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PubMed1984

Endoscopic manometry of the sphincter of Oddi in patients with and without juxtapapillary duodenal diverticula.

The motor activity of the sphincter of Oddi (SO) has been evaluated, by endoscopic manometry, in 48 subjects, 8 with and 40 without duodenal juxtapapillary diverticula. All values were expressed in mm Hg, taking duodenal pressure as zero reference. In subjects with diverticula the SO basal pressure was 14.1 +/- 4.3 mm Hg, peak pressure was 52.3 +/- 17.2 mm Hg, and wave height was 39.75 +/- 14.19 mm Hg; in subjects without diverticula these values were 31.2 +/- 8.9 mm Hg, 93.2 +/- 21.3 mm Hg, and 68.17 +/- 25.86, respectively. The difference was statistically significant (P less than 0.001 for basal and peak pressure; P less than 0.002 for wave height). Wave frequency was not significantly different in controls (4.99 +/- 1.17/min) and in subjects with diverticula (4.98 +/- 1.13/min). These findings seem to indicate that in patients with diverticula the SO is insufficient or dysfunctioning . The insufficiency of the SO and a reflux of bacteria from the duodenum into the bile duct could play a major role in the formation of stones in patients with diverticula. The same mechanism could be responsible for duodenopancreatic reflux and possible pancreatic lesion.

Adult↗
PubMed1988

Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.

Adult↗
PubMedDate not supplied

Functional biliary-type pain: update and controversies.

Recurrent biliary-type abdominal pain is a perplexing clinical dilemma that occurs in patients with an acalculous gallbladder in situ or in patients who have undergone a previous cholecystectomy. The pathogenesis of functional biliary-type pain is often unclear; therefore, evaluation and management remain controversial. In patients with an acalculous gallbladder in situ, critical importance has been given to delayed gallbladder emptying using cholescintigraphy (CCK-CS) to determine if gallbladder dysfunction is present. However, several issues remain unresolved, including methodology, definition of delayed emptying, and the absence of high-quality studies to determine if CCK-CS can predict who will do well with cholecystectomy. In patients with previous cholecystectomy, the main area of controversy is the evaluation of patients with sphincter of Oddi Type III, including the role of endoscopic retrograde cholangiopancreatography with SO manometry and sphincterotomy in these patients. Suggested algorithms for management of both clinical scenarios are provided.

Biliary Tract Diseases↗
PubMed1993

Effects of ethanol on the motility of papillary sphincter and exocrine pancreas in the monkey.

The effects of acute and chronic ethanol administration on the motility of the papillary sphincter, pancreatic duct pressures, and exocrine pancreas were studied. Acute administration (n = 5) significantly reduced the peak pressure of the papillary sphincter from 84.2 +/- 19.6 to 15.8 +/- 3.0 mm Hg (p < 0.05) and increased the frequency from 0.041 +/- 0.002 to 0.067 +/- 0.005/s (p < 0.01). Chronic administration (n = 5) significantly increased pancreatic duct pressure and frequency of the papillary sphincter from 8.6 +/- 2.9 to 22.1 +/- 2.9 mm Hg (p < 0.01) and from 0.039 +/- 0.002 to 0.071 +/- 0.004/s (p < 0.01), respectively. However, it reduced the peak pressure of the papillary sphincter from 84.8 +/- 15.1 to 21.1 +/- 2.8 mm Hg (p < 0.05). Electron microscopy showed dilation and a concentric arrangement of the rough endoplasmic reticulum in the acinar cells. The exocrine function test showed an increased concentration and output of bicarbonate, protein, and amylase. These findings suggest that chronic alcohol intake may cause papillary dysfunction and pancreatic exocrine hypersecretion, which could play a role in increasing pancreatic duct pressure.

Amylases↗
PubMed2000

Sphincter of Oddi motility in patients with hepatolithiasis and common bile duct stones.

The purpose of this study was to explore a difference in sphincter of Oddi (SO) motor activity among patients with intrahepatic (I, N = 5), intra- and extrahepatic (IE, N = 15), and common bile duct (CBD, N = 6) stones. Interdigestive motility of the SO and duodenum was studied by pneumohydraulic infusion manometry via the percutaneous route. SO phasic contractions showed a cyclic change in concert with the duodenal migrating motor complex (MMC) in all these patients. There was no significant difference in the cycle length, frequency, or amplitude of the SO phasic waves among the three groups throughout the whole cycle. The SO basal pressure during duodenal phases I and II of the duodenal MMC was significantly lower in patients with the IE type of hepatolithiasis than in those with the I type (P = 0.04), but there was no significant difference during phase III between the two groups. The SO basal pressure during phases I and II of the CBD group was also significantly lower than that of the I group (P = 0.02). The significance became even more prominent (P = 0.001) when a subgroup of patients with a dilated CBD (diameter > 1 cm) was examined. Lower basal pressure in the IE group or CBD group than in the I group suggested that stones in the common duct might injure or irritate the SO and cause SO dysfunction. In the subgroup with dilated CBD, which may have resulted from repeated and severe SO injury, the statistics became more prominent.

Adult↗
PubMed1991

Biliary pain in postcholecystectomy patients without biliary obstruction. A prospective radionuclide study.

Biliary pain without obvious biliary obstruction is common in postcholecystectomy patients. We studied 20 symptomatic patients with episodes of biliary-type pain after cholecystectomy (all having undergone endoscopic retrograde cholangiography), and in 18 asymptomatic postcholecystectomy controls. We performed quantitative hepatobiliary radionuclide analysis with dimethyl-imidodiacetic acid. From a series of 90 dynamic images at 1-min intervals using a gamma camera coupled to a computer, time-activity curves were produced in regions of interest in the liver, intrahepatic biliary tree, common duct, and heart, from which quantitative biliary excretion indexes were obtained. The results demonstrate a biliary kinetic dysfunction in patients with postcholecystectomy pain without morphological abnormalities.

Abdominal Pain↗
PubMed2001

Increased sphincter of Oddi basal pressure in patients affected by gall stone disease: a role for biliary stasis and colicky pain?

BACKGROUND AND AIMS: Even if the motor activity of the gall bladder and sphincter of Oddi (SO) are integrated, it is not known if the presence of stones in the gall bladder affects SO function. The aim of the study was to compare SO motor activity in patients with and without gall stones. PATIENTS AND METHODS: In a series of 155 patients consecutively submitted to endoscopic retrograde cholangiopancreatography and SO manometry for suspected biliary or pancreatic disease, 23 gall stone patients had recurrent episodes of biliary or pancreatic pain (colicky group); 52 patients had non-biliary/pancreatic-type abdominal pain/discomfort, and of these, 15 had gall stones (non-colicky group), 25 were free of stones (controls), and 12 had undergone cholecystectomy. RESULTS: SO basal pressure in gall stone patients in the colicky or non-colicky group was significantly higher than in controls (p<0.001). SO basal pressure recorded in postcholecystectomy patients did not differ from controls. SO phasic activity did not differ between the patient groups. SO dysfunction was detected in more than 40% of gall stone patients irrespective of associated biliary/pancreatic pain but in none of the control subjects (p<0.001). CONCLUSIONS: Gall stones are frequently associated with increased SO tone which may obstruct bile flow thus acting to facilitate gall bladder stasis, and may play a role as a cofactor in biliary/pancreatic pain.

Adolescent↗
PubMed2000

Endoscopic sphincter of Oddi manometry with a portable electronic microtransducer system: comparison with the perfusion manometry method and routine clinical application.

BACKGROUND AND STUDY AIMS: Endoscopic perfusion manometry (PM) of the sphincter of Oddi (SO) requires expensive equipment which is relatively large and uncomfortable to handle in the endoscopic retrograde cholangiopancreatography (ERCP) setting. Furthermore, the volume load of the biliopancreatic system may contribute to the increased risk of pancreatitis after SO manometry. PATIENTS AND METHODS: The newly developed small and lightweight microtransducer system consists of a portable data-logger with integrated online display which is connected to a 4-Fr manometry probe. The manometry catheter is inserted endoscopically into the biliopancreatic system via a 7-Fr Teflon sheath. SO motility can be observed online on the display but the data can also be stored for later analysis on a personal computer (PC). To validate the new method, 15 patients with suspected biliary SO dysfunction underwent both PM as well as microtransducer manometry (MTM) in randomized order. Thereafter, 50 consecutive patients with suspected biliary or pancreatic SO dysfunction were investigated solely by MTM. RESULTS: PM was possible in 13 of 15 cases whereas MTM could be performed in all 15 patients. The basal SO pressure tended to be lower (approximately 5 mmHg) when measured with the MTM, compared with the PM method, but there was a significant and nearly linear correlation between the basal SO pressures obtained by both methods (r=0.98, P<0.001). SO dysfunction was diagnosed in the same five patients using both methods. Furthermore, the parameters of phasic SO motility were highly comparable when measured by MTM and PM. MTM was carried out successfully in 49 of 50 patients and only one MTM probe was used for all examinations, without malfunction. The endoscopist was able to diagnose SO dysfunction (by immediate observation of SO motility on the display) in 19 of 20 patients (when compared with the later PC analysis) and SO motility was judged correctly as normal in the remaining 29 cases. MTM was repeated in five patients with SOD 1-6 weeks after the first examination and the manometric findings were confirmed in all cases. Mild postmanometry pancreatitis was observed in only one of 49 patients (2%). CONCLUSIONS: Endoscopic MTM is a reliable, safe, very easy to handle, and low-cost alternative for the clinical assessment of SO motility.

Adult↗
PubMed1991

Pressure measurements from biliary and pancreatic segments of sphincter of Oddi. Comparison between patients with functional abdominal pain, biliary, or pancreatic disease.

Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27-69) had the diagnosis of functional abdominal pain, 19 patients (ages 30-76) had partial biliary obstruction, and 24 patients (ages 15-80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis.

Abdominal Pain↗
PubMed2003

Clinical significance of sphincter of Oddi dyskinesia.

Sphincter of Oddi dyskinesia (SOD) is a functional disorder of the papilla region that can lead to clinical symptoms and functional obstruction of biliary and pancreatic outflow. Based on the severity of the clinical symptoms, the disorder is classified as one of three types (biliary or pancreatic type I-III). Diagnosis of SOD is hampered by the relative risk of endoscopic sphincter manometry to cause pancreatitis. Manometrically, SOD is characterized by increased pressure in the biliary or pancreatic sphincter segment and can be treated with endoscopic papillotomy. This review is an attempt to balance the arguments for invasive diagnosis with a pragmatic clinical approach in which papillotomy is performed if clinical suspicion and patient presentation support a dysfunction of the papilla. For patients with biliary or pancreatic type I, endoscopic papillotomy is the treatment of choice. In biliary type II, SO manometry may be helpful for clinical decision making; however, the ratio of risks to benefits is difficult to assess based on the present data. In type III SOD, patient selection and the low predictive value of manometry for treatment success raise questions about the clinical usefulness of SO manometry.

Animals↗
PubMed1994

Effects of gastrectomy on motility, perfusion pressure, and caerulein-induced relaxation of sphincter of Oddi in dogs.

The effects of subtotal-gastrectomy (gastrectomy) on the spontaneous motility and caerulein-induced relaxation of the sphincter of Oddi (SO) were investigated in the dog. The spontaneous motility and the response to caerulein of the SO were recorded using perfusion method. The basal perfusion pressure (5.1 +/- 0.5 cmH2O) and the frequency of phasic contractions (6.1 +/- 0.5 cycles/min, c/min) of the SO increased to 8.2 +/- 0.6 cmH2O (p < 0.05) and 9.3 +/- 0.4c/min (p < 0.05) after gastrectomy, respectively. They were observed one month after operation (7.8 +/- 0.5 cmH2O and 9.1 +/- 0.9 c/min, p < 0.05), but did not change by vagotomy with sympathectomy (vagosympathectomy). In the spontaneous motility of the SO, the motility index increased to 143.7 +/- 18.7% (p < 0.05) at 4 hrs and 135.0 +/- 9.1% (p < 0.05) at one month after gastrectomy, but did not increase after vagosympathectomy. Caerulein had an inhibitory effect on the SO motility in the normal animal 48.0 +/- 4.2%). Gastrectomy reversed to the excitatory effect from the inhibitory effect to caerulein at 4 hrs (127.6 +/- 5.3%, p < 0.05) and at one month (126.6 +/- 5.3%, p < 0.05) after operation, but not reversed by vagosympathectomy and sham gastrectomy. The excitatory response to caerulein after gastrectomy was not effected by vagosympathectomy. It is concluded that gastrectomy induced the SO dysfunction, an increase of the perfusion pressure and the frequency of phasic contractions of the SO, and a change of the response to caerulein of the SO. These alterations suggests that one of the mechanisms of the regulation of the SO motility exist as the reflex from the stomach and/or uppermost duodenum through intrinsic nervous pathways.

Animals↗
PubMed2003

The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog.

AIM: To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regularizing effect of gallbladder. METHODS: Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed. RESULTS: According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0+/-2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8+/-0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P<0.01) in the interval period of bile draining, but significative difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8+/-0.5 mmHg) and the bile flowing period (15.9+/-0.9 mmHg) (P>0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling. CONCLUSION: During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.

Animals↗
PubMed2003

Alcohol-induced pancreatic injury.

Alcoholic pancreatitis is a major complication of alcohol abuse. Until recently, it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, evidence is now emerging in support of the 'necrosis-fibrosis' hypothesis that alcoholic pancreatitis begins as an acute process and that repeated episodes of acute injury lead to the changes of chronic pancreatitis (acinar atrophy and fibrosis) resulting in exocrine and endocrine dysfunction. The treatment of acute pancreatitis follows the regimen of bed rest, nasogastric suction, analgesia and intravenous support. The role of additional therapeutic measures such as prophylactic antibiotics, antioxidants and enteral nutrition in severe cases has not yet been precisely defined. The treatment of chronic pancreatitis involves attention to its three cardinal features: pain, maldigestion and diabetes. With respect to the pathogenesis of alcoholic pancreatitis, the focus of research over the past 30 years has shifted from the sphincter of Oddi and ductular abnormalities to the acinar cell itself. It has now been established that the acinar cell is capable of metabolizing alcohol and that direct toxic effects of alcohol and/or its metabolites on acinar cells may predispose the gland to injury in the presence of an appropriate trigger factor. A significant recent development relates to the characterization of pancreatic stellate cells, increasingly implicated in alcoholic pancreatic fibrosis. This chapter summarizes the natural history, clinical features, current trends in treatment as well as recent advances in our understanding of the pathogenesis of alcoholic pancreatitis.

Acute Disease↗
PubMed1986

Endoscopic measurement of papillary sphincter zone and pancreatic main ductal pressure in patients with chronic pancreatitis.

To determine the significance of manometric pressure of the pancreatic duct, 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 20 patients with chronic pancreatitis, and recorded the effect of exogenous glucagon or secretin. There was no significant difference between control subjects and patients with chronic pancreatitis without papillitis in the motility of the sphincter of Oddi. The pancreatic main ductal pressure was significantly higher in the patients with chronic pancreatitis (54.5 +/- 29.9 mmHg) than in the control subjects (16.2 +/- 8.7 mmHg). The viscosity of pure pancreatic juice of patients with chronic pancreatitis [5.8 centipoise (cp)] in the basal secretory state was significantly higher than that of the control subjects (1.61 cp). These data lead to the hypothesis that increased pancreatic ductal pressure in patients with chronic pancreatitis without papillitis is due not to papillary dysfunction, but to increased viscosity or other unknown factors.

Ampulla of Vater↗
PubMed1995

Octreotide-associated biliary tract dysfunction and gallstone formation: pathophysiology and management.

Octreotide exerts a wide range of biological actions, many of which have important clinical applications, notably in treatment of acromegaly, gastroenteropancreatic endocrine tumors, and secretory diarrhea. In most patients, octreotide is well tolerated. Side effects are primarily gastrointestinal and are usually transient. Short term (< or = 1 month) octreotide therapy appears to pose minimal risk of gallstone formation, but the risk may increase with longer treatment periods. Chronic octreotide administration may increase the incidence of small, cholesterol gallstones that are typically asymptomatic. The mechanism of octreotide-associated gallstone formation is not delineated but may involve inhibition of gallbladder emptying, hepatic bile secretion, and sphincter of Oddi motility, as well as modification of bile composition. Gallbladder stasis may sequentially lead to increased bile concentration, precipitation of cholesterol and calcium salts, retention of biliary precipitates, and maturation of gallstones. Octreotide-associated gallstones are usually asymptomatic and do not require surgical or medical therapy. Some physicians advocate periodic gallbladder ultrasound evaluations, but, in most cases, the results would not influence management of asymptomatic patients. Symptomatic gallstones may require surgery or nonsurgical treatments after an appropriate work-up. Gallstone prevention strategies (e.g., bile acid or nonsteroidal anti-inflammatory drug therapy) during long term octreotide therapy are under investigation. Currently, clinicians may want to consider noninvasive strategies to reduce gallstone incidence, such as timing octreotide injections in relation to meals or periodic cessation of octreotide treatment. Octreotide is a valuable therapeutic option in managing a variety of hypersecretory states associated with high morbidity and mortality (e.g., acromegaly, carcinoid syndrome, and VIP-secreting tumors), so the benefits of long term octreotide therapy (such as increased quality of life) outweigh the risk of asymptomatic gallstone formation in many patients.

Bile↗
PubMed1999

Postcholecystectomy syndrome: evaluation by biliary cholescintigraphy and MR cholangiopancreatography

PURPOSE: The aim of this study was to compare the anatomic data obtained by magnetic resonance cholangiopancreatography (MRCP) with the functional data obtained by Tc-99m iminodiacetic acid (IDA) hepatobiliary imaging in patients with postcholecystectomy syndrome. MRCP provides good quality imaging of the biliary tract, highlighting walls and dilatation or stenosis of the biliary tract, stones in the cystic duct remnant, the pancreas, and the pancreatic ducts. Hepatobiliary imaging permits evaluation of hepatocellular function and the dysfunctional components of biliary obstruction. METHODS: MRCP showed biliary tract dilatation in four of five patients; this was associated with pathologic dilatation of the cystic duct and stenosis of the distal end of the common bile duct in three patients. Tc-99m IDA imaging showed hepatocellular functional changes (prolonged maximum concentration time and lower hepatic extraction fraction) in five of five patients, and delayed visualization of the hepatic duct and common bile duct in four patients. Intestinal passage of the radiopharmaceutical occurred in all patients only after a high-fat meal. Two patients had slow biliary emptying of Tc-99m IDA with normal results of MRCP. RESULTS: These data, together with the absence of structural changes in the biliary tract walls, suggest that sphincter of Oddi spasm during fasting causes slower passage, whereas the physiologic stimulation of a high-fat meal aids intestinal bile flow. CONCLUSION: The combined study of the biliary tract by MRCP and Tc-99m IDA imaging yields an efficient and complete evaluation of the postcholecystectomy syndrome.

Journal Article↗
PubMedDate not supplied

[Cineradiological study of the activity of sorbiperan on the gallbladder and colon (author's transl)].

The activity of sorbiperan was assessed during radiological examinations of 15 patients with hypomobility of the gallbladder, associated in some cases with atonic dyspepsia, and 25 cases of spastic colon with constipation and/or diarrhea due to diverticulosis, dolichocolon, sigmoiditis, or parasitosis. Patients with gallbladder dysfunction were examined radiologically before and after oral administration of 20 to 40 ml of sorbiperan, the dose varying as a function of bodyweight. In 3 patients, the hypermobility of the gallbladder provoked by this agent was greater than that observed with all usually employed products, in 11 cases the cholagogue produced an excellent effect, while in one case there was no observed effect. Patients with colitis were administered a barium enemea, and an initial series of films were taken. These were repeated after addition of 80 ml of sorbiperan to the same enema. Total, rapid evacuation of the colon was observed in 8 cases, while in 15 cases it was of excellent quality. No effect was noted in 2 cases. Sorbiperan provokes effective contractions of the gallbladder, favours sphincter of Oddi dynamics, increases motility of all digestive tract segments, and very significantly accelerates gastro-entero-colic peristalsis. Tolerance was excellent.

Adult↗