Sphincter of Oddi dysfunction

[Gallbladder agenesis: about three cases]

L’agénésie de la vésicule biliaire est une anomalie congénitale rare. Le but de ce travail est d’étudier, à travers trois cas que nous rapportons, les aspects épidémiologiques de cette affection ainsi que les particularités de diagnostic et de prise en charge thérapeutique. Les 2 adultes ont été admis pour coliques hépatiques et troubles dyspeptiques avec à l’échographie une vésicule scléroatrophique multilithiasique. L’un des deux a eu un scanner qui a objectivé l’aspect d’un calcul au niveau d’une vésicule scléroatrophique. Ces 2 malades ont été opéréspar voie classique à tort pour lithiase vésiculaire. L’absence de vésicule biliaire a été découverte en per opératoire. Afin de confirmer le diagnostic en post opératoire, on a pratiqué une bili-IRM pour la 1ère patiente. L’autre malade a été perdu de vue. Notre 3^ème cas, une enfant de 13 ans, hospitalisée pour pancréatite aigüe et l’agénésie vésiculaire a été suspectée devant l’aspect scannographique, puis confirmée par la Bili-IRM et elle n’a pas été opérée.

Post-cholecystectomy syndrome and sphincter of Oddi dysfunction: past, present and future

Post-cholecystectomy syndrome and the concept of a causal relationship to sphincter of Oddi dysfunction, despite the controversy, has presented a clinically relevant conflict for decades. Historically surgeons, and now gastroenterologists have expended tremendous efforts towards trying to better understand the dilemma that is confounded by unique patient phenotypes. Areas covered: This review encompasses the literature from a century of experience on the topic of post-cholecystectomy syndrome. Relevant historical and anecdotal experiences are examined in the setting of insights from evaluation of recently available controlled data. Expert commentary: Historical observations and recent data suggest that patients with post-cholecystectomy syndrome can be categorized as follows. Patients with sphincter of Oddi stenosis will most often benefit from treatment with sphincterotomy. Patients with classic biliary pain and some objective evidence of biliary obstruction may have a sphincter of Oddi disorder and should be considered for endoscopic evaluation and therapy. Patients with atypical post-cholecystectomy pain, without any evidence consistent with biliary obstruction, and/or with evidence for another diagnosis or dysfunction should not undergo ERCP.

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Medical treatment for sphincter of oddi dysfunction: Can it replace endoscopic sphincterotomy?

AIM: To report the results of a medical management of sphincter of oddi dysfunction (SOD) after an intermediate follow-up period.

METHODS: A total of 59 patients with SOD (2 men and 57 women, mean age 51 years old) were included in this prospective study. After medical treatment for one year, the patients were clinically re-evaluated after an average period of 30 mo.

RESULTS: The distribution of the patients according to the Milwaukee’s classification was the following: 11 patients were type 1, 34 were type 2 and 14 were type 3. Fourteen patients underwent an endoscopic sphincterotomy (ES) after one year of medical treatment. The median intermediate follow-up period was 29.8 ± 3 mo (3-72 mo). The initial effectiveness of the medical treatment was complete, partial and poor among 50.8%, 13.5% and 35%, respectively, of the patients. At the end of the follow-up period, 37 patients (62.7%) showed more than 50% improvement. The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively (64.2% vs 62.2%, respectively).

CONCLUSION: Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because, after an intermediate follow-up period, the two treatments show the same success rates.

Is endoscopic sphincterotomy avoidable in patients with sphincter of Oddi dysfunction?

AIM

Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management.

METHODS

A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful.

RESULTS

Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile-duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured.

CONCLUSION

In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

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.

Secretin-stimulated magnetic resonance pancreaticogram to assess pancreatic duct outflow obstruction in evaluation of idiopathic acute recurrent pancreatitis: a pilot study

Magnetic resonance pancreatography is a new modality to visualize the pancreatic duct. Prolonged dilation of the pancreatic duct following secretin administration may suggest obstruction at the level of the pancreatic duct orifice. We describe 10 patients with idiopathic acute recurrent pancreatitis who underwent secretin-stimulated magnetic resonance pancreatography with subsequent endoscopic retrograde pancreatogram with or without manometry. All patients had complete visualization of the main pancreatic duct and no evidence of chronic duct disease. Two patients had pancreas divisum. Three had prolonged dilation of the pancreatic duct on secretin-stimulated magnetic resonance pancreatography and evidence of pancreatic duct outflow obstruction. Four additional patients with pancreatic duct outflow obstruction had normal secretin-stimulated magnetic resonance pancreatography. In conclusion, secretin stimulated magnetic resonance pancreatography provides high quality pancreatic duct images and has high specificity but low sensitivity for diagnosing pancreatic duct outflow obstruction using manometric/clinical criteria.

Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography

Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Technique-related risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient's coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.

Acute Pancreatitis in Children

There are no drugs that cure or abate pancreatitis. The treatment of patients with mild and moderate episodes of pancreatitis (85%) is supportive and expectant. Central issues include the removal of the initiating process (if possible), relief of pain, and maintenance of fluid and electrolyte balance. Endoscopic retrograde cholangiopancreatography may be required for stone extraction in patients with biliary pancreatitis. Surgery is rarely required. The aims of treatment for patients with severe disease includes treatment of local, systemic, and septic complications in addition to those for mild and moderate disease. Homeostasis is maintained by the correction of hypocalcemia, anemia, hypoalbuminemia, electrolyte imbalances, and hypoxemia. A large number of medications have been used unsuccessfully in an attempt to halt the progression of the autodigestive process within the pancreas and to reduce pancreatic secretions. Nutritional support with either enteral or parenteral feeding is given. Intravenous antibiotics or selective bowel decontamination decrease mortality in patients with severe episodes of pancreatitis. The treatment for these individuals is often prolonged. Surgical treatment of traumatic pancreatitis with ductal rupture includes repair or resection. At times, simple drainage is performed and definitive surgery is deferred until later. Surgical treatment of severe pancreatitis includes debridement of necrotic and infected tissue. The emerging consensus appears to be that necrosectomy and local lavage or open management with planned re-exploration offers better survival than the conventional therapy of resection plus drainage alone.

Chronic Visceral Right Upper Quadrant Pain Without Gallstones

Patients with chronic visceral right upper quadrant pain without gallstones can be broadly categorized into two groups: patients with gallbladder dyskinesia, and patients with sphincter of Oddi dysfunction (SOD). Treating patients with these disorders is often challenging to clinicians due to the difficulty at arriving at a definite diagnosis, and the lack of efficacy of various treatment modalities. The only real treatment option for patients with gallbladder dyskinesia is cholecystectomy; however, the results are difficult to predict in an individual patient. Patients with SOD can be approached according to a classification that at least partially reflects the underlying pathophysiology. Patients with type I SOD have underlying papillary stenosis, and benefit from empiric sphincterotomy. Patients with type II SOD may have muscle spasm as predominant pathophysiology; this group of patients benefit from sphincterotomy only if increased sphincter pressure is demonstrated by sphincter of Oddi manometry. Patients with type III SOD may have visceral hyperalgesia; a trial of antidepressants or a therapeutic trial with botulinum toxin injection into the ampulla should be considered prior to more invasive endoscopic therapy.

Cholecysto-sphincter inhibitory reflex: identification of a reflex and its role in bile flow in a canine model

To study the effect of gallbladder (GB) distension on the sphincter of Oddi (SO), 9 mongrel dogs (mean weight 15.3+/-3.6 kg) were studied. Under anesthesia, the abdomen was opened and the GB and SO were exposed. A balloon-tipped catheter was introduced into the GB and a manometric catheter into the common bile duct so that its fluoroscopically controlled tip lay within the SO. The pressure response of the GB and SO to GB distension by the balloon without and with selective anesthetization of the GB and SO was recorded. The test was repeated in four vagotomized dogs. GB distension effected pressure rise within the GB and pressure drop within the SO. The GB pressure increased progressively as the distending volume increased, while the SO pressure drop was not affected. Selective anesthetization of the GB or the SO produced no SO pressure changes upon GB distension. The SO pressure response to GB distension after vagotomy was similar to that before vagotomy. The SO relaxation on GB contraction, being reproducible and abolished by selective anesthetization of either the SO or the GB, postulates a reflex relationship that we call the cholecysto-sphincter inhibitory reflex. This reflex seems to regulate the bile flow from the GB to the duodenum through the SO.