Choledochoduodenal flow: effect of the sphincter of Oddi in opossums and cats

Histologic characterization of the major duodenal papilla and association with concurrent biliary, pancreatic, and intestinal pathology in cats

Conjoining of the major pancreatic duct and common bile duct at the major duodenal papilla (MDP) is suspected to predispose cats to the clinical syndrome of "triaditis." However, microanatomy of the MDP or presence of lesions at the MDP has not been assessed in cats with or without triaditis. The aims of this study were to characterize feline MDP histomorphology and to identify associations between MDP anatomy/disease and the presence of biliary, pancreatic, or intestinal inflammation or neoplasia. Histologic assessment was prospectively performed on the MDP, duodenum, jejunum, ileum, liver, and pancreas from 124 client-owned cats undergoing postmortem examination. The majority of cats (104/124, 84%) had a complex ductular network at the MDP, with no distinction between pancreatic and common bile ducts. Lymphoid aggregates at the MDP were common (63/124, 51%). Inflammation of the MDP (MDPitis) was present in 35 of 124 cats (28%) and was often concurrent with cholangitis, pancreatitis, or enteritis (32/35, 91%), but was only associated with enteritis (19/35, 54%, P < .05). Triaditis was less common (19/124, 15%), but was associated with both conjoined MDP anatomy (19/19, 100%, P < .05) and MDPitis (12/19, 63%, P < .05). Neoplasia was present in 37 of 124 cats (29%), with lymphoma (28/37, 78%) predominating. Enteropathy-associated T-cell lymphoma type 2 (EATL2) was most common (n = 16/37, 43%) and was associated with triaditis and MDPitis (P < .05). These findings suggest that anatomy, immune activation, and/or inflammation of the MDP may play a role in the pathogenesis of triaditis. Further studies are needed to elucidate the relationships between triaditis, MDPitis, and EATL2.

Sphincter of Oddi manometry by choledochoscope in patients with duodenobiliary reflux

BACKGROUND AND AIM

  Previous research has confirmed that duodenobiliary reflux exists in patients with choledocholithiasis. The objective of this study was to investigate whether the motor activity of the sphincter of Oddi (SO) has an effect on duodenobiliary reflux.

METHODS

  A total of 51 patients orally ingested 1mL water containing technetium-99m diethylenetriaminepentaacetatic acid, and a 2-h bile collection was obtained from the T tube. Technetium counts in the collected bile were performed using an RM905 radioactivity meter. The patients were divided into two groups: reflux group (duodenobiliary reflux positive) and control group (duodenobiliary reflux negative). Next, 33 cases were randomly selected and double blinded to receive SO manometry by choledochoscope.

RESULTS

  Of the 51 total cases, 16 bile samples exhibited radioactivity. The average SO basal pressure and contraction pressure values were 7.2±3.9mmHg and 53.5±24.5mmHg, respectively, in the reflux group, and 14.7±11.0mmHg and 117.2±65.6mmHg, respectively, in the control group. The choledochus pressure values were 5.1±1.6mmHg and 11.5±7.4mmHg in the reflux group and the control group, respectively. The differences between the groups were statistically significant; however, the SO contraction frequency, SO contraction duration, and duodenum pressure values were not significantly different between the groups.

CONCLUSION

  The decreases in the SO basal pressure and SO contraction pressure, and the decrease in choledochus pressure, might play a role in duodenobiliary reflux.

A series of six cases of sphincter of Oddi pathology in the cat (2008-2009)

The sphincter of Oddi (SO) is located within the wall of the duodenum as the terminal part of the common bile duct. Six cats are reported with obstructive processes within their SO. Three of them may have had some form of sphincter dysfunction associated with the pre-existing complex known as 'inflammatory bowel disease' (IBD), two may have had the equivalent of the infant human condition known as 'bile plug syndrome' and the sixth had sphincter dysfunction associated with a tumour at the confluence of the common and right hepatic duct. In all six cases, the sphincter obstructions were surgically managed. The outcomes for 4/6 were favourable but 1/6 was euthanased intraoperatively, and 1/6 had a metastatic neoplasia and was euthanased 2 months postoperatively.

Sphincter of Oddi hypomotility and its relationship with duodenal-biliary reflux, plasma motilin and serum gastrin

AIM: To detect whether patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux by measuring the radioactivity of Tc99m-labeled diethylene triamine penta-acetic acid (DTPA) in the bile and whether the patients with duodenal-biliary reflux have sphincter of Oddi hypomotility, by measuring the level of plasma and serum gastrin of the patients. Finally to if there is close relationship among sphincter of Oddi hypomotility, duodenal-biliary reflux and gastrointestinal peptides.

METHODS: Forty-five patients with a T tube after cholecystectomy and choledochotomy were divided into reflux group and control group. The level of plasma and serum gastrin of the patients and of 12 healthy volunteers were measured by radioimmunoassay. Thirty-four were selected randomly to undergo choledochoscope manometry. Sphincter of Oddi basal pressure (SOBP), amplitude (SOCA), frequency of contractions (SOF), duration of contractions (SOD), duodenal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed.

RESULTS: Sixteen (35.6%) patients were detected to have duodenal-biliary reflux. SOBP, SOCA and CBDP in the reflux group were much lower than the control group (t = 5.254, 3.438 and 3.527, P < 0.001). SOD of the reflux group was shorter than the control group (t = 2.049, P < 0.05). The level of serum gastrin and plasma motilin of the reflux group was much lower than the control group (t = -2.230 and -2.235, P < 0.05). There was positive correlation between the level of plasma motilin and SOBP and between the level of serum gastrin and SOBP and CBDP.

CONCLUSION: About 35.9% of the patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux. Most of them have sphincter of Oddi hypomotility and the decreased level of plasma motilin and serum gastrin. The disorder of gastrointestinal hormone secretion may result in sphincter of Oddi dysfunction. There is a close relationship between sphincter of Oddi hypomotility and duodenal-biliary reflux.

Calcium channel antagonists and inhibition of human sphincter of Oddi contractions

OBJECTIVE

Nifedipine has been used in the treatment of sphincter of Oddi dyskinesia, a biliary disease characterized by upper abdominal pains and increased pressure in the sphincter. The effects of other calcium channel antagonists on sphincter of Oddi have not been elucidated.

MATERIAL AND METHODS

We compared the effects of three calcium blockers with differing smooth muscle selectivity (verapamil, nifedipine and felodipine) on human sphincter of Oddi contractions. Transverse sections of the sphincter obtained from five patients undergoing Whipple resection were studied in an organ bath chamber in vitro.

RESULTS

All three calcium blockers significantly (>50%) inhibited the acetylcholine-induced and KCl-induced sphincter contractions in a dose-dependent manner. Both nifedipine and felodipine were more potent than verapamil in inhibiting the acetylcholine-induced contractions, whereas only nifedipine, but not felodipine, reduced the KCl-elicited contractions more than verapamil.

CONCLUSIONS

The smooth muscle selective calcium channel antagonists are potent inhibitors of human sphincter of Oddi contractions. Although nifedipine is, to date, the only agent studied in clinical settings, other dihydropyridines are also likely to be useful in sphincter of Oddi dyskinesia.

Decreased distribution of nitric oxide synthase and vasoactive intestinal polypeptide positive nerve cells in the sphincter of Oddi in humans with pancreatobiliary diseases

To better understand the relationship between innervation in the sphincter of Oddi and pancreatobiliary diseases, nerve cells which possess nitric oxide synthase (NOS) and/or vasoactive intestinal polypeptide (VIP) were studied immunohistochemically in the sphincter of Oddi and duodenum of humans. Specimens from autopsies included 11 cases with pancreatobiliary diseases and 7 cases without such diseases. An elaborate nerve network was revealed with an anti-S-100 antibody in the sphincter of Oddi and duodenum of all specimens. In the sphincter of Oddi of the control group, approximately 47% of the myenteric nerve cells were NOS positive, whereas 54% were VIP positive. Of the NOS positive nerve cells, 21% were also VIP positive. In contrast, 11% of the nerve cells in the sphincter of Oddi of the disease group were NOS positive while 32% were VIP positive. Within the duodenal myenteric plexus of the control group, 35% of all nerve cells were NOS positive while 40% was VIP positive; among them, 23% of the NOS positive cells were VIP positive. Similar results were observed in the duodenum of the disease group. These data indicate that abundant NOS and VIP positive innervation is present in the sphincter of Oddi and duodenum in humans. The lower proportion of NOS positive or VIP positive nerve cells of the disease group may suggest an inadequacy of the sphincter of Oddi to relax.

Does topical GTN on the sphincter of Oddi facilitate ERCP? A double-blind randomized control trial

BACKGROUND

Endoscopic retrograde cholangio pancreatography (ERCP) is a technically challenging procedure. Glyceryl trinitrate (GTN) has been shown to reduce tone in the sphincter of Oddi (SO), cannulation of which is a rate-limiting factor. A double-blind randomized control trial was performed to assess whether topical GTN on the SO would facilitate cholangiography and/or bile duct cannulation.

METHODS

104 patients requiring ERCP for biliary symptoms were randomized into two groups, 52 controls pretreated with 5 ml 0.9% normal saline (NS) and 52 pretreated with 5 ml GTN (concentration 1 mg/ml).

RESULTS

There was no significant between the control group and the GTN group in primary cannulation rate (p = 0.76), time taken to cholangiography (p = 0.58), or time to cannulation (p = 0.43).

CONCLUSION

Topically administered GTN to the SO does not aid in obtaining a cholangiogram or cannulation during an ERCP.

The possum sphincter of Oddi pumps or resists flow depending on common bile duct pressure: a multilumen manometry study

The sphincter of Oddi (SO) regulates trans-sphincteric flow (TSF) by acting primarily as a pump or as a resistor in specific species. We used the Australian possum SO, which functions similarly to the human SO, to characterize SO motility responses to different common bile duct (CBD) and duodenal pressures. Possum CBD, SO and attached duodenum (n= 18) was mounted in an organ bath. External reservoirs were used to impose CBD (0-17 mmHg) and duodenal (0, 4, 7 mmHg) pressure. Spontaneous SO activity was recorded using four-lumen pico-manometry and TSF was measured gravimetrically. Temporal analysis of manometric and TSF recordings identified three functionally distinct biliary-SO regions, the proximal-SO (juxta-CBD), body-SO and papilla-SO. At CBD pressures < 3 mmHg the motor activity of these regions was coordinated to pump fluid. Proximal-SO contractions isolated fluid within the body-SO. Peristaltic contraction through the body-SO pumped this fluid through the papilla-SO (17-27 microl contraction), which opened to facilitate flow. CBD pressure > 3.5 mmHg resulted in progressive changes in TSF to predominantly passive 'resistor'-type flow, occurring during proximal-SO-body-SO quiescence, when CBD pressure exceeded the pressure at the papilla-SO. Progression from pump to resistor function commenced when CBD pressure was 2-4 mmHg greater than duodenal pressure. These results imply that TSF is dependent on the CBD-duodenal pressure difference. The papilla-SO is pivotal to TSF, relaxing during proximal-SO-body-SO pumping and closing during proximal-SO-body-SO quiescence. The pump function promotes TSF at low CBD pressure and prevents bile stasis. At higher CBD pressure, the papilla-SO permits TSF along a pressure gradient, thereby maintaining a low pressure within the biliary tract.

Sphincter of Oddi dysfunction: is there a role for medical therapy?

If the mechanism of pain in patients with sphincter of Oddi (SO) dysfunction is functional obstruction of the biliary tract, and at least in some patients it results from sphincter smooth muscle hypertrophy, then smooth muscle relaxants should have a theoretic role in the management of these patients. Calcium channel antagonists and other smooth muscle relaxants have been shown in "acute" manometric studies to alter SO motility. However, the effect of these agents on vascular smooth muscle remains a concern and often limits their use. At present the role of medical therapy is somewhat unclear because few well-conducted studies have used manometric criteria for the diagnosis of SO dysfunction and the selection of patients for therapy. The main drawback is that no drugs appear to be specific for the SO, long acting, and free of side effects.

Effect of cholesterol liposomes on calcium mobilization in muscle cells from the rabbit sphincter of Oddi

AIM: To analyze the influence of cholesterol liposome on the Ca²⁺ mobilization of cultured muscle cells in rabbit sphincter of Oddi’s.

METHODS: New Zealand rabbit was sacrificed and the sphincter of Oddi (SO) segement was obtained aseptically. The SO segment was cut into pieces and cultured in DMEM solution. Then the smooth muscle cells were subcultured, and the 4th-7th passage cells were used for further investigation. The intracellular Ca²⁺ increase was measured under confocal microscope after the addition of 20 mmol·L^-1 KCl, 10^-7 mol·L^-1 acetylcholine and 10^-7 mol·L^-1 cholecystokinin, and different antagonists were added to analyze the Ca²⁺ mobilization pathway. After the cells were incubated with 1 g·L^-1 cholesterol liposome (CL)(molar ratio was-2:1), the intracellular Ca²⁺ increase was measured again to determine the effect of CL on cellular Ca²⁺ mobilization.

RESULTS: The resting cellular calcium concentration of cultured SO cell was 108 nmol·L^-1± 21 nmol·L^-1. The intracellular Ca²⁺ increases induced by 20 mmol·L^-1 KCl, 10^-7 mol·L^-1 ACh and 10^-7 mol·L^-1 CCK were 183% ± 56%, 161% ± 52% and 130% ± 43%, respectively. When the extracellular Ca²⁺ was eliminated by 2 mmol·L^-1 EGTA and 5 μmol·L^-1 verapamil, the intracellular Ca²⁺ increases induced by KCl, ACh and CCK were 20% ± 14%, 82% ± 21% and 104% ± 23%, respectively. After the preincubation with heparin, the Ca²⁺ increases were 62% ± 23% and 23% ± 19% induced by ACh and CCK, as for preincubation with procaine they were 72% ± 28% and 85% ± 37% induced by ACh and CCK, respectively. Pretreatment with CL for 18 h, the resting cellular Ca²⁺ concentration elevated to 152 nmol·L^-1± 26 nmol·L^-1, however, the cellular Ca²⁺ increase percentages in response to these agonists were 67% ± 32%, 56% ± 33% and 34% ± 15%.

CONCLUSION: KCl elicite the SO cellular Ca²⁺ increase depends on influx of extracellular Ca²⁺, ACh evoked the SO celllular Ca²⁺ increase is through the mobilization of intracellular Ca²⁺ pool and influx of extracellular Ca²⁺ as well, CCK excites the SO cells mainly through mobilization of intracellular IP3-sensitive Ca²⁺ store. After the incorporation with cholesterol liposome, KCl,ACh and CCK induced cellular Ca²⁺ increase percentages decreased.

Histamine in the control of porcine and human sphincter of Oddi activity

Histamine decreases sphincter of Oddi (SO) contractility in vivo in opossum, but increases contractility in vitro in guinea-pig. In resistor-like SO, such as in pig and man, the histamine effect is poorly known. We investigated the effect of histamine on pig SO in vivo and in vitro and on human SO in vitro. Perfusion manometry catheter and two silver electrodes for simultaneous pressure and electromyography registration were inserted into the SO transduodenally by laparotomy in six anaesthetized pigs weighing for 25-28 kg. Histamine (5-10 microgram kg-1) was infused intra-arterially (i.a.) into the pancreaticoduodenal artery with and without diphenhydramine (75 microgram kg-1) i.a. premedication. Acetylcholine (4 microgram kg-1) i.a., a potent SO stimulator, was used as positive control. After these experiments, the SO was removed and, together with seven human SO from Whipple specimens, were cut into 1.0-1.5 mm thick transverse sections (rings). The rings were placed between two hooks in oxygenated organ bath solution at 37 degrees C. The SO contraction force was measured with isometric force-displacement transducers and registered on a polygraph. SO rings were incubated with histamine (10-100 micromol L-1) and acetylcholine (100 micromol L-1) with or without diphenhydramine (10 micromol L-1), cimetidine (10 micromol L-1), or atropine (1 micromol L-1). Acetylcholine induced huge electrical bursts, and basal SO pressure increased by 20 +/- 10 mmHg. Histamine (10 microgram kg-1) induced strong SO contraction and the SO remained oedematous for over 10 min. Histamine (5 microgram kg-1) resulted in electromyographic burst activity with phasic SO contractions and increase in basal SO pressure by 34 +/- 19 mmHg for over 15 min. Diphenhydramine did not alter acetylcholine-induced SO motility, but significantly decreased histamine-induced contractions and almost abolished electrical activity. In vitro, acetylcholine induced SO contractions in pig (335 +/- 111 mg) and in man (323 +/- 54 mg). Histamine did not change SO tone in man, but in pig it induced dose-dependent contractions in the same way as acetylcholine. These contractions could be inhibited by diphenhydramine, but not by cimetidine or atropine. We conclude that histamine has a stimulatory effect, mediated by H1-receptor, on the pig SO motility. The SO response to histamine is different in adult humans from that observed in young pigs.

Functional innervation of the biliary sphincter of the guinea-pig revealed by anti-autonomic drugs

1. The roles of excitatory and inhibitory intrinsic motor nerves on contractions reflexly evoked by wall distension were investigated in the isolated sphincter of Oddi of the guinea-pig (SO-GP). 2. Distension of the terminal bile duct for 30-60 s time periods increased the frequency of contractions from about 2 to 12 min(-1) (n = 16). 3. Hexamethonium (HEX; 300 microM) largely prevented the distension-evoked increase in contraction frequency (4.5 min(-1), n = 8) as did atropine (ATR; 1 microM) (0.8 min(-1), n = 6), while tetrodotoxin (TTX; 1 microM) blocked the contractions triggered during distension. 4. L-nitroarginine (L-NA; 100 microM) significantly increased the frequency of contractions during and in the absence distension while apamin (APAM; 0.5 microM) significantly increased their frequency and doubled their mean amplitude during distension. 5. These results suggest that distension activates excitatory cholinergic motor nerves to increase the frequency of contractions in the SO-GP. These actions are modulated by the concomitant activation of intrinsic nitrergic and non-nitrergic inhibitory motor nerves.

In vitro characterisation of intramural neural pathways between the duodenum and the sphincter of Oddi of the brush-tailed possum

The aims of this study were to determine if neural pathways between the duodenum and sphincter of Oddi are intramural, activated by duodenal electrical field stimulation (EFS) in vitro, and contain capsaicin-sensitive primary afferents. The possible involvement of cholinergic (muscarinic and/or nicotinic) and adrenergic receptors in these pathways were also investigated. Duodenal EFS (5-60 Hz, 70 V, 0.5 ms duration, 10 s train) at sites 2 cm oral and 2 cm anal to the sphincter of Oddi-duodenal junction produced frequency-dependent excitatory responses in the sphincter of Oddi, measured by manometry (n = 3). Excitatory responses from duodenal circular muscle were also evident. Tetrodotoxin (1 microM; n = 7) pretreatment abolished both sphincter of Oddi and duodenal responses to duodenal EFS. Crushing the duodenum between the site of stimulation and the sphincter of Oddi-duodenal junction also abolished sphincter of Oddi response. The sphincter of Oddi responses to duodenal EFS at the oral and anal sites were reduced by pretreatment with (i) atropine (100 nM: n = 7) to 19 +/- 6% (P < 0.05) and 22 +/- 8% (P < 0.05) of control respectively. (ii) hexamethonium (100 microM: n = 9) to 10 +/- 2% (P < 0.01) and 6.0 + 2.5% (P < 0.01) of control respectively and (iii) guanethidine (1 microM; n = 6) to 75 +/- 6% (P < 0.05) and 78 +/- 10% (P < 0.05) of control, respectively. Combined pretreatment with phentolamine and propranolol (both 1 microM; n = 7) was without effect, as was capsaicin (1 microM; n = 12) pretreatment. Excitatory intramural pathways between the sphincter of Oddi and the duodenum are primarily cholinergic in nature and contain an adrenergic component. Capsaicin-sensitive primary afferents are not involved.

Neuropeptides in pig sphincter of Oddi, bile duct, gallbladder, and duodenum

To better understand the complex structure and function of the sphincter of Oddi (SO), the occurrence and localization of nine neuropeptides, including vasoactive intestinal polypeptide (VIP), bombesin, neuropeptide Y, peptide histidine-isoleucine (PHI), calcitonin gene-related peptide (CGRP), galanin, substance P, serotonin, and somatostatin, were studied by immunohistochemical methods in the pig SO. The SO innervation was compared to gallbladder, common bile duct, and duodenal innervation. Specimens from the SO, gallbladder, common bile duct, and duodenum demonstrated a rich network of nerves, as suggested by light microscopy and confirmed by a myelin marker S-100. SO demonstrated very strong immunoreactivity for VIP, strong immunoreactivity for neuropeptide Y and galanin, moderate immunoreactivity for PHI and CGRP, and borderline immunoreactivity for bombesin and substance P. Serotonin and somatostatin immunoreactivity was also observed, not in the nerves, but in some of the epithelial cells. The gallbladder innervation was virtually identical to the SO innervation, whereas common bile duct and duodenal innervation were slightly different. To our knowledge this is the first time that galanin- and PHI-like immunoreactivities have been observed in the SO. Our observations suggest that these peptides, along with VIP, neuropeptide Y, and CGRP, might play a role in the neural control of biliary motility.

Anatomy of the bilioduodenal junction of the opossum

Prevention of reflux is a major function of the terminal biliary duct system at its junction with the duodenum. We examined this area via scanning electron microscopy and light microscopy to explore anatomic features that might play such a role in the Virginia opossum, a species with a highly developed sphincter of Oddi (SO). The terminal apparatus, most of which consists of a dilated extramural ampulla, has a lumen with abundant folds. Mucus is produced by the lining epithelium and by a plethora of glands. Three muscle layers constitute the SO: an inner longitudinal, an outer circular, and a less consistent outermost longitudinal. The terminal apparatus forms an acute angle and narrows as it enters the duodenum; at this point, the SO becomes continuous with the muscularis externa of the intestine. Four anatomical features with potential antireflux properties may be identified: mucus production, luminal folds, and the narrow opening and oblique course of the intramural duct.