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PubMed1989

What is sphincter of Oddi dysfunction?

Ever since its description approximately 100 years ago, the sphincter of Oddi has been surrounded by controversy. First, whether it indeed existed, second, whether it had a significant physiological role in man and more recently whether abnormalities in its function give rise to a clinical syndrome. Data from animal and human studies, using sensitive techniques, have helped define the physiological role of the sphincter of Oddi, and more recent studies are determining the factors which control sphincter of Oddi function. These studies support Oddi's original description that the sphincter has a major role in the control of flow of bile and pancreatic juice into the duodenum, and equally importantly helps prevent the reflux of duodenal contents into the biliary and pancreatic ductal systems. The controversy of whether abnormalities in sphincter of Oddi motility result in clinical syndromes has not been totally resolved. Part of the difficulty has been inability to document normal and hence abnormal function of the sphincter. With the emergence of endoscopic biliary manometry as a sensitive and reproducible technique, however, the motility of the human sphincter of Oddi has come under closer scrutiny and allowed definition of possible disorders. We have used the term sphincter of Oddi dysfunction to define manometric abnormalities in patients who present with signs and symptoms consistent with a biliary or pancreatic ductal origin. Based on the manometry, we have subdivided the dysfunction into two groups; a group characterised by a stenotic pattern - that is, raised sphincter basal pressure - and a second group having a dyskinetic pattern - that is, paradoxical response to cholecystokinin injection, rapid contraction frequency, high percentage of retrograde contractions, or short periods of raised basal percentage of retrograde contractions, or short periods of raised basal pressure. It is apparent from the mamometry but also from the clinical data that the patients are a heterogeneous group and thus any therapy would need to be tailored for each patient and abnormality. The most recent therapeutic data suggest that patients with the stenotic pattern on manometry respond to division of the sphincter, however, those patients with the dyskinetic manometric pattern show no significant effect after sphincterotomy. Further prospective trials evaluating therapeutic options are under way and their results are eagerly awaited.

Ampulla of Vater↗

PubMed1988

Sphincter of Oddi dysfunction: a clinical controversy.

This report analyzes the literature on sphincter of Oddi dysfunction as it applies to biliary-type pain. The sensitivities and specificities of the tests used to diagnose this condition (e.g., size of bile duct, drainage time of bile duct, provocative tests with morphine, sphincter of Oddi manometry) are poorly defined. Recent studies suggest that noninvasive tests such as quantitative nuclear scintigraphy and fatty meal sonography may aid in diagnosing functional common bile duct obstruction. Continuous manometry of the biliary tree with microtransducer technologies may allow a greater understanding of the causes of pain in this group of patients. Only 1 case report of pharmacologic management for this disorder exists in the literature. Endoscopic sphincterotomy may be helpful in relieving the pain that occurs in this condition but is associated with increased risks. There is no consensus in the literature as to the best test that will predict response to sphincterotomy. Controlled trials of medical therapies are needed.

Ampulla of Vater↗

PubMed2000

Sphincter of Oddi dysfunction: two case reports and a review of the literature.

Sphincter of Oddi dysfunction is an underdiagnosed but important clinical condition. It should be considered in the differential diagnosis of biliary pain when the gallbladder sonogram shows no evidence of gallbladder disease. Hepatobiliary scanning (Tc-99m dimethyl iminodiacetic acid) may provide valuable information in the evaluation of these patients and may be helpful in monitoring response to treatment.

Adult↗

PubMed1999

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept.

BACKGROUND: The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition. METHODS: We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians. RESULTS: An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis. CONCLUSIONS: Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.

Adolescent↗

PubMedDate not supplied

Sphincter of Oddi dysfunction in patients with intact gallbladder: therapeutic response to endoscopic sphincterotomy.

Increasing evidence exists of the occurrence of sphincter of Oddi dysfunction in patients with an intact gallbladder. Optimal therapy for such patients has not been defined. From 1989 to 1991, 35 patients with sphincter of Oddi dysfunction (abnormal basal sphincter pressure > 40 mm Hg) and an intact gallbladder were identified. The patients with abnormal ductography (except for duct dilation), pancreas divisum, or pancreato-biliary malignancy were excluded. All patients had disabling upper abdominal pain, which was quantified on a 0 = none to 10 = severe pain scale. All patients received standard endoscopic biliary sphincterotomy and were followed up for 4 to 26 months with a mean of 13 months. Initially, 27 of 35 patients (77%) showed at least 50% improvement in the pain score, whereas only 15 of the 27 remained improved throughout the follow-up interval. Patients who were unimproved or had relapses were offered cholecystectomy and 11 patients underwent the procedure. These patients were followed up after cholecystectomy for 2 to 24 months, with a mean of 13 months. Eight of 11 were improved. In summary, the combination of endoscopic sphincterotomy and selective cholecystectomy and minimal medical treatment resulted in a good and excellent response rate of 68%. Better techniques are needed to select patients who will respond to these therapies.

Abdominal Pain↗

PubMed1994

Intrasphincteric injection of botulinum toxin for suspected sphincter of Oddi dysfunction.

Botulinum toxin is a potent inhibitor of the release of acetylcholine from nerve endings. It has previously been shown that it can effectively reduce lower oesophageal sphincter pressures both in animals and humans with achalasia. This study examined the hypothesis that locally injected botulinum toxin could also reduce sphincter of Oddi pressure in patients with sphincter of Oddi dysfunction. Two patients with postcholecystectomy pain syndrome were diagnosed with sphincter of Oddi dysfunction (by biliary manometry in one patient and by hepatobiliary scanning criteria in the other). Botulinum toxin was injected into the sphincter of Oddi, by a sclerotherapy needle passed through a duodenoscope. In the first patient, intrasphincteric injection of botulinum toxin reduced sphincter pressure by about 50%, an effect that was sustained for at least four months. In the second patient, intrasphincteric injection caused about a 50% improvement in bile flow, with normalisation of scintigraphy. Neither patient showed any sustained improvement in pain despite these objective findings. Both patients eventually had endoscopic sphincterotomy, which also did not result in symptomatic improvement in either patient. No side effects were seen. Intrasphincteric botulinum toxin is a simple and effective means of lowering sphincter of Oddi pressure. This technique has potential for being useful clinically.

Adult↗

PubMed1995

Biopsies of the ampullary region in patients suspected to have sphincter of Oddi dysfunction.

Tumors of the ampulla of Vater that develop within the ampulla can go unrecognized during endoscopic examination. Patients with intra-ampullary tumors may present with a clinical picture very similar to that of sphincter of Oddi dysfunction. We wished to determine what percentage of patients initially diagnosed with sphincter of Oddi dysfunction are later found to have an intra-ampullary neoplasm. Sixty-nine consecutive patients were considered to have sphincter of Oddi dysfunction and subsequently were treated with endoscopic sphincterotomy. No gallstones were found in the gallbladder or bile duct. Patients returned for biopsies of the ampulla at least 10 days after the endoscopic sphincterotomy. Three patients (4.3%) were found to have ampullary adenocarcinoma. Thirty-six had normal results of biopsy analysis and 30 had inflammatory or fibrotic changes on biopsy specimens. No objective criteria (clinical, biologic, endoscopic, or radiographic) that would help to distinguish between an ampullary tumor and sphincter of Oddi dysfunction were identified. Biopsies of the ampulla should be performed in all patients suspected of having sphincter of Oddi dysfunction and treated by endoscopic sphincterotomy.

Adenocarcinoma↗

PubMed2004

Suspected sphincter of Oddi dysfunction type II: empirical biliary sphincterotomy or manometry-guided therapy?

BACKGROUND AND STUDY AIMS: Sphincter of Oddi manometry is considered to be the gold standard for diagnosing sphincter of Oddi dysfunction (SOD). Elevated basal sphincter pressures are found in about half of the patients with findings consistent with biliary type II SOD, and most of these patients will symptomatically improve after endoscopic sphincterotomy. Since manometric sphincter evaluation is not widely available, a decision analysis was used to compare the overall costs and outcomes of manometry-directed therapy with "empirical" sphincterotomy in patients with suspected biliary type II SOD. PATIENTS AND METHODS: A decision analysis model was constructed using a software program. In a hypothetical cohort of 100 patients with suspected type II SOD, the following strategies were evaluated: a). endoscopic retrograde cholangiopancreatography (ERCP) with manometry followed by biliary sphincterotomy only if an elevated sphincter of Oddi basal pressure was found; and b). "empirical" biliary sphincterotomy without manometry. Data on the probability of an elevated sphincter of Oddi basal pressure at the time of ERCP in patients with suspected biliary SOD type II, the proportion of patients who improved after biliary sphincterotomy (with and without elevated basal pressures), the proportion of patients who improved without biliary sphincterotomy, complications, and death were obtained from the literature and from our center. The procedural and hospitalization costs represented the average Medicare reimbursement at our institution. The expected overall costs and numbers of patients improving with each strategy were compared.[nl] RESULTS: The strategy of ERCP with manometry resulted in total costs of US dollars 2790 per patient, whereas a strategy of "empirical" biliary sphincterotomy resulted in total costs of US dollars 2244. In a cohort of 100 patients with suspected SOD, 55 % of patients would be expected to improve if manometry were performed, compared to 60 % of patients improving with "empirical" biliary sphincterotomy. Univariate sensitivity analyses demonstrated that "empirical" biliary sphincterotomy continued to be a cost-saving strategy in comparison with ERCP with manometry as long as the probability of spontaneous improvement in patients with "normal" manometry was less than 41 %, the probability of complications associated with manometry was greater than 6 %, and the probability of complications due to biliary sphincterotomy was less than 19 %. CONCLUSIONS: For patients with suspected biliary SOD type II, empirical biliary sphincterotomy performed by experienced endoscopists appears to be cost-saving in comparison with a strategy based on the results of manometry.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2000

Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction.

AIM: To evaluate the technical feasibility, safety, and short-term efficacy of botulinum toxin injection for pancreatic sphincter of Oddi dysfunction and to analyse whether the symptomatic response to botulinum toxin might be a predictor of outcome for endoscopic sphincterotomy. METHODS: Fifteen consecutive patients (nine female, aged 38 +/- 12 years) with frequent attacks (median four) of acute pancreatitis within 6 months, and manometrically proven pancreatic sphincter of Oddi dysfunction underwent endoscopic injection of 100 units of botulinum toxin into the major papilla. All patients underwent prospective follow-up thereafter and in cases of recurrent pancreatitis manometry this was repeated and pancreatic sphincterotomy was performed. RESULTS: No side-effects occurred after botulinum toxin injection in any patient. Within 3 months after botulinum toxin treatment, 12 out of 15 patients remained asymptomatic (80% primary response). Only one out of three patients without symptomatic benefit showed continued elevated pancreatic sphincter pressure at manometry and only this patient benefited from pancreatic sphincterotomy later on. Eleven of the 12 patients initially responding to botulinum toxin injection developed a symptomatic relapse 6 +/- 2 months after botulinum toxin treatment. These patients then achieved long-term clinical remission from pancreatic or combined (biliary and pancreatic, n=5) sphincterotomy (median follow-up, 15 months). CONCLUSION: Endoscopic botulinum toxin injection into the papilla of Vater is a safe procedure for treatment of pancreatic sphincter of Oddi dysfunction that may provide short-term relief in about 80% of the patients. Those patients who respond to botulinum toxin may subsequently gain definitive cure from sphincterotomy.

Acute Disease↗

PubMed2007

Predictors of outcomes after biliary and pancreatic sphincterotomy for sphincter of oddi dysfunction.

BACKGROUND: There are few data on combined pancreatic and biliary sphincterotomy for sphincter of Oddi dysfunction (SOD), especially regarding clinical features that might predict outcomes. We sought to examine the relative importance of various clinical features and the presence or absence of objective biliary abnormalities in determining responses to endoscopic therapy. METHODS: A cohort of consecutive patients with suspected SOD was treated with biliary sphincterotomy, with additional pancreatic sphincterotomy at initial or subsequent endoscopic retrograde cholangiopancreatography if there was abnormal pancreatic manometry in conjunction with pain refractory to biliary sphincterotomy, continuous pain, or a history of amylase elevation. Repeat intervention was offered until response was achieved or complete ablation of all treated sphincters was achieved. Response was assessed by patients using a 5-point Likert scale, and multivariate logistic regression analysis used to identify predictors of response. RESULTS: Of 121 patients, 112 (92%) were female, 105 (87%) postcholecystectomy, and by modified Milwaukee biliary classification 18 (15%) were type I, 53 (44%) type II, and 50 (41%) type III. All patients underwent biliary sphincterotomy and 49 (40%) pancreatic sphincterotomy. Good or excellent response at final follow-up was reported by 83 (69%) of 121 patients, including 37 (61%) of 61 patients requiring repeated intervention. Response was not significantly different between biliary types I, II, and III. Patient characteristics (with adjusted odds ratios) that were significant predictors of poor response were normal pancreatic manometry (4.6), delayed gastric emptying (6.0), daily opioid use (4.0), and age <40 (2.7). Abnormal liver function tests or dilated bile duct were not significant. CONCLUSIONS: For the treatment of SOD incorporating pancreatic and biliary sphincterotomy, patient characteristics and pancreatic sphincter manometry may be more important predictors of outcome than the traditional classification based on liver chemistries and bile duct dilation.

Adolescent↗

PubMedDate not supplied

[Acute recurrent pancreatitis in a patient with Oddi's sphincter dysfunction].

Alcohol consumption and gallstones are the most common causes of acute pancreatitis in developed countries. However, some episodes of acute pancreatitis have being regarded "idiopathic" once blood samples have been analyzed and diagnostic procedures (abdominal ultrasonography, CT and ERCP) have been performed. Sphincter of Oddi (SO) dysfunction is a rare entity that may be involved in the development of recurrent acute pancreatitis. SO manometry is the first option to investigate SO dysfunction. A recurrent idiopathic pancreatitis case in a young patient is presented. The manometric study revealed SO dysfunction, and oral nidefipine 10 mg was started. After a 12-months follow-up undergoing this therapy, the patient remains asymptomatic.

Acute Disease↗

PubMed1992

A noninvasive test of sphincter of Oddi dysfunction in postcholecystectomy patients: the scintigraphic score.

The ideal noninvasive test of sphincter of Oddi dysfunction (SOD) does not exist and the diagnosis of patients with postcholecystectomy pain often relies on invasive procedures. In this paper we describe a scintigraphic test for SOD: the scintigraphic score. This score combines quantitative and visual criteria for interpretation of hepatobiliary scans. Twenty-six consecutive postcholecystectomy patients underwent hepatobiliary imaging, ERCP, and sphincter manometry. Twelve patients had SOD and 14 had normal sphincters determined by clinical findings, ERCP, and manometric studies. All patients with normal sphincter had scores of 0-4, while patients with SOD had values of 5-12 for a perfect sensitivity and specificity of 100%. Hepatobiliary scans scored in this fashion may become the noninvasive test of choice to screen postcholecystectomy patients with suspected SOD.

Adult↗

PubMed2006

Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction: effect of papillotomy.

AIM: To characterize functional biliary pain and other gastrointestinal (GI) symptoms in postcholecystectomy syndrome (PCS) patients with and without sphincter of Oddi dysfunction (SOD) proved by endoscopic sphincter of Oddi manometry (ESOM), and to assess the post-endoscopic sphincterotomy (EST) outcome. METHODS: We prospectively investigated 85 cholecystectomized patients referred for ERCP because of PCS and suspected SOD. On admission, all patients completed our questionnaire. Physical examination, laboratory tests, abdominal ultrasound, quantitative hepatobiliary scintigraphy (QHBS), and ERCP were performed in all patients. Based on clinical and ERCP findings 15 patients had unexpected bile duct stone disease and 15 patients had SOD biliary type I. ESOM demonstrated an elevated basal pressure in 25 patients with SOD biliary-type III. In the remaining 30 cholecystectomized patients without SOD, the liver function tests, ERCP, QHBS and ESOM were all normal. As a control group, 30 'asymptomatic' cholecystectomized volunteers (attended to our hospital for general cardiovascular screening) completed our questionnaire, which is consisted of 50 separate questions on GI symptoms and abdominal pain characteristics. Severity of the abdominal pain (frequency and intensity) was assessed with a visual analogue scale (VAS). In 40 of 80 patients having definite SOD (i.e. patients with SOD biliary type I and those with elevated SO basal pressure on ESOM), an EST was performed just after ERCP. In these patients repeated questionnaires were filled at each follow-up visit (at 3 and 6 mo) and a second look QHBS was performed 3 mo after the EST to assess the functional response to EST. RESULTS: The analysis of characteristics of the abdominal pain demonstrated that patients with common bile duct stone and definite SOD had a significantly higher score of symptomatic agreement with previously determined biliary-like pain features than patient groups of PCS without SOD and controls. In contrary, no significant differences were found when the pain severity scores were compared in different groups of PCS patients. In patients with definite SOD, EST induced a significant acceleration of the transpapillary bile flow; and based on the comparison of VASs obtained from the pre- and post-EST questionnaires, the severity scores of abdominal pain were significantly improved, however, only 15 of 35 (43%) patients became completely pain free. Post-EST severity of abdominal pain by VASs was significantly higher in patients with predominant dyspepsia at initial presentation as compared to those without dyspeptic symptoms. CONCLUSION: Persistent GI symptoms and general patient dissatisfaction is a rather common finding after EST in patients with SOD, and correlated with the presence of predominant dyspeptic symptoms at the initial presentation, but does not depend on the technical and functional success of EST.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1996

Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5-year prospective trial.

OBJECTIVES: To assess the incidence of elevated sphincter of Oddi baseline pressure and the response to endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction. DESIGN: A 5-year prospective clinical trial. METHODS: One-hundred and eight patients with recurrent biliary-type pain after cholecystectomy were enrolled. After thorough investigation, 35 patients with suspected type II sphincter of Oddi dysfunction (SOD) and another 29 type III patients remained for further investigation. Both groups were similar with respect to demographic data and severity of pain. Biliary manometry was performed in all except three patients in either group. Endoscopic sphincterotomy was performed in all patients with abnormal sphincter of Oddi baseline pressure (> 40 mmHg). All patients were clinically re-evaluated after 4-6 weeks, and thereafter the sphincterotomized patients were followed for a median period of 2.5 years. RESULTS: An abnormal sphincter of Oddi baseline pressure was found in 62.5% of the type II patients and in 50% of the patients with suspected type III SOD (P = 0.66). At the 4-6 week follow-up none of those patients without abnormal manometry, but 70% of the patients with type II SOD, and 39% of the type III SOD patients, respectively, reported subjective benefit after sphincterotomy (P = 0.13 type II vs. type III). However, after a median follow-up of 2.5 years, sustained symptomatic improvement after sphincterotomy was found in 60% of the type II patients, but only in 8% of the patients with type III SOD (P < 0.01). CONCLUSION: Disregarding a lack of difference in the incidence of abnormal sphincter of Oddi baseline pressure between type II and type III SOD, the Geenen-Hogan classification helps to predict the clinical outcome after endoscopic sphincterotomy.

Cholecystectomy↗

PubMed2002

Prevalence of sphincter of Oddi dysfunction: can results from specialized centers be generalized?

Recent studies suggest a high prevalence of sphincter of Oddi dysfunction (SOD) in patients referred to specialized centers for sphincter of Oddi manometry (SOM). Whether these results can be generalized to other centers is unknown. From September 1998 to April 2000, patients undergoing SOM were prospectively identified. Patients were classified as having either biliary or pancreatic SOD, according to the modified Milwaukee classification, and underwent SOM of either the biliary or pancreatic sphincter based on clinical history. SOD was diagnosed when the mean basal sphincter pressure was >40 mm Hg. Standard cholangiography and/or pancreatography were performed following manometry. Fifty-one patients were studied (43 women, median age 46 years, range 7-74 years). Prior to SOM, patients were classified by the modified Milwaukee classification as biliary type I in 1 patient, type II in 8, and type III in 20; pancreatic type I in 4 patients, type II in 14, and type III in 3; and biliary type III and pancreatic type III in 1 patient. Indications for SOM included abdominal pain in 35 patients (69%), recurrent idiopathic pancreatitis in 12 (24%), chronic pancreatitis in 3 (7%), and acute pancreatitis in 1 (2%). Overall, 30 patients (59%; 95% CI 41.1-76.9%) were found to have SOD; abnormal biliary sphincter pressure in 16 of 29 patients (55%) undergoing biliary manometry, and abnormal pancreatic sphincter pressures in 14 of 21 patients (67%) undergoing pancreatic sphincter manometry, and abnormal biliary and pancreatic sphincter pressures in 1. SOD was diagnosed in 1 biliary type I patient (100%), 4 type II patients (50%), and 11 type III patients (52.4%) with a mean pressures of 92, 47, and 80 mm Hg, respectively. SOD was identified in 4 pancreatic type I patients (100%), 7 type II patients (50%), and 3 type III patients (100%) with mean sphincter pressures of 83 mm Hg, 96 mm Hg, and 102 mm Hg, respectively. In conclusion, the prevalence of SOD in patients with suspected biliary disease was 55%, suspected pancreatic disease 66%, yielding an overall prevalence of SOD of 59%. These results confirm the high prevalence of SOD in patients referred for SOM.

Adolescent↗

PubMed2001

Outcome of surgical treatment of chronic pancreatitis associated with sphincter of Oddi dysfunction.

The clinical management of patients with chronic pancreatitis (CP) associated with sphincter of Oddi dysfunction (SOD) presents many challenges. The aim of this study was to evaluate patient outcome after surgical management of CP associated with SOD intractable to medical management. The records of patients with CP and SOD who underwent surgical treatment between 1994 and 1998 were retrospectively reviewed and analyzed. Manometry of biliary and pancreatic ducts was performed. Basal pressures were considered abnormal if > or = 40 mm Hg for at least 30 seconds. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and clinical criteria were utilized in the diagnosis of CP. Quality-of-life issues were assessed. Twenty-nine patients were identified (21 women and eight men) with a mean age of 43.3 years (range 24-54). Mean basal biliary and pancreatic sphincter pressures were 155.1 and 90.4 mm Hg respectively. Chronic pancreatitis was graded as mild in nine patients, moderate in six, severe in two, and normal or equivocal in 12 patients according to the Cambridge classification. A Whipple procedure was performed in 17 (59%) patients, lateral pancreaticojejunostomy in nine (31%), and distal resections or a combination of procedures in three (10%). The morbidity and mortality rates were 21 and 0 per cent respectively. Mean follow-up was 30 months (range 3-48). Pain relief ranging from fair to excellent was seen in 83 per cent of patients with pain scores decreasing from an average of 9 (scale 1-10) before surgery to 3 postoperatively. Seventy per cent maintained their weight, 45 per cent continued to require pancreatic enzyme supplementation, and there were no changes in the status of diabetes. Rehospitalizations for recurrent pancreatitis or persistent pain were necessary in 24 per cent of patients. Surgical management of patients with CP and SOD who fail medical management is safe and effective in most patients. Operative morbidity and mortality are low, and the majority of patients have improvement in pain, although some require rehospitalization for recurrent pancreatitis and chronic pain.

Adult↗

PubMed1994

Sphincter of Oddi dysfunction following liver transplantation. Screening by bedside manometry and definitive manometric evaluation.

Although sphincter of Oddi dysfunction (SOD) has been extensively studied in the nontransplant setting, the diagnostic criteria after liver transplantation are not well defined and have been based on clinical features without manometric documentation. The purpose of this study was twofold: (1) to determine the manometric patterns associated with SOD following orthotopic liver transplantation (OLT) and (2) to define the usefulness of bedside T-tube manometry as a screening tool for SOD. ERCP with simultaneous manometry of the sphincter of Oddi (SO) was performed in five patients following OLT with choledochocholedochostomy (CDCD) between 1990 and 1992. The diagnosis of SOD was suspected based on persistently elevated liver function tests, distal common bile duct dilatation in the absence of strictures, and an elevated resting bile duct pressure as measured by bedside T-tube manometry. Two different manometric patterns of SOD were observed. The first pattern (N = 4) consisted of elevated SO basal pressures, infrequent simultaneous phasic activity, and an abnormal response to cholecystokinin-octapeptide (CCK-OP). The second pattern (N = 1) consisted of low basal pressures and absent phasic activity. Four patients were successfully treated with papillotomy and stenting, while the fifth patient required conversion to a choledochojejunostomy because of a concomitant anastomotic stricture. The abnormal SO manometric profiles in patients suspected of having SOD after OLT were different from those observed in the nontransplant setting. Bedside T-tube manometry allowed measurement of the resting bile duct pressure and may be a useful screening tool for SOD.

Adult↗

PubMed1992

Efficacy of nifedipine therapy in patients with sphincter of Oddi dysfunction: a prospective, double-blind, randomized, placebo-controlled, cross over trial.

1. Twenty-eight patients who fulfilled entry criteria for sphincter of Oddi dysfunction were randomly allocated to receive nifedipine and placebo in a cross over design with 12 week treatment periods separated by a 2 week wash-out. 2. All patients had episodic pain resembling biliary pain, had previously undergone cholecystectomy, had elevated alkaline phosphatase during episodes of pain and had elevated basal pressure on sphincter of Oddi manometry. 3. Compared with placebo, significant decreases in cumulative pain score, number of pain episodes, oral analgesic tablets consumed and emergency room visits were observed during nifedipine treatment. 4. Overall 21 patients improved during nifedipine therapy while seven patients did not. None of the following predicted response to nifedipine therapy: enzyme levels, morphine-Prostigmine test, fatty meal sonography, common duct diameter and pressure, sphincter of Oddi phasic pressure, frequency and duration of phasic waves and maximal fall in the basal pressure at sphincter of Oddi manometry after sublingual administration of nifedipine. However patients with predominant antegrade propagation of phasic contractions of sphincter of Oddi did significantly better on nifedipine than those with abnormal propagation of phasic contractions. 5. Nifedipine therapy orally in maximal tolerated doses relieves pain in patients with sphincter of Oddi dysfunction who have elevated basal pressure and sphincter of Oddi phasic contractions of predominantly antegrade nature.

Adult↗