[Oddi's sphincter dysfunction in "idiopathic" recurrent pancreatitis].
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Common Bile Duct Diseases↗
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Results for “Sphincter of Oddi Dysfunction”
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Transduodenal sphincteroplasty and transampullary septotomy for primary sphincter of Oddi dysfunction.
We examined 29 patients without stone disease or pancreatic ductal ectasia who underwent transduodenal sphincteroplasty and transampullary septotomy for symptoms of biliary colic or pancreatitis. The combination of biliary symptoms and a fibrotic ampulla of Vater portends a favorable surgical outcome in virtually all such patients. Patients with pancreatitis did worse overall, perhaps due to the existence of unappreciated subclinical parenchymal disease not related to sphincter dysfunction. Although endoscopic retrograde cholangiography was sensitive in demonstrating abnormalities of the pancreaticobiliary system, its specificity as a predictor of good results was poor. It seems prudent to temper one's enthusiasm for sphincteroplasty in the patient with pancreatitis, whereas patients with biliary symptoms, the postcholecystectomy syndrome, or both will usually benefit significantly from this procedure.
Adult↗
Evaluation of endoscopic sphincterotomy in sphincter of Oddi dysfunction.
In this prospective study the efficacy of endoscopic sphincterotomy was evaluated in ten post-cholecystectomy patients with clinical and biliary manometric evidence of SO dysfunction. Ten patients (8 females, 2 males, median age 59 years) were assessed at a median period of 24 months (range 12-48) after endoscopic sphincterotomy. Eight of the ten patients (80%) were symptomatically improved after endoscopic sphincterotomy although only four were totally asymptomatic. The two patients who had unchanged symptoms after sphincterotomy have since had alternative diagnoses made and have improved on appropriate therapy. It is concluded that endoscopic sphincterotomy is effective in relieving symptoms in post-cholecystectomy patients with clinical and manometric evidence of SO dysfunction.
Cholecystectomy↗
Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment.
Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.
Abdominal Pain↗
Noninvasive imaging for diagnosis of sphincter of Oddi dysfunction.
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Comment↗
True culprit or guilt by association? Is sphincter of Oddi manometry the cause of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction, or is it the patients' susceptibility?
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Comment↗
[Endoscopic manometry in suspected dysfunction of the sphincter of Oddi].
BASIC PROBLEM AND OBJECTIVE OF STUDY: Dysfunction of the sphincter of Oddi may be a cause of persistent problems after cholecystectomy. The aim was to find out whether various factors are of value in predicting abnormal manometric results and thus aid in deciding whether endoscopic manometry is indicated. PATIENTS AND METHODS: 97 patients were investigated prospectively (13 men, 84 women; mean age 50.2 [29-72] years) in which endoscopic cholangiopancreatography (ERCP) had not revealed any cause of the biliary complaints. The patients were divided into three types according to four criteria: (1) history (biliary colics); (2) biochemistry (cholestasis); (3) dilated biliary tract (at ERCP); (4) contrast retention in biliary tract (at ERCP). Type I: all four criteria present; type II: positive history and one or two other criteria; type III: biliary colic only. Endoscopic manometry (EM) was performed after classification of the patients. RESULTS: EM was successful in 83 of 97 patients (86%). All 15 patients of type I had sphincter of Oddi dysfunction (SOD) defined as basic sphincter pressure > 40 mm Hg. SOD was demonstrated in only 23 of 38 patients of type II (61%) and 15 of 30 patients of type III (50%) (P < 0.01). Increased rate of sphincter of Oddi contraction ("tachyoddi") was demonstrated in only four patients (4%), in two of them in combination with an increased basic sphincter pressure. Mild to moderate pancreatitis occurred within 24 hours of manometry in ten of 83 patients. CONCLUSIONS: Endoscopic manometry is not necessary in patients of type I for confirming the diagnosis. But it is obligatory for patients of type II and III, because the demonstration of SOD has therapeutic consequences, and should be performed in clinical studies, if possible.
Adult↗
[Dysfunction of the sphincter of Oddi in cholecystectomy patients].
Sphincter of Oddi dysfunction (SOD) is an obstructive syndrome of the papilla not resulting from a stone. It may cause recurrent biliary type pain to cholecystectomized patients. SOD is caused by sphincter dyskinesia or benign stenosis. Diagnosis is usually based on symptoms, serum biochemistry, endoscopic retrograde cholangiopancreatography and Sphincter of Oddi manometry. The latter is the best means of evaluating Sphincter of Oddi dynamics. However, because of the many inconveniences of Sphincter of Oddi manometry and of its high morbidity rate, it is seldom used. Non invasive techniques, such as cholescintigraphy, have been developed to replace Sphincter of Oddi manometry in diagnosing SOD. Patients can be cured by sphincterotomy. Certain drugs could also be effective but few controlled studies have been carried out of date.
Biliary Tract Diseases↗
Secretin MRCP and endoscopic pancreatic manometry in the evaluation of sphincter of Oddi function: a comparative pilot study in patients with idiopathic recurrent pancreatitis.
BACKGROUND: Sphincter of Oddi dysfunction plays an important etiologic role in idiopathic acute recurrent pancreatitis. Sphincter of Oddi manometry is the most accurate test of sphincter of Oddi function, but it is associated with an increased risk of post-procedure pancreatitis and is non-diagnostic in about a third of cases. Secretin MRCP has a diagnostic efficacy comparable to ERCP, but data on its sensitivity with regard to sphincter of Oddi function are lacking. The aim of this study was to compare secretin MRCP and pancreatic sphincter of Oddi manometry for evaluation of sphincter of Oddi function in patients with idiopathic acute recurrent pancreatitis. METHODS: Eighteen consecutive patients with idiopathic acute recurrent pancreatitis underwent secretin MRCP and pancreatic sphincter of Oddi manometry/ERCP. Data from 15 patients were suitable for analysis. Fifteen subjects with asymptomatic, non-pancreatic hyperamylasemia matched for age and gender underwent secretin MRCP and served as a control group. RESULTS: Sphincter of Oddi manometry documented sphincter dysfunction in 6/15 patients (40%) and secretin MRCP, in 4/15 patients (26.7%). Sphincter of Oddi manometry confirmed the presence of elevated basal sphincter of Oddi pressure in two of the 4 patients with abnormal and other forms of sphincter of Oddi dyskinesia in the other two. None of the control subjects had an abnormal secretin MRCP. Secretin MRCP and sphincter of Oddi manometry were concordant in 13/15 patients (86.7%); positive and negative diagnoses for sphincter of Oddi dysfunction agreed in, respectively, 81.8% and 100% (kappa value 0.706). CONCLUSIONS: Secretin MRCP seems to be a useful noninvasive procedure for investigation of pancreatic sphincter of Oddi function, but evaluation in larger series is needed.
Adolescent↗
Sincalide-augmented quantitative hepatobiliary scintigraphy (QHBS): definition of normal parameters and preliminary relationship between QHBS and sphincter of Oddi (SO) manometry in patients suspected of having SO dysfunction.
Sphincter of Oddi (SO) dysfunction presents with vague abdominal pain and/or abnormal liver function tests, and is presumably due to SO stenosis or spasm. Clinical, laboratory, and imaging methods of diagnosis have been less than ideal. Initially, we determined normal quantitative hepatobiliary scintigraphy (QHBS) parameters both pre- and post-sincalide administration. Thirty-one "normals" were analyzed, and post-sincalide common bile duct (CBD) dynamics could be satisfactorily determined in 29 (94%) subjects. Normal values at sincalide-augmented QHBS are reported. Next, 10 patients suspected of having SO dysfunction were studied prospectively using SO manometry and QHBS. The two tests were in agreement in seven cases (4: normal CBD dynamics, 3: abnormal). In one case of advanced SO stenosis, QHBS was abnormal, but SO manometry could not be performed. In the two remaining cases, SO manometry and QHBS gave discordant results. Of greatest importance, no significant correlation existed between the quantitative parameters of these two tests. Sincalide-augmented QHBS is possible and may, in the future, be of value in the diagnosis of SO dysfunction and/or partial CBD obstruction.
Adult↗
Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis.
BACKGROUND: Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction. METHODS: Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups. RESULTS: Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis. CONCLUSIONS: Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.
Acute Disease↗
Biliary Dyskinesia.
Biliary dyskinesia is a motility disorder that affects the gallbladder and sphincter of Oddi. The motility disorder of the gallbladder is called gallbladder dyskinesia. Patients with this condition present with biliary-type pain, and investigations show no evidence of gallstones in the gallbladder. The diagnosis is made by performing a gallbladder ejection fraction, which is a radionuclide investigation. An abnormal gallbladder ejection fraction has a value less than 40%. Patients with an abnormal gallbladder ejection fraction should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 90% of patients. Motility disorder of the sphincter of Oddi is called sphincter of Oddi dysfunction. This disorder is categorized as two distinct types--biliary sphincter of Oddi dysfunction and pancreatic sphincter of Oddi dysfunction. Typically, patients with biliary sphincter of Oddi dysfunction present with biliary-type pain on average 4 to 5 years after having undergone cholecystectomy. Sphincter of Oddi manometry is essential in making a diagnosis of abnormal motility of the sphincter. On manometry, diagnosis of a sphincter of Oddi stenosis should lead to division of the sphincter. Sphincterotomy results in long-term relief of symptoms in more than 80% of patients. Pancreatic sphincter of Oddi dysfunction clinically presents with recurrent episodes of pancreatitis of unknown cause. Having ruled out all of the common causes of pancreatitis, sphincter of Oddi manometry of the pancreatic duct sphincter should be performed. When manometric stenosis is diagnosed, these patients should undergo division of both the biliary and pancreatic duct sphincter. This treatment results in relief of symptoms in more than 80% of patients.
Journal Article↗
Evaluation of the biliary tract in patients with functional biliary symptoms.
The aim of this paper was to describe functional biliary syndromes and methods for evaluation of the biliary tract in these patients. Functional biliary symptoms can be defined as biliary symptoms without demonstrable organic substrate. Two main syndromes exist: Gallbladder dysfunction and sphincter of Oddi dysfunction. The most important investigative tools are cholescintigraphy and endoscopic sphincter of Oddi manometry. In gallbladder dysfunction a scintigraphic gallbladder ejection fraction below 35% can select patients who will benefit from cholecystectomy. Endoscopic sphincter of Oddi manometry is considered the gold standard in sphincter of Oddi dysfunction but recent development in scintigraphic methods is about to change this. Thus, calculation of hilum-to-duodenum transit time and duodenal appearance time on cholescintigraphy have proven useful in these patients. In conclusion, ambient methods can diagnose functional biliary syndromes. However, there are still a number of issues where further knowledge is needed. Probably the next step forward will be in the area of sensory testing and impedance planimetric methods.
Biliary Dyskinesia↗
Video manometry of the sphincter of Oddi: a new aid for interpreting manometric tracings and excluding manometric artefacts.
BACKGROUND AND STUDY AIMS: Endoscopic sphincter of Oddi manometry (ESOM) allows direct assessment of motor function in the sphincter of Oddi. However, variations in examination conditions and duodenal motility may have a critical effect on the results of ESOM. The aim of the present study was to develop a new method sphincter of Oddi video manometry-based on simultaneous ESOM and real-time endoscopic image analysis, and to investigate the usefulness of video manometry for detecting manometric artefacts during ESOM. PATIENTS AND METHODS: Seven consecutive patients who had undergone cholecystectomy and were referred with a suspicion of sphincter of Oddi dysfunction were investigated. Sphincter of Oddi pressure and endoscopic images (20 frames/s) were recorded simultaneously on a Synectics PC Polygraf computer system with a time-correlated basis, and then compared. RESULTS: On ESOM, 69 sphincter of Oddi phasic contractions were identified, with an average amplitude of 153.9+/-85.0 mm Hg and a duration of 7.9+/-1.2 seconds. Visual analysis of the real-time endoscopic images, replayed in cine loop by the computer, revealed 236 separate duodenal contractions, with an average frequency of 3.5+/-2.4/min (range: 1-12/min). On the ESOM tracing, 78% of the duodenal contractions had a corresponding pressure wave with an average duration of 2.8+/-0.4 seconds and an amplitude of 71.9+/-16.7 mm Hg. Other artefacts on the ESOM tracings, such as catheter movements, pseudocontractions, hyperventilation, or retching, were also easily recognized using simultaneous ESOM and real-time endoscopic image analysis. CONCLUSIONS: Video manometry of the sphincter of Oddi is a promising new method for improving the analysis and documentation of ESOM tracings. It has several advantages over the conventional technique, allowing visual detection of duodenal activity and enabling enhanced recognition of other manometric artefacts.
Adult↗
Hypertensive pancreatic sphincter.
Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis or pancreatic-type pain. Endoscopic manometry as performed at endoscopic retrograde cholangiography is the most commonly used method to identify sphincter dysfunction. Noninvasive testing, such as secretin-stimulated ultrasound analysis of duct diameter, is less reliable and of relatively low sensitivity. Two-thirds of patients with sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. Patients with suspected or documented sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but warrant evaluation of their pancreatic sphincter if symptoms persist after therapy. Whether such pancreatic and biliary sphincters should be treated at the first treatment session is controversial. Pancreatic sphincterotomy is associated with a complication rate very similar to that of biliary sphincterotomy except that the pancreatitis rate is two- to fourfold higher. Prophylactic pancreatic stenting diminishes such pancreatitis by approximately 50%.
Catheter Ablation↗
[Endoscopic treatment of dyskinesia of the Oddi's sphincter].
Oddi sphincter dysfunction is manifested as a biliary- or pancreatic-type pain syndrome. At present, imaging studies are not very trustworthy for the diagnosis of this dysfunction, because of which direct endoscopic manometry offers the gold standard for confirming or ratifying the problem, supported by the Milwaukee Biliary Classification. Currently, the endoscopic approach has become the most effective alternative used for this type of diagnosis. Among the techniques may be found the following: endoscopic sphincterotomy, balloon dilation, the placing of biliary endoprostheses, and the injection of botulinic toxin in the Oddi sphincter. In our modest and short experience with six patients, of which five corresponded to group I of the Milwaukee bile classification, the above patients were treated successfully with sphincterotomy. The other two patients belonged to group type III of the Milwaukee classification, and were treated with botulinic toxin until the moment of a satisfactory response, for a period of 8 months.
Adult↗
Controlled study of the effect of nicardipine and ceruletide on the sphincter of Oddi.
Although sphincter of Oddi dysfunction is a recognised cause of post cholecystectomy pain, the control mechanisms involved in sphincter of Oddi function are poorly understood. Pharmacological relaxation of the sphincter of Oddi may have a beneficial effect particularly in sphincter of Oddi dysfunction where basal sphincter pressure is high. The aim of this study was to investigate the effects of calcium channel blockade (nicardipine) and synthetic cholecystokinin (ceruletide) on sphincter of Oddi pressures. Nineteen patients (median age 49 years; range 21-75) attending for routine endoscopic retrograde cholangiopancreatographic (ERCP) examination were studied. No patients with evidence of sphincter of Oddi dysfunction were included in the study. Each patient was randomly allocated to receive a three minute intravenous infusion of nicardipine 3 mg (six) ceruletide 5 ng/kg (seven) or placebo (six). Endoscopic biliary manometry was done with recording of basal sphincter of Oddi pressures, sphincter of Oddi phasic wave amplitude and frequency before and after intravenous infusions. In the nicardipine group patients showed a decrease in both basal and phasic amplitude sphincter of Oddi pressure (mm Hg) from the preinfusion values (mean (SEM)) of 24.7 (3.6) and 112.3 (13.4) to 12.9 (2.9) (p less than 0.01) and 89.9 (12.4) (p less than 0.03) after infusion respectively. Ceruletide produced a decrease in sphincter of Oddi phasic wave frequency (c/min) from 3.4 (0.3) before infusion to 2.6 (0.5) after infusion (p less than 0.05). We conclude that nicardipine effectively decreases sphincter of Oddi pressure. This drug may therefore be of value in the treatment of sphincter of Oddi dysfunction where raised sphincter pressures are thought to be the primary pathogenic feature.
Adult↗
[Indications for endoscopic papillotomy].
Endoscopic sphincterotomy (ES) with stone removal is indicated in the post-cholecystectomy patient with retained or recurrent stones and for the very high risk surgical patient. ES has a role in the treatment of severe acute biliary pancreatitis (ABP), but not in mild ABP. Acute suppurative cholangitis refractory to antibiotics can be successfully treated by ES with stone removal or nasobiliary drainage not only in high risk surgical patients. However, concomitant occurrence of abscesses in the liver and other locations, and of gallbladder empyema, calls for an interdisciplinary approach (surgical, endoscopic and radiological). Controlled studies in this field are needed. The role of ES and stone removal in cholelithiasis of patients with gallbladders in situ and low surgical risk remains controversial, as does the treatment of patients with sump syndrome after choledochoduodenostomy, with biliary-cutaneous or biliary-enteric fistulas and benign strictures, which must be evaluated by accurate comparative studies. Whereas ES has its place in the treatment of Oddi sphincter dysfunction with elevated sphincter pressures, and for the introduction of large bore endoprostheses for palliative treatment of malignant biliary stenoses, ES is still experimental in the treatment of pancreatolithiasis, pancreatic duct stenoses, endoscopic gallbladder stone removal and transpapillary retrograde cholangioscopy.
Cholangitis↗