitis.

The functional activity of the sphincter of Oddi complex has been examined by ceruletide manometry in patients undergoing cholecystectomy with a normal peroperative cholangiogram. In Group I (n = 14), which included patients with previous acute cholecystitis/biliary colic, the sphincter activity appeared to be normal and responded to intravenous ceruletide by a marked relaxation with a significant fall in both the infusion and postinfusion pressures. In patients undergoing cholecystectomy for gallstone-associated pancreatitis (n = 8), the sphincter exhibited manometric features of hypotonia with low infusion and postinfusion pressures which were not significantly altered by intravenous ceruletide.

Acute Disease↗
PubMed2003

Effects of bioactive agents on biliary motor function.

Our understanding of biliary motility under normal and pathophysiologic conditions is still incomplete, but there have been recent advances. Of particular interest are the mechanisms involved in gallbladder filling and emptying, with a focus on understanding the processes underlying impaired gallbladder emptying leading to gallbladder dyskinesia and the formation of gallstones or cholecystitis. The sphincter of Oddi (SO) is a complex neuromuscular structure. Recent studies have attempted to unravel the specific neural or hormonal mechanisms operating under normal physiologic conditions and those that may lead to SO dysfunction. Furthermore, new research fronts are emerging, including the role of leptin in obese patients with impaired biliary motility and the action of electroacupuncture for possible treatment of SO dysfunction. This review illustrates the broad front of current research regarding the effects of bioactive agents on biliary motility, including enteric hormones, nitric oxide, opioids, inflammatory mediators, leptin, protease inhibitors, neurotransmitters, and electroacupuncture.

Animals↗
PubMed1983

Direct choledochography and related diagnostic methods. Part 2: Sphincter of Oddi manometry.

Pressure measurement of the sphincter of Oddi segment during ERCP has enhanced the current understanding of normal biliary-pancreatic tract motor physiology as well as the effects of drugs and hormones. ERCP manometry has also provided information about SO function in pathological conditions in humans, such as bile duct stones, SO stenosis and SO dyskinesia. Finally, SO pressure measurements appear to be helpful in identifying patients with symptomatic SO dysfunction who will derive benefit from endoscopic sphincterotomy or surgical sphincteroplasty.

Ampulla of Vater↗
PubMed1988

Pharmacology of the sphincter of Oddi.

The sphincter of Oddi is the smooth muscle connection between the bile duct and the duodenum. Its physiological function is associated with a regular motility characterized by phasic contractions superimposed on the sphincter of Oddi baseline pressure. Recently introduced ERCP-manometry permits further studies of sphincter of Oddi pharmacology. A number of drugs have so far been studied. Sedatives of the diazepam type had no effect on the sphincter, while butylscopolaminium bromide, a typical neurotropic agent, brings about cessation of the sphincter motility for 3-8 minutes. Hymecromon lowered the sphincter baseline pressure from 9.8 to 7.8 mmHg. A 1.2 mg sublingual dose of nitroglycerin, a typical musculotropic agent, caused significant relaxation of the sphincter, and decreased baseline pressure from 8.9 mmHg to 2.9 mmHg; Sphincter motility was not affected. Morphine-like analgetics, in particular pentazocine, elevated sphincter baseline pressure, but buprenorphine and tramadol did not. Pharmacological doses of gastrointestinal hormones also affect the sphincter; CCK octapeptide, glucagon and secretin are able to decrease sphincter of Oddi baseline pressure, and CCK octapeptide abolishes sphincter motility. Sphincter of Oddi pharmacology is of clinical interest. The administration of sphincter-relaxing agents, in particular nitroglycerin and butylscopolaminium bromide, enables the endoscopist to extract small common bile duct stones without previous papillotomy. Analgetics that induce sphincter contraction and thus hinder the flow of bile and pancreatic juice, may be helpful for the treatment of pain in patients with pancreatico-biliary disease. Investigations into the effect of CCK on the healthy and diseased sphincter permit us to identify patients with sphincter dysfunction using a special CCK-provocation test.

Ampulla of Vater↗
PubMed2004

Normal sphincter of oddi motor function.

With the introduction of endoscopic retrograde cholangiopancreatography (ERCP) manometry, the characteristics of sphincter of Oddi (SO) motor activity have been described. SO manometry is the only available method to measure SO motor activity directly and is usually performed at the time of ERCP. SO manometry is considered to be the gold standard for evaluating patients for sphincter dysfunction. This review reports the technique of SO manometry and normal values for SO manometry. SO motility is characterized by prominent phasic contractions superimposed on a tonic pressure. Elevated basal SO pressure is the most consistent and reliable criteria to diagnose SO dysfunction. Basal pressures obtained from the biliary sphincter are similar to the basal pressure obtained from the pancreatic sphincter. Abnormal SO manometric values are shown. Factors that influence SO pressures, and interpretation of SO manometric tracing are discussed. The most common and serious complication of SO manometry is post-manometry pancreatitis. In healthy volunteers with normal sphincter function, pancreatitis is almost never seen. However, in patients with SO dysfunction, the incidence of pancreatitis is high. The use of new nonperfused microtransducers may reduce this complication.

Catheterization↗
PubMed1993

Effect of midazolam on sphincter of Oddi motility.

Midazolam is a more recent benzodiazepine used for sedation during endoscopic procedures, including sphincter of Oddi (SO) manometry. However, the effect of this drug on the human SO has so far not been studied. In this paper we explored the effect of midazolam on human SO motility by means of endoscopic manometry. Twelve patients with suspected SO dysfunction were investigated. We found that in patients with normal manometry findings, midazolam had no effect on the sphincter motility. In contrast, in all patients with elevated SO pressure (SOP), as well as in one of the three patients with borderline SO tone, midazolam (2.5 mg i.v.) produced a relaxatory effect. Due to this effect the final readings were affected in three out of five patients, i.e. the abnormally elevated SOP decreased to a borderline level in two and in the remaining patient the borderline level in two and in the remaining patient the borderline SOP decreased to normal. In one other patient with a markedly elevated SOP the additional injection of 2.5 mg of midazolam caused a further decrease in SOP to a borderline level. We conclude that midazolam, due to its relaxatory effect on SO, appears to be a less suitable sedative for SO manometry.

Biliary Dyskinesia↗
PubMed1982

Manometric study during endoscopic retrograde cholangiopancreatography--a new technique for the evaluation of pathology in the pancreatic and biliary systems.

During endoscopic retrograde cholangiopancreatography, pressures of the common bile duct, the pancreatic duct and the sphincter of Oddi were recorded in 64 patients with various diseases of the pancreaticobiliary system. The manometric study was found to be helpful in the diagnosis of papillary dysfunction and in the assessment of the adequacy of papillotomy and the size of a choledochoduodenostomy. Furthermore, it is possible that nitrates may be effective in the treatment of patients with papillary dysfunction.

Aged↗
PubMed1988

Pressure of papillary sphincter zone and pancreatic main duct in patients with alcoholic and idiopathic chronic pancreatitis.

To determine the significance of manometric pressure of the pancreatic duct in patients with alcoholic and idiopathic chronic pancreatitis, we used a microtransducer inserted through a duodenoscope to measure pressures in the papillary sphincter zone and pancreatic main duct in 20 control subjects and 31 patients with chronic pancreatitis without papillary stenosis including 10 cases of alcoholic chronic pancreatitis (ALCP) and 21 cases of idiopathic chronic pancreatitis (ICP). The pancreatic main ductal pressure was significantly higher in the patients with ALCP (55.7 +/- 28.9 mm Hg) or ICP (44.5 +/- 25.8 mm Hg) than in the controls (16.2 +/- 8.7 mm Hg), but there was no significant difference between ALCP and ICP. There was no significant difference between control subjects and ICP in the motility of the sphincter of Oddi. In ICP there were no correlationships between pancreatic ductal pressure and the motility of papillary sphincter zone. In ALCP, the frequency of the papillary sphincter waves was significantly higher than in normal subjects and there was a correlation between the pancreatic ductal pressure and the motility of the papillary sphincter zone. These data suggest that increased pancreatic ductal pressure in ALCP may be in part due to papillary dysfunction, but not in ICP.

Alcoholism↗