Postcholecystectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III

Routine upper gastro-intestinal tract endoscopy before elective cholecystectomy for symptomatic gallstones-justified

Gallstones are common in Western countries and increasing in developing countries through adoption of western lifestyle. Gallstones may cause life-threatening complications, including acute cholecystitis, acute cholangitis, and acute pancreatitis. Cholecystectomy is the treatment of choice for symptomatic gallstones. Presentation of symptomatic gallstones may be indistinguishable from that of other upper gastro-intestinal tract (UGI) pathologies. Some surgeons routinely perform preoperative UGI endoscopy to diagnose and treat concomitant UGI pathology. A prospective cross-sectional observational study was undertaken at University of Pretoria teaching hospitals to evaluate this practice. Patients aged 18 years and older, with symptomatic gallstones but did not satisfy Tokyo guidelines for acute cholecystitis were recruited. UGI endoscopy was performed before cholecystectomy. There were 124 patients, 110 (88.7%) females and 14 (11.3%) males, mean age 44.0 (13.2) (range: 22-78) years. Most common symptoms were right upper quadrant (RUQ) pain (87%), epigastric pain (59.7%), nausea (58.1%) and vomiting (47.9%). Clinically, 80% had RUQ tenderness and 52.4% epigastric tenderness. UGI endoscopy found 35.4% pathology, 28.2% were active, and comprised acute gastritis (27.4%), peptic ulcers (4.8%), duodenitis (3.2%) and oesophagitis (2.4%). Twelve patients had more than one pathology. This warranted treatment before elective cholecystectomy and justifies the practice of routine preoperative UGI endoscopy.

Current treatment of biliary Sphincter of Oddi Dysfunction

The sphincter of Oddi is a delicate neuromuscular structure located at the junction of the biliary-pancreatic system and the duodenum. Sphincter of Oddi Dysfunction (SOD) can result in various clinical manifestations, including biliary-type pain and recurrent idiopathic pancreatitis. The management of SOD has been challenging. With the publication of the landmark Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial and the Rome IV consensus, our clinical practice in the treatment of SOD has changed significantly in recent years. Currently, the management of type II SOD remains controversial and there is a lack of non-invasive therapy options, particularly for patients not responding to endoscopic treatment. In this mini review, we aimed to discuss the current knowledge on the treatment of biliary SOD.

Intra-sphincteric botulinum toxin in the management of functional biliary pain

Background and study aims  The management of functional biliary-type pain remains a clinical challenge. Intra sphincteric botulinum toxin putatively exerts an anti-spasmodic and anti-nociceptive effect. The objective of this study was to examine the clinical response to intra sphincteric botulinum toxin in patients with functional biliary-type pain. Patients and methods  This was a cross-sectional (hypothesis-generating) study of prospectively collected data from patients referred to a tertiary center from 2014 to 2019. The efficacy of ampullary botulinum toxin injection for relief of pain was recorded at post-procedure outpatient review. Opioid analgesia, neuromodulatory medication, and frequency of hospital admissions were recorded. Results  A total of 119 consecutive patients (109 women, 10 men, mean age 45 years; range 17-77) underwent 411 intra-sphincteric botulinum toxin injection procedures (mean 2 procedures; range 1-15). A total of 103 patients (87 %) had a significant improvement in pain on post-procedure review and 77 % and 76 % of patients were opioid and admission free, respectively. Of the patients, 59 % were prescribed tricyclic antidepressants (amitriptyline), 18 % duloxetine, 13 % pregabalin, and 3 % mirtazapine. Loss of response with the initial dose of botulinum toxin occurred in 56 % of patients. Pain control was reestablished in 80 % of patients in this cohort following botulinum toxin injection at a higher dose. Conclusions  These data suggest that botulinum toxin may improve outcomes in patients with functional biliary pain. Further controlled studies are needed to clarify the role of Botox and neuromodulatory agents.

The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification

Background

Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria.

Methods

We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP.

Results

Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up.

Conclusions

PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.

Long-term Follow-up of Patients Undergoing Endoscopic Intervention for Abdominal Pain with Minimal Biliary Ductal Dilation, Stone Disease, or Malignancy

BACKGROUND

Safety and efficacy of endoscopic methods in management of biliary colic after cholecystectomy in patients with minimal biliary ductal dilation and no evidence of biliary stones or malignancy have not been clearly demonstrated. This study aimed to assess the efficacy of endoscopic management of such patients.

METHODS

The University of Louisville database was queried for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for colicky abdominal pain between 1996 and 2016 who had a common bile duct (CBD) diameter of ≤12 mm. All patients had undergone prior cholecystectomy and were free of malignancy. Demographic, serologic, procedural, and outcome variables were assessed.

RESULTS

A total of 35 patients underwent a total of 99 ERCPs. Median CBD diameter was 10 (range 4-12) mm. A total of 31 patients (89%) underwent sphincterotomy, 28 (80%) underwent stent placement, and 5 (14%) underwent balloon dilation. The median number of ERCPs performed was 2 (range 1-10). Three of the 35 patients (9%) developed post-ERCP pancreatitis at some point during their treatment. At last follow-up since initial ERCP (median 16 months, range 2.4-184 months), 12 (34%) patients endorsed abdominal pain and 11 (31%) reported experiencing nausea.

CONCLUSION

For select patients with abdominal pain in the setting of minimal CBD dilation and no evidence of stone disease or malignancy, ERCP can safely and effectively be used to manage symptoms. While patients may require multiple interventions, they can derive long-term relief from these procedures.

Clinical course of biliary-type sphincter of Oddi dysfunction: endoscopic sphincterotomy and functional dyspepsia as affecting factors

BACKGROUND AND STUDY AIMS

The objective of this study was to clarify the effectiveness of treatment selection for biliary-type sphincter of Oddi dysfunction by severe pain frequency and the risk factors for recurrence including the history of functional gastrointestinal disorder.

PATIENTS AND METHODS

Thirty-six sphincter of Oddi dysfunction patients who were confirmed endoscopic retrograde cholangiopancreatography enrolled in this study. Endoscopic sphincterotomy was performed for type I and manometry-confirmed type II sphincter of Oddi dysfunction patients with severe pain (⩾2 times/year; endoscopic sphincterotomy group). Others were treated medically (non-endoscopic sphincterotomy group).

RESULTS

The short-term effectiveness rate of endoscopic sphincterotomy was 91%. The final remission rates of the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups were 86% and 100%, respectively. Symptoms relapsed after endoscopic sphincterotomy in 32% of patients. Patients in the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups had or developed functional dyspepsia in 41% and 14%, irritable bowel syndrome in 5% and 14%, and gastroesophageal reflux disorder in 14% and 0%, respectively. History or new onset of functional dyspepsia was related to recurrence on multivariate analysis. The frequency of occurrence of post-endoscopic retrograde cholangiopancreatography pancreatitis and post-endoscopic retrograde cholangiopancreatography cholangitis was high in both groups. Two new occurrences of bile duct stone cases were observed in each group.

CONCLUSION

According to the treatment criteria, endoscopic and medical treatment for biliary-type sphincter of Oddi dysfunction has high effectiveness, but recurrences are common. Recurrences may be related to new onset or a history of functional dyspepsia.

The EPISOD study: long-term outcomes

BACKGROUND AND AIMS

The EPISOD (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction) study randomized patients with post-cholecystectomy pain, and little or no objective evidence for biliary obstruction, to sphincterotomy or sham intervention. Results at 1 year showed no benefit for the active treatment. We now report the outcomes at up to 5 years.

METHODS

One hundred three patients completing 1 year, and still blinded to treatment allocation, were enrolled and followed by phone every 6 months for a median of 58 months (range, 17-71 months). Their success was assessed at the final visit by 2 criteria: (1) a low pain score (Recurrent Abdominal Pain and Disability instrument [RAPID] <6) and (2) much or very much improved on the Patients' Global Impression of Change (PGIC) questionnaire (both with no repeat intervention and not taking narcotics).

RESULTS

By the RAPID criteria, success rates for the patients in the sphincterotomy and sham arms were similar: 26/65 (40%) versus 16/38 (42%), respectively. However, by the PGIC criteria, actively treated patients fared worse: 16/43 (37%) versus 16/22 (73%). A total of 75 patients underwent active treatment during the entire study. Their success rate by the RAPID criteria was 31 (41%) compared with 16 (62%) who had no active treatment at any time.

CONCLUSIONS

These data confirm our initial report that endoscopic sphincterotomy is no better than sham intervention in these patients (and, by some criteria, worse), and that ERCP can no longer be recommended. The patients have genuine and often severe symptoms, and further research is needed to establish effective management. (Clinical trial registration number: 00688662 05/3/2008.).

Sphincter of Oddi Function and Risk Factors for Dysfunction

The sphincter of Oddi (SO) is a smooth muscle valve regulating the flow of biliary and pancreatic secretions into the duodenum, initially described in 1887 by the Italian anatomist, Ruggero Oddi. SO dysfunction (SOD) is a broad term referring to numerous biliary, pancreatic, and hepatic disorders resulting from spasms, strictures, and relaxation of this valve at inappropriate times. This review brings attention to various factors that may increase the risk of SOD, including but not limited to: cholecystectomy, opiates, and alcohol. Lack of proper recognition and treatment of SOD may be associated with clinical events, including pancreatitis and biliary symptoms with hepatic enzyme elevation. Pharmacologic and non-pharmacologic approaches are discussed to help recognize, prevent, and treat SOD. Future studies are needed to assess the treatment benefit of agents such as calcium-channel blockers, glyceryl trinitrate, or tricyclic antidepressants in patients with SOD.

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.

Contrast-enhanced ultrasound may distinguish gallbladder adenoma from cholesterol polyps: a prospective case-control study

PURPOSE

The aim of this study was to find the independent risk factors related with gallbladder (GB) adenoma compared to cholesterol polyp by contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

Between January 2010 and September 2014, a total of 122 consecutive patients undergoing cholecystectomy for GB polypoid lesions were enrolled. Before cholecystectomy, each patient underwent conventional US and CEUS examination and all image features were documented. The patients were divided into adenoma group and cholesterol polyp group according to the pathological findings. All the image features between two groups were statistically compared.

RESULTS

There were differences in patient age, lesion size, echogenicity, and vascularity of lesion between two groups (P < 0.05). There were differences in stalk width and enhancement intensity between the two groups (P < 0.05). Multiple logistic regression analysis proved that enhancement intensity, stalk of lesion, and vascularity were the independent risk factors related with GB adenoma (P < 0.05).

CONCLUSIONS

CEUS could offer useful information to distinguish adenoma from cholesterol polyp. The treatment algorithm for gallbladder polyp lesions would likely benefit from CEUS as a routine imaging investigation, especially in cases where the polyp is larger than 1 cm.

Sphincter of Oddi Dysfunction: Updates from the Recent Literature

Sphincter of Oddi dysfunction (SOD) has long been a controversial topic, starting with whether it even exists, as a sphincterotomy-responsive entity to treat, for either: (1) post-cholecystectomy abdominal pain and/or (2) idiopathic recurrent acute pancreatitis (IRAP). Many of its aspects had required further research to better prove or refute its existence and to provide proper recommendations for physicians to diagnose and treat this condition. Fortunately, there has been major advancement in our knowledge in several areas over the past few years. New studies on challenging the classification, exploring alternative diagnostic methods, and quantifying the role of sphincterotomy in treatment of SOD for post-cholecystectomy pain and for IRAP were recently published, including a randomized trial in each of the two areas. The goal of this paper is to review recent literature on selected important questions and to summarize the results of major trials in this field.

[Sphincter of Oddi dyskinesia]

Sphincter of Oddi dyskinesia is a functional disorder of the papillary region which can lead to clinical symptoms due to functional obstruction of biliary and pancreatic outflow. Based on the severity of the clinical symptoms the disorder can be graded into three types (biliary and pancreatic types I-III). The manometric diagnosis of this disorder using sphincter of Oddi manometry is hampered by the relatively high risk of pancreatitis after endoscopic retrograde cholangiopancreatography. Although papillary manometry is often carried out in North America, in Europe this is the exception rather than the rule. Manometrically, sphincter of Oddi dyskinesia is characterized by an increased pressure in the biliary and/or the pancreatic sphincter segments and can be treated by endoscopic papillotomy. This overview counterbalances the arguments for primary invasive diagnostics and a pragmatic clinical approach, i.e. papillotomy should be directly carried out when a sphincter of Oddi dyskinesia is clinically suspected. For patients with biliary or pancreatic type I, endoscopic papillotomy is the treatment of choice. In biliary type II sphincter of Oddi manometry could be helpful for clinical decision-making; however, the exact risk-benefit ratio is still difficult to assess. In type III patient selection and the low predictive value of manometry for treatment success questions the clinical usefulness of sphincter of Oddi manometry.

Rome IV. Gallbladder and Sphincter of Oddi Disorders

The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.

Sphincter of Oddi Dysfunction

This article reviews the diagnosis and management of sphincter of Oddi dysfunction (SOD), including the various factors to consider before embarking on endoscopic therapy for SOD. Selection starts with patient education to include possible patient misconceptions related to symptoms caused by the pancreaticobiliary sphincter as well as reinforcing the risks associated with the diagnosis and therapy. The likelihood of relief of recurrent abdominal pain attributed to SOD is related to the classification of SOD type and a crucial consideration before considering endoscopic therapy in light of recent evidence.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Black bile of melancholy or gallstones of biliary colics: historical perspectives on cholelithiasis

Barely 130 years after its first description, cholecystectomies are among the most commonly performed surgeries in the USA. The success of this operation with subsequent technical improvements, such as laparoscopic approaches, caused a paradigm shift in the management of gallstone disease. However, symptoms persist in 10-40 % of successfully operated patients. Reviewing monographs, textbooks, and articles published during the last 300 years, several important factors emerge as likely contributors to limited or poor treatment responses. Early on, clinicians recognized that cholelithiasis is quite common and thus often an incidental finding, especially if patients present with vague or atypical symptoms. Consistent with these observations, patients with such atypical symptoms are less likely to benefit from cholecystectomy. Similarly, lasting improvements are more reliably seen in patients with symptoms of presumed biliary origin and documented gallstones compared to individuals without stones, an important point in view of increasing rates of surgery for biliary dyskinesia. While cholelithiasis can cause serious complications, the overall incidence of clinically relevant problems is so low that prophylactic cholecystectomy cannot be justified. This conclusion corresponds to epidemiologic data showing that the rise in elective cholecystectomies decreased hospitalizations due to gallstone disease, but was associated with a higher volume of postoperative complications, ultimately resulting in stable combined mortality due to gallstone disease and its treatment. These trends highlight the tremendous gains in managing gallstone disease, while at the same time reminding us that the tightening rather than expanding indications for cholecystectomy may improve outcomes.

Psychosocial characteristics and pain burden of patients with suspected sphincter of Oddi dysfunction in the EPISOD multicenter trial

OBJECTIVES

Patients with several painful functional gastrointestinal disorders (FGIDs) are reported to have a high prevalence of psychosocial disturbance. These aspects have not been studied extensively in patients with suspected Sphincter of Oddi dysfunction (SOD).

METHODS

A total of 214 patients with post-cholecystectomy pain and suspected SOD were enrolled in seven US centers in a multicenter-randomized trial (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction). Baseline assessments included pain descriptors and burden, structured psychosocial assessments of anxiety/depression, coping, trauma, and health-related quality of life. Patients with high levels of depression, suicidal ideation, or psychosis were excluded.

RESULTS

The study population (92% female, mean age 38) reported anxiety (9%), depression (8%), past sexual trauma (18%), and physical abuse (10%). Of the total screened population (n=1460), 3.9% of the patients were excluded because of the presence of defined severe psychological problems. The mean medical outcomes study short-form-36 (SF-36) physical and mental composite scores were 38.70 (s.d.=7.89) and 48.74 (s.d.=9.60), respectively. Most subjects reported symptoms of other FGIDs. There were no correlations between the extent of the pain burden in the 3 months before enrollment and the baseline anxiety scores or victimization history. However, those with greater pain burden were significantly more depressed. There were no meaningful differences in the psychosocial parameters in subjects with or without irritable bowel, and those who had cholecystectomy for stones or functional gallbladder disease. Those declining randomization were comparable to those randomized.

CONCLUSIONS

Psychosocial comorbidity in SOD is high. However, it does not appear to differ significantly from that reported in surveys of age- and gender-matched general populations, and may be lower than reported with other FGIDs.

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.

Diagnosis and management of gallbladder calculus disease

BACKGROUND

The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease.

METHODS

Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research.

RESULTS

Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series.

CONCLUSIONS

Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

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.

Dynamic changes of echogenicity and the size of the papilla of Vater before and after cholecystectomy

This study investigated the changes in echogenicity, as measured by endoscopic ultrasound, and the surface area of the papilla of Vater (PV) and their relationship with postoperative symptoms in a group of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. After cholecystectomy, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The surface area of the PV was larger than normal prior to surgery and increased after surgery. The healthy PV is isoechogenic, but 48% of all patients were anisoechogenic preoperatively, increasing to 61% at 3 months after surgery, and decreasing to 25% at 6 months postsurgery. There was no significant difference between the two patient groups, suggesting that the changes observed in the PV do not explain the presence of the atypical symptoms of PCS.

Gallbladder dyskinesia

The most appropriate means to diagnose and manage patients with suspected gallbladder dyskinesia remain contentious. A major problem relates to difficulties in clearly identifying the features that characterize biliary-like pain. Conflicting reports in the literature regarding whether symptoms alone are reliable predictors of pain relief after cholecystectomy in patients with suspected gallbladder dysfunction underscore the perceived need by clinicians for a reliable test to help confirm a clinical suspicion of gallbladder dysfunction before cholecystectomy. Most studies report use of cholecystokinin-cholescintigraphy (CCK-CS) with calculation of gallbladder ejection fraction in predicting symptom outcome after cholecystectomy in patients with suspected gallbladder dyskinesia. However, quality evidence is lacking, thereby precluding a definitive recommendation regarding its use. Nevertheless, CCK-CS may be useful when performed using a slow infusion of CCK in a well-selected patient population. Based on our clinical experience and interpretation of the literature, we currently suggest consideration of cholecystectomy to our patients based on high clinical suspicion. This is performed after adequate follow-up with trials of pharmacologic therapies and exclusion of other disease entities and counseling the patient on postoperative expectations. Clearly, a large, prospective, controlled study is needed with patients meeting the Rome definition of gallbladder dyskinesia, randomized to surgery or no surgery, and using standardized CCK-CS methods and outcome measures with long-term follow-up. This study would help us better understand the pathophysiology and optimal management of this clinically challenging condition.

Outcomes of sphincter of oddi manometry when performed in low volumes

Background. Sphincter of Oddi manometry is a highly specialized procedure associated with an increased risk of procedural complications. Published studies have typically been performed in large volume manometry centers. Objective. To examine the outcomes and complication rate of SOM when performed in small volumes. Design. Retrospective analysis at a tertiary care referral hospital that infrequently performs Sphincter of Oddi manometry. Patient records were reviewed for procedural details, patient outcomes, and complications after sphincter of Oddi manometry. Results. 36 patients, 23 (23 type II sphincter of Oddi dysfunction (SOD), 13 type III SOD) underwent sphincter of Oddi manometry and were followed up for mean of 16 months. Nine Type II patients (90%) with elevated basal sphincter pressures noted symptom improvement after sphincterotomy compared with only 3 patients (43%) of the patients with normal basal pressures. In type III SOD, 7 patients had elevated basal SO pressure and underwent sphincterotomy. Three patients (43%) improved. There were six (16%) procedure-related complications. There were four cases of post ERCP pancreatitis (11%), all of which were mild. Conclusion. In low numbers, sphincter of Oddi manometry can be performed successfully and safely by experienced biliary endoscopists with results that are comparable to large volume centers.

The Size of the Papilla of Vater and Its Relation to Its Height in Comparison with the Visibility of the Sphincter of Oddi before and after Cholecystectomy

This study investigated the changes in the surface area and height of the papilla of Vater (PV) and the visibility of the sphincter of Oddi complex (SOK) using endoscopic ultrasound (EUS) examinations of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. Following surgery, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The PV measurements were greater in all patients compared with normal reference values and increased significantly from before surgery to 3 months postsurgery. At 6 months postsurgery, both the surface area and height of the PV had significantly decreased to preoperative values but remained higher than normal. The proportion of patients with a visible SOK had increased by 3 months postsurgery but had reduced again by 6 months. There were no significant differences between symptomatic and asymptomatic patients, suggesting that the changes observed in the PV and SOK do not explain the presence of the atypical symptoms of PCS.

Gallbladder dyskinesia: fact or fiction?

Gallbladder dyskinesia is a functional (motility) disorder of the gallbladder resulting in episodic abdominal pain that, in carefully selected cases, resolves with cholecystectomy. It is a diagnosis of exclusion: several functional and organic disorders have to be excluded, and confounding factors addressed, before a diagnosis of gallbladder dyskinesia can be entertained. The combination of high clinical suspicion and an abnormally low gallbladder ejection fraction on cholecystokinin stimulated-cholescintigraphy predict benefit from removing the gallbladder.

Management of patients with biliary sphincter of Oddi disorder without sphincter of Oddi manometry

Background

The paucity of controlled data for the treatment of most biliary sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice and several trials has generated controversy as to the best course of management of these patients. In this observational study we aimed to assess the outcome of patients with biliary SOD managed without sphincter of Oddi manometry.

Methods

Fifty-nine patients with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment.

Results

At follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% deterioration. Fifty-one percent experienced symptom resolution/improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% complication rate (16% post-ERCP pancreatitis). The majority of complications occurred in the first ERCP these patients had. Most complications were mild and treated conservatively. Age, gender, comorbidity, SOD type, dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p > 0.05 for all).

Conclusions

Patients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature in cohorts of patients assessed by manometry.

Functional gallbladder disorder: gallbladder dyskinesia

Functional gallbladder disorder, commonly referred to as gallbladder dyskinesia, is characterized by the occurrence of abdominal pain resembling gallbladder pain but in the absence of gallstones. The diagnosis and management of this condition can be confusing even for the most astute clinician. The aim of this article is to clarify the identification and management of patients with suspected functional gallbladder disorder.

Sphincter of Oddi dysfunction: Psychosocial distress correlates with manometric dyskinesia but not stenosis

AIM: To compare postcholecystectomy patients with Sphincter of Oddi (SO) dyskinesia and those with normal SO motility to determine the psychosocial distress, gender and objective clinical correlates of dyskinesia, and contrast these findings with comparisons between SO stenosis and normal SO motility.

METHODS: Within a cohort of seventy-two consecutive postcholecystectomy patients with suspected SO dysfunction, manometric assessment identified subgroups with SO dyskinesia (n = 33), SO stenosis (n = 18) and normal SO motility (n = 21). Each patient was categorized in terms of Milwaukee Type, sociodemographic status and the severity of stress-coping experiences.

RESULTS: Logistic regression revealed that in combination certain psychological, sociodemographic and clinical variables significantly differentiated SO dyskinesia, but not SO stenosis, from normal SO function. Levels of psychosocial stress and of coping with this stress (i.e. anger suppressed more frequently and the use of significantly more psychological coping strategies) were highest among patients with SO dyskinesia, especially women. Higher levels of neuroticism (the tendency to stress-proneness) further increased the likelihood of SO dyskinesia.

CONCLUSION: A motility disturbance related to psychosocial distress may help to explain the finding of SO dyskinesia in some postcholecystectomy patients.

Somatosensory hypersensitivity in the referred pain area in patients with chronic biliary pain and a sphincter of Oddi dysfunction: new aspects of an almost forgotten pathogenetic mechanism

BACKGROUND AND AIMS

Somatosensory hyperalgesia in the referred pain area (RPA) in patients with acute or chronic abdominal pain syndromes may result from the convergence of nerve fibers from visceral and somatic tissues at the spinal and supraspinal levels. Chronic biliary pain in patients with the postcholecystectomy syndrome (i.e., biliary hypersensitivity) may be explained by persistent hyperexcitability of neurons in the central nervous system (CNS). The aim of this study was to evaluate the cutaneous neural sensory perception in the RPA in patients with chronic postcholecystectomy biliary pain and a sphincter of Oddi (SO) dysfunction (SOD).

METHODS

Forty-two patients with persistent biliary pain and suspected SOD, 27 age-matched healthy volunteers, and 18 age-matched asymptomatic cholecystectomized controls were prospectively investigated by quantitative sensory testing (Neurometer CPT). The biliary symptoms and the severity of pain were classified on a visual analog pain severity scale system via a previously validated and standardized questionnaire. The patients helped the doctors locate the RPA in the right upper quadrant. The sensory detection threshold was determined noninvasively (Neurometer CPT) with transcutaneous electrical stimulation at 5, 250, and 2,000 Hz, and different current intensities (range from 0.01 to 9.99 mA) applied in a single (patient) blinded method. These three frequencies selectively excite small unmyelinated (C fibers), small myelinated (A-delta), and large myelinated (A-beta) fibers, which transmit dull pain, sharp pain, and touch, respectively. The contralateral region of the abdomen left upper quadrant served as the control area. The sensory current perception threshold ratio (SCPTR) of the data measured in the contralateral area and the RPA was calculated.

RESULTS

The SCPTRs in the definite SOD patients with biliary pain, healthy volunteers, the asymptomatic cholecystectomized controls, and the symptomatic cholecystectomized patients but without SOD were 2.32 +/- 1.4 versus 1.06 +/- 0.24 versus 0.97 +/- 0.16 versus 0.83 +/- 0.35 at 2,000 Hz; 2.19 +/- 1.0 versus 1.01 +/- 0.26 versus 1.02 +/- 0.25 versus 0.88 +/- 0.35 at 250 Hz; and 2.19 +/- 1.1 versus 1.12 +/- 0.26 versus 0.99 +/- 0.37 versus 0.84 +/- 0.32 at 5 Hz, respectively. Significant hypersensitivity was detected in the RPA at different stimulation frequencies in the SOD patients with biliary pain versus the cholecystectomized controls: at 5 Hz: P = 0.00001; at 250 Hz: P = 0.00001; and at 2,000 Hz: P = 0.0001, respectively.

CONCLUSION

Continuous visceral pain (biliary pain) caused by local inflammatory/sensitizing processes or a CNS malfunction could lead to significant hypersensitivity of the peripheral nociceptive nerve fibers in SOD patients. Postcholecystectomy pain may be explained by persistent hyperexcitability of the nociceptive neurons in the CNS with or without objective motility disorders of the SO.

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.

Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis

BACKGROUND

Microlithiasis has been identified as a cause of idiopathic acute pancreatitis in patients with an intact gallbladder. Microlithiasis has also been identified in the bile of some patients who have undergone cholecystectomy. However, it is unknown whether bile microlithiasis causes postcholecystectomy pain.

OBJECTIVE

To identify bile microlithiasis in patients with postcholecystectomy pain and to investigate the therapeutic effect of ursodeoxycholic acid (urso) on such patients with microlithiasis in the bile.

DESIGN

Prospective randomized trial.

SETTING

Tertiary medical center.

PATIENTS

Patients with postcholecystectomy pain and bile crystals.

INTERVENTIONS

Urso treatment.

MAIN OUTCOME MEASUREMENTS

The severity and frequency of right upper-quadrant abdominal pain were compared with and without urso treatment, and before and after urso treatment.

RESULTS

A total of 118 patients with postcholecystectomy pain were screened for the study. Twelve patients (10%) were identified with bile crystals. In the first phase, 6 of these patients received urso treatment, whereas the other 6 patients did not receive urso treatment. In the second phase, the latter 6 patients were given the urso treatment. After using urso for a few months, their biliary-type abdominal pain significantly improved or resolved. In the control group, there was no improvement in symptoms. There was a significant difference between the 2 groups (P = .01).

LIMITATIONS

Single-center, small number of patients.

CONCLUSIONS

This study provided evidence that supports the hypothesis that bile microlithiasis is indeed a cause for postcholecystectomy pain. Patients with such postcholecystectomy pain may benefit from a microscopic examination of bile for crystals or microlithiasis, and urso treatment if bile crystals are identified.

Biliary dyskinesia in the pediatric patient

The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.

Defined indications for elective cholecystectomy for gallstone disease

BACKGROUND

This study examined symptomatology and quality of life following elective cholecystectomy for symptomatic gallstone disease with defined indications for surgery.

METHODS

In this prospective study of 200 consecutive patients (161 women; median age 46.5 (range 24-79) years), strict indications for elective cholecystectomy were stipulated. Digestive symptoms and quality of life were recorded with a self-administered questionnaire before and at 3 and 12 months after surgery.

RESULTS

Of 149 patients who experienced abdominal pain with typical location before surgery, 136 (91.3 per cent) reported total remission or reduced frequency of that type of pain 12 months later. Of 35 patients who reported atypical or multiple pain location before operation, 27 (77 per cent) experienced reduced frequency or disappearance of that type of pain. Frequency of pain episodes, atypical or multiple pain location, specific food intolerance and frequency of disturbing abdominal gas at baseline correlated positively with the frequency of abdominal pain episodes at 12 months after surgery. There was a tendency towards an inverse relation to age.

CONCLUSION

The frequency of persistent abdominal pain after elective cholecystectomy was low among patients with typical pain location before surgery. Atypical pain location, and frequent pain episodes before operation significantly reduced the chance of becoming pain-free.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type I, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with type I SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type I SOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as typeI, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with typeISOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in typeISOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Health-related quality of life, somatization, and abuse in Sphincter of Oddi dysfunction

BACKGROUND

Most of the focus on patients with Sphincter of Oddi dysfunction (SOD) has centered on endoscopic management, and thus little is known about quality of life in these patients.

AIMS

We sought to determine what health-related quality of life components are troublesome to patients with SOD and compare to patients with recurrent pancreatitis.

METHODS

Using the Brief Symptom Inventory and the SF-12 version 1, as well as proprietary questionnaires, we measured health-related quality of life in patients with biliary SOD and patients with recurrent idiopathic pancreatitis who underwent sphincter of Oddi manometry.

RESULTS

Both groups had significantly worse quality of life than nonpatients and both groups somatized. Abuse histories were surprisingly common and similar between both groups.

CONCLUSIONS

Health-related quality of life is impaired and abuse histories are common in SOD patients, and similar to patients with recurrent idiopathic pancreatitis. Whether these characteristics are predictors of healthcare seeking remains to be determined.

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.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Somatosensory changes in the referred pain area before and after cholecystectomy in patients with uncomplicated gallstone disease

OBJECTIVE

It is estimated that 25-40% of patients have continuing symptoms after cholecystectomy and that 5-10% have pain. The pain may be related to central neuroplastic changes of sensory pathways induced by the gallstone disease. Such neuronal hyperexcitability can be reflected in the somatic referred pain area sharing central pathways with the gallbladder. The aim of this study was to examine somatosensory changes in the referred pain area evoked by painful gallstone attacks before and after cholecystectomy in patients with uncomplicated gallstone disease.

MATERIAL AND METHODS

Thirty-seven patients with uncomplicated gallstone disease were included in the study. The sensations and pain thresholds to pinprick, pinching, pressure, thermal and electrical stimulation were studied before and 4-12 weeks after surgery in the area where the pain was referred to during the previous gallstone attacks. An area on the contralateral side of the abdomen served as the control.

RESULTS

Somatosensory hyperalgesia in the referred pain area was observed in 84% of the patients before surgery. After elective cholecystectomy, none of the patients had pain complaints, and the sensibility in the referred area was normalized.

CONCLUSIONS

Uncomplicated gallstone disease leads to significant hyperalgesia in the somatic referred pain area. At the time of the postoperative investigation none of the patients suffered from pain, which was reflected in the normal sensory findings in the previous referred pain area.

Management of patients with chronic abdominal pain in clinical practice

A practical approach to the management of chronic abdominal pain is needed, given the high prevalence and impact of this problem. This article describes an approach that has evolved based on clinical experience and review of the literature: identifying predominant bloaters and abdominal wall pain; exclusion of organic disease, including consideration of laparoscopy for diagnosis; consideration of chronic functional abdominal pain and the first and second line pharmacotherapies; and seeking specialist care in a pain clinic, psychiatry, or behavioural therapy.

Sphincter of Oddi dysfunction: managing the patient with chronic biliary pain

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to functional obstruction of pancreaticobiliary flow at the level of the sphincter of Oddi. The Milwaukee classification stratifies patients according to their clinical picture based on elevated liver enzymes, dilated common bile duct and presence of abdominal pain. Type I patients have pain as well as abnormal liver enzymes and a dilated common bile duct. Type II SOD consists of pain and only one objective finding, and Type III consists of biliary pain only. This classification is useful to guide diagnosis and management of sphincter of Oddi dysfunction. The current gold standard for diagnosis is manometry to detect elevated sphincter pressure, which correlates with outcome to sphincterotomy. However, manometry is not widely available and is an invasive procedure with a risk of pancreatitis. Non-invasive testing methods, including fatty meal ultrasonography and scintigraphy, have shown limited correlation with manometric findings but may be useful in predicting outcome to sphincterotomy. Endoscopic injection of botulinum toxin appears to predict subsequent outcome to sphincterotomy, and could be useful in selection of patients for therapy, especially in the setting where manometry is unavailable.

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.

Chronic pancreatitis patients show hyperalgesia of central origin: a pilot study

BACKGROUND

The pain of chronic pancreatitis remains challenging to manage, with treatment all too often being unsuccessful. A main reason for this is lacking understanding of underlying mechanisms of chronic pain in these patients.

AIM

To document, using somatic quantitative sensory testing, changes in central nervous system processing (neuroplasticity) associated with chronic pancreatitis pain and thus gain insight into underlying pain mechanisms.

PATIENTS AND METHODS

We studied 10 chronic pancreatitis patients on stable opioid analgesic medication. Ten matched surgical patients without pain served as controls. Pain verbal numeric rating scores (NRS) and thresholds to electric skin stimulation and pressure pain were measured in dermatomes T10 (pancreatic area), C5, T4, L1 and L4.

RESULTS

The pancreatitis patients had a median NRS pain score of 5 (range 3-8). Electric sensation and pain thresholds were significantly increased in the pancreatic region, tending to be more so in female pancreatitis patients. Pressure pain thresholds were significantly lower in pancreatitis patients than in controls, with men tending towards greater generalised relative hyperalgesia than women.

CONCLUSIONS

Chronic pancreatitis patients show pronounced generalised deep hyperalgesia that is present despite opioid therapy. These signs, consistent with central sensitisation, appear relatively more prominent in men than women. There is also evidence suggesting that women may have a better segmental inhibitory response than men, possibly explaining their relatively less prominent generalised deep tissue hyperalgesia compared to men.

Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain

Acalculous biliary-type abdominal pain is a commonly encountered clinical problem whose pathophysiology is unclear and evaluation and management are controversial. Cholecystokinin cholescintigraphy to measure the gallbladder ejection fraction (GEF) has been advocated as a criterion for cholecystectomy. However, there is no consensus regarding the dose and rate of infusion of cholecystokinin, both of which can alter the GEF, and the definition of an abnormal ejection fraction varies among studies. Many but not all studies have concluded that a low GEF predicts good outcomes after cholecystectomy, but most studies suffer from poor methodology and there is only one prospective randomized controlled trial. Also, some patients with a normal GEF have responded to cholecystectomy. Another controversial area has been the role of sphincter of Oddi dysfunction (SOD) in patients with biliary-type pain and gallbladder in situ. Some reports suggest an overlap between SOD and low GEF, although a causal relationship has not been established. Yet another subject of interest is the role of visceral hyperalgesia in patients with acalculous biliary-type pain. We have reviewed the relevant literature relating to these issues and have highlighted the controversial aspects. In the absence of high-quality studies, an evidence-based treatment algorithm is difficult to design but will be proposed. More prospective controlled trials are warranted to better define the appropriate evaluation and management of patients with this syndrome.