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PubMed2005

Sphincter of Oddi Dysfunction.

Sphincter of Oddi dysfunction (SOD) is a benign noncalculous obstruction of bile or pancreatic drainage at the level of the sphincter of Oddi. The disorder is clinically associated with either biliary pain or idiopathic pancreatitis, depending on the portion of the sphincter affected. Patients with suspected SOD are subdivided into three categories: these are type I, II, and III, depending on associated clinical evidence for the diagnosis. Multiple noninvasive tests have been utilized to aid in the diagnosis but have been complicated by poor sensitivity and specificity. Sphincter of Oddi manometry is the gold standard for confirming the diagnosis, although questions remain about its sensitivity and specificity. Sphincterotomy of the affected portion of the sphincter is the treatment of choice and has been shown effective for palliation of symptoms in two sham-controlled studies of patients with suspected type II biliary SOD.

Journal Article↗

PubMed2004

Intestinal dysmotility and its relationship to sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) is a clinical entity that presents with pain as the predominant symptom, and patients may require invasive procedures for its proper diagnosis. Those with abnormal sphincter of Oddi manometry (SOM) are commonly treated with endoscopic ablation of the sphincter. The results of such therapy vary and depend on the type of SOD. In the past several years, evidence has emerged of an association between SOD, intestinal dysmotility, and visceral hyperalgesia. This article reviews the evidence supporting such an association.

Animals↗

PubMed2001

Efficacy of biliary scintigraphy in suspected sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) can pose diagnostic challenges for the physician. SOD is classified into types I, II, and III, but clinical outcome after sphincterotomy for suspected types II and III SOD has been unpredictable. Therefore, accurate diagnosis of types II and III SOD is important because of the increased risk of sphincterotomy in patients with SOD. Endoscopic sphincter of Oddi manometry (ESOM) is the gold standard for diagnosis of SOD; however, it is associated with significant morbidity and is not an appropriate screening test. Quantitative hepatobiliary scintigraphy (QHBS) has demonstrated good sensitivity as a screening test for SOD in patients following cholecystectomy; however, studies using this methodology are criticized for poor design and patient selection. Recent publications address these criticisms and provide evidence that QHBS and ESOM are comparable diagnostic tools after exclusion of organic biliary obstruction. QHBS can effectively replace invasive ESOM in the diagnostic algorithm of SOD.

Biliary Tract↗

PubMed1988

Quantitative 99mTc-DISIDA scanning and endoscopic biliary manometry in sphincter of Oddi dysfunction.

Sphincter of Oddi (SO) dysfunction is a recognised cause of postcholecystectomy pain, but a difficult condition to diagnose, requiring endoscopic biliary manometry (EBM) to confirm sphincter motor abnormalities. We have assessed quantitative cholescintigraphy in 10 postcholecystectomy (PC) patients with clinical and manometric evidence of SO dysfunction, 10 PC patients with non-biliary type abdominal pain and 10 asymptomatic PC volunteers acting as controls to determine its value as a non-invasive screening test. Quantitative 99mTc-DISIDA scans lasted 60 minutes, activity/time curves being created by computer analysis using the entire hepatobiliary system as region-of-interest (ROI). Scintigraphic analysis demonstrated that the time in minutes to maximum counts (Tmax) was significantly increased in the SO dysfunction group compared with the non-biliary pain group and the asymptomatic volunteers (p less than 0.001). The per cent of biliary tracer emptied was also significantly less in the SO dysfunction group than either of the other groups at both 45 minutes (p less than 0.01) and 60 minutes (p less than 0.02). We conclude that quantitative cholescintigraphy may be a valuable non-invasive screening test in clinically suspected SO dysfunction.

Adult↗

PubMed1996

Defining sphincter of oddi dysfunction.

Sphincter of Oddi (SO) dysmotility may give rise to pain. The golden standard for the demonstration of SO dysfunction is endoscopic manometry. A number of abnormalities are observed in patients with postcholecystectomy pain and in patients with idiopathic recurrent pancreatitis. Criteria for defining SO dysfunction and the possible mechanisms for the precipitation of pain are discussed.

Endoscopy, Digestive System↗

PubMed1985

Manometric disorders in patients with suspected sphincter of Oddi dysfunction.

Sphincter of Oddi (SO) manometry was conducted in 48 subjects who had previously undergone cholecystectomy. Ten of these subjects had no detectable biliary or pancreatic disease and served as controls. The other 38 patients were presumed to have SO dysfunction and had presented with episodes of severe biliary-type pain with either dilatation of the bile duct on a retrograde cholangiogram, transient changes in liver function tests, or both of these abnormalities. A triple-lumen low-compliance manometric system was used to record the SO basal pressure, SO phasic contraction amplitude, SO wave frequency, direction of wave propagation, and SO response to intravenously administered cholecystokinin-octapeptide 20 ng/kg. Satisfactory manometric recordings were obtained from 32 of 38 patients and of these, 25 patients showed one or more abnormalities when compared with data from the 10 controls. The abnormalities included excess of retrograde contractions (12), high frequency of SO phasic contractions (11), elevation of the SO basal pressure (8), and paradoxical cholecystokinin-octapeptide response (10). The study has demonstrated a spectrum of manometric abnormalities in the SO of patients with suspected SO dysfunction.

Adult↗

PubMed1999

Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction.

BACKGROUND: Sphincter of Oddi manometry as performed at ERCP is the most accepted method to evaluate for sphincter of Oddi dysfunction. To fully assess for sphincter of Oddi dysfunction, both the pancreatic and the bile ducts must be evaluated. We assessed the frequency of pancreatic and biliary sphincter abnormalities in a large series of patients. METHODS: A total of 593 patients underwent manometry of the biliary and pancreatic ducts at one endoscopic retrograde cholangiopancreatography session. Basal sphincter pressure greater than or equal to 40 mm Hg was considered abnormal. Phasic waves were not evaluated. Manometric abnormalities were correlated with the clinical presentation as categorized using a modified Geenen/Hogan classification. RESULTS: Of 360 patients with intact sphincters, 18.9% had abnormal pancreatic sphincter basal pressure alone, 11.4% had abnormal biliary basal sphincter pressure alone, and in 31.4% the basal pressure was abnormal for both sphincters; thus, 60.1% of the patients had sphincter dysfunction. The frequency of sphincter of Oddi dysfunction did not differ whether typed by biliary or pancreatic criteria: approximately 65% type II and 59% type III. Of patients without pancreatitis, 55.9% had an abnormal basal sphincter pressure, whereas sphincter dysfunction was present in 72.3% of those with idiopathic pancreatitis and 53.9% of patients with chronic pancreatitis. Of patients with an ablated biliary sphincter, 45.9% had abnormal basal pancreatic sphincter pressure and only 0.6% had an abnormal biliary sphincter pressure alone. Abnormal pressure in both sphincters was found in 9.3%. CONCLUSION: If both portions of the sphincter of Oddi are studied simultaneously, abnormalities are found very commonly (55% to 72%). Assessment of both sides of the sphincter is necessary. Classifying patients according to both pancreatic and biliary sphincter segments is cumbersome, and may be replaced by an overall type. Using this modified classification, the frequency of sphincter of Oddi dysfunction is similar in both type II and type III patients (59% to 67%).

Acute Disease↗

PubMed2001

Comparison of sphincter of Oddi manometry, fatty meal sonography, and hepatobiliary scintigraphy in the diagnosis of sphincter of Oddi dysfunction.

BACKGROUND: Sphincter of Oddi dysfunction (SOD) afflicts approximately 1% to 5% of patients after cholecystectomy. The diagnostic standard for SOD is sphincter of Oddi manometry (SOM), a technically difficult, invasive test that is frequently complicated by pancreatitis. A sensitive and accurate noninvasive imaging modality is thus needed for the diagnosis of SOD. Quantitative hepatobiliary scintigraphy (HBS) and fatty meal sonography (EMS) are frequently used for this purpose, but results vary. This study compared SOM, HBS, and EMS in the diagnosis of SOD in a large group of patients. METHODS: Three hundred four consecutive patients after cholecystectomy (38 men, 266 women, age 17-72 years) suspected to have SOD were evaluated by SOM, FMS, and HBS. SOM was considered abnormal if any of the following were observed: (1) increased basal pressure (greater than 40 mm Hg), (2) increased phasic activity with amplitude greater than 350 mm Hg, (3) frequency of contractions greater than 8 per minute, (4) greater than 50% of propagation sequences retrograde, and (5) paradoxical response to cholecystokinin. FMS was considered abnormal if ductal dilation was greater than 2 mm at 45 minutes after fatty meal ingestion. Quantitative HBS was performed with sequential images obtained every 5 minutes for 90 minutes to monitor excretion of the radionuclide. Time-to-peak, halftime, and downslope were calculated according to predetermined ranges. RESULTS: A diagnosis of SOD was made in 73 patients (24%) by using SOM as the reference standard. HBS was abnormal in 86 whereas EMS was abnormal in 22 patients. A true-positive result was obtained in 15 patients by EMS and 36 patients with HBS. EMS and HBS gave false-positive results, respectively, in 7 and 50 patients. Sensitivity of EMS was 21% and for HBS 49%, whereas specificities were 97% and 78%, respectively. EMS, HBS, or both were abnormal in 90% of patients with Geenen-Hogan Type I SOD, 50% with Type II, and 44% of Type III. Of the 73 patients who underwent sphincterotomy, 40 had a long-term response. Of those with SOD, 11 of 13 patients (85%) with an abnormal HBS and EMS had a good long-term response. CONCLUSIONS: In this series, the largest reported to date, correlation of FMS and HBS with SOM in the diagnosis of SOD was poor. When HBS and EMS are used together, a slight increase in sensitivity can be expected. The accuracy of EMS and HBS in the diagnosis of SOD decreases across the spectrum from Type I to Type III SOD. EMS and HBS, nonetheless, may by of assistance in predicting long-term response to endoscopic sphincterotomy in patients with elevated sphincter of Oddi basal pressure.

Adolescent↗

PubMedDate not supplied

Somatization disorder in sphincter of Oddi dysfunction.

OBJECTIVE: Sphincter of Oddi dysfunction (SOD) is a biliary disorder with a recognized pathophysiology and demonstrated surgical treatment. We sought to examine whether women with SOD were overrepresented on measures of somatization, sexual and physical abuse, socially compliant attitudes, and familial psychiatric illness. METHOD: We matched 33 women with SOD to 33 normal controls by age, sex, and race, and, with a case-controlled cross-sectional questionnaire, compared the groups on the study variables. Statistics included a chi 2 for categorical variables, t tests for scores of somatization and attitudes of social desirability, and Pearson correlation coefficients for post hoc associations of variables. Bonferroni corrections were used with chi 2 values to reduce capitalization by chance. RESULTS: SOD patients exhibited excessive nongastroenterological somatic complaints compared with controls (p < .0001). There was a statistical increase in reports of childhood sexual, but not physical, abuse in the SOD women (p < .02) compared with controls. The severity of the abuse correlated strongly with the severity of somatic complaints. There were no differences in social desirability attitudes or family psychiatric histories of the two groups. CONCLUSIONS: We conclude that SOD is associated with a high degree of somatization in adulthood, and a mean rate more than four times that of controls in self-reports of sexual abuse in childhood. The severity of childhood sexual abuse is correlated with the severity of somatization in later life. A psychological model for this disorder is suggested by the data. Increased psychiatric attention is indicated in the treatment of women with this disorder.

Case-Control Studies↗

PubMed2003

Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction.

INTRODUCTION: Sphincter of Oddi (SO) manometry is at present the "gold standard" investigation for patients with suspected biliary SO dysfunction. Non-invasive scintigraphy in cholecystectomised patients using a complex scoring system or the transit time from the hepatic hilum to the duodenum (HDTT) have been promoted as sensitive and specific alternatives. AIM: To evaluate the scintigraphic scoring system and HDTT in patients with suspected biliary SO dysfunction undergoing SO manometry. METHODS: Cholecystectomised patients undergoing SO manometry for persistent biliary-type pain, as defined by the Rome II criteria, for which all other causes had been excluded, were prospectively studied. Scintigraphy with cholecystokinin octapeptide infusion was performed within a month prior to manometry. Scoring of the scans and measurement of HDTT was performed by independent blinded observers. Manometry of the biliary sphincter was performed per-endoscopically and defined as abnormal if basal pressure was > or = 40 mm Hg. RESULTS: Thirty two patients were enrolled (30 females, mean age 45.1 years). Three patients were excluded from analysis because manometry from the bile duct was not technically possible. Eight patients had abnormal manometry. Scintigraphic scoring had a sensitivity of 25-38%, a specificity of 86-89%, positive predictive value (PPV) of 40-60%, and a negative predictive value (NPV) of 75-79%. The coefficient of variation for interobserver variation in scores was 0.72. HDTT sensitivity was 13%, specificity 95%, PPV 50%, and NPV 74%. CONCLUSIONS: Our findings indicate that scintigraphy using these methods of analysis correlates poorly with manometry in post cholecystectomy patients with suspected biliary SO dysfunction.

Adult↗

PubMed1998

Diagnosis and treatment of sphincter of Oddi dysfunction.

UNLABELLED: BACKGROUND Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives. METHODS: A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject. RESULTS AND CONCLUSION: Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2001

Sphincterotomy for biliary sphincter of Oddi dysfunction.

BACKGROUND: The sphincter of Oddi regulates both bile and pancreatic juice flow into the duodenum. When dysfunction occurs it leads to problems relating to either the bile or pancreatic ducts. On the biliary side, the most common problem is recurrent biliary type pain following cholecystectomy. OBJECTIVES: Is sphincterotomy effective treatment for biliary sphincter of Oddi dysfunction patients? SEARCH STRATEGY: Electronic data bases, including the Collaborative Review Group trial registers, MEDLINE, and EMBASE, as well as checking reference lists in as many languages as possible that had the titles: sphincter of Oddi dysfunction, biliary dyskinesia, papillary stenosis, biliary dyssynergia, odditis, papillitis, post-cholecystectomy pain, right upper quadrant pain, or unexplained right upper quadrant pain were included. These titles were matched with sphincterotomy. SELECTION CRITERIA: Randomised placebo-controlled trials performing sphincterotomy in patients with suspected biliary sphincter of Oddi dysfunction using manometry as part of the patient evaluation. A basal pressure > 40 mmHg was defined as abnormal. The primary outcome measure were symptomatic response (defined either as cure/improvement or not improved) to sphincterotomy. DATA COLLECTION AND ANALYSIS: Electronic data bases were used to search for the studies. Studies were attempted to be stratified as randomised clinical trials, controlled clinical trials (i.e., quasi-randomised clinical trials), well designed observational studies using a well matched control group, or other. These groupings were then entered into a meta-analysis. MAIN RESULTS: Only two randomised clinical trials met the inclusion criteria. In 49 patients studied, sphincterotomy was more effective than placebo in treating patients with an elevated basal pressure (Peto odds ratio 9.08, 95% confidence interval 2.97-277.77). In 77 patients studied, sphincterotomy was no better than placebo in treating patients with a normal normal basal pressure (Peto odds ratio 1.28, 95% confidence interval 0.52-3.13). There was no data on quality of life or health economics. REVIEWER'S CONCLUSIONS: These results suggest that sphincterotomy for biliary sphincter of Oddi dysfunction appears effective in those patients with an elevated sphincter of Oddi basal pressure (>40 mmHg), but is no better than placebo in those patients with a normal basal pressure. The results reported in this review must be interpreted with caution as there are only two studies and one of the reviewers (Toouli) has been an author in both studies. Further trials by independent groups are recommended.

Common Bile Duct Diseases↗

PubMedDate not supplied

Correlation of basal sphincter pressures measured from the bile duct and the pancreatic duct in patients with suspected sphincter of Oddi dysfunction.

If basal sphincter of Oddi pressures measured from the pancreatic duct and the bile duct are essentially equal, then measurement of basal pressures from only one duct would be adequate in evaluating sphincter of Oddi dysfunction. We report a series of 88 patients whom we evaluated with sphincter of Oddi manometry. Cannulation of both the biliary sphincter segment and pancreatic sphincter segment was achieved in these patients. Basal sphincter pressures were measured (normal, less than 40 mm Hg). In 45 of the 88 patients (51%), normal sphincter of Oddi basal pressures were seen in both ducts. Elevated basal sphincter of Oddi pressures were seen in both ducts in 28 of 88 patients (32%). In 15 of 88 cases (17%) there was an elevation of only one sphincter segment. Elevation in only the biliary sphincter segment occurred in 7 of 88 patients (8%). Elevation in the pancreatic sphincter segment alone occurred in 8 of 88 patients (9%). We conclude that sphincter of Oddi manometry of both the pancreatic and bile ducts is needed if complete manometric information is desired.

Bile Ducts↗

PubMed2006

Sphincter of Oddi dysfunction in children.

Sphincter of Oddi dysfunction (SOD) is a clinical entity caused by a primary motility alteration of either the biliary or the pancreatic sphincter. SOD is a rare condition that has been scarcely reported in children. Most of the reported literature has been in children with idiopathic recurrent pancreatitis. These children are treated endoscopically by dual sphincterotomy of the pancreatic and common duct sphincters. However, the safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Case-Control Studies↗

PubMed1994

[Diagnostic and therapeutic possibilities in suspected Oddi's sphincter dysfunction].

Endoscopic manometry and quantitative cholescintigraphy are the diagnostic cornerstones for the detection of suspected sphincter of Oddi dysfunction. In patients with recurrent biliary pain after cholecystectomy, endoscopic manometry proves an elevated sphincter of Oddi baseline pressure as the most common finding. The probability for the detection of an elevated baseline pressure in these patients is significantly correlated with the presence of certain clinical features (i.e. biliary pain and/or cholestasis and/or dilated bile duct and/or delayed drainage of contrast material after ERCP). Therefore, these features enable a clinical classification of patients with suspected sphincter of Oddi dysfunction. Isolated baseline pressure elevations in the pancreatic portion of the sphincter of Oddi were reported in patients with recurrent, idiopathic, acute pancreatitis. In patients with biliary sphincter dysfunction, therapeutic relief can be expected from pharmacological therapy, but controlled studies are lacking. However, the clinical value of endoscopic sphincterotomy could be established in this field. Despite endoscopic manometry is not a prerequisite for the performance fo endoscopic sphincterotomy in every case of suspected sphincter of Oddi dysfunction, in most patients endoscopic manometry allows the only definitive diagnosis of sphincter dysfunction. Further on, the clinical value of semi-invasive methods as alternative treatment strategies (i.e. botulinum-toxin, transcutaneous electric nerve stimulation, balloon dilation) for sphincter of Oddi dysfunction has to be evaluated in the future.

Acute Disease↗

PubMedDate not supplied

The incidence of post-sphincterotomy stenosis in group II patients with sphincter of Oddi dysfunction.

Patients with group II sphincter of Oddi dysfunction documented by elevated sphincter of Oddi pressure improve after endoscopic sphincterotomy. A large group II population was studied to determine the incidence of post-endoscopic sphincterotomy stenosis. Eighty-five patients (82 women and 3 men), ages 21 to 88 years (mean, 50 years), fulfilled the clinical criteria for group II sphincter of Oddi dysfunction; each had an elevated basal sphincter of Oddi pressure (> or = 40 mm Hg), and received endoscopic sphincterotomy. These patients were observed for a mean of 7 +/- 3 years. Four patients re-presented with clinical findings suggestive of recurrent sphincter of Oddi dysfunction; all were found to have a basal sphincter of Oddi pressure greater than or equal to 40 mm Hg. Symptoms re-developed within 4 months after endoscopic sphincterotomy (mean, 3.3 months). Endoscopic sphincterotomy was repeated in all four patients with one endoscopically treated complication. On 25-month mean follow-up, none of the patients had further signs or symptoms of papillary stenosis. Endoscopic sphincterotomy in patients with group II sphincter of Oddi dysfunction is associated with a low incidence of restenosis (4.7%). Repeat endoscopic sphincterotomy was found to be effective management in patients with papillary restenosis.

Adult↗

PubMed1998

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction.

BACKGROUND & AIMS: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. METHODS: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3). CONCLUSIONS: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.

Adult↗

PubMed2002

Pseudomonas aeruginosa liver abscesses after diagnostic endoscopic retrograde cholangiography in two patients with sphincter of Oddi dysfunction type 2.

Patients with sphincter of Oddi dysfunction have a significantly increased rate of pancreatitis after manometry or sphincterotomy, but septic complications after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients with sphincter of Oddi dysfunction type 2 have not been reported. We describe two patients with sphincter of Oddi dysfunction type 2 in whom Pseudomonas aeruginosa serotype 10 septicemia and multiple small hepatic abscesses developed, all within 48 h after they underwent diagnostic ERCP. The sepsis and hepatic abscesses resolved after successful intravenous antibiotic administration. Despite scrupulous examination of the duodenoscope washing machine and the bottle of water, the bacteria responsible for the sepsis could not be isolated. It is possible that despite disinfection, a nondetectable colony of P. aeruginosa remained in a part of duodenoscope and proliferated to reach a potentially hazardous level the following day. This report highlights the importance administering antibiotic prophylaxis to patients with sphincter Oddi dysfunction type 2 who undergo ERCP, despite the functional nature of the disease.

Abscess↗