Pain on common bile duct injection during ERCP: does it indicate sphincter of Oddi dysfunction?

[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.

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.

Clinical significance of sphincter of Oddi dyskinesia

Sphincter of Oddi dyskinesia (SOD) is a functional disorder of the papilla region that can lead to clinical symptoms and functional obstruction of biliary and pancreatic outflow. Based on the severity of the clinical symptoms, the disorder is classified as one of three types (biliary or pancreatic type I-III). Diagnosis of SOD is hampered by the relative risk of endoscopic sphincter manometry to cause pancreatitis. Manometrically, SOD is characterized by increased pressure in the biliary or pancreatic sphincter segment and can be treated with endoscopic papillotomy. This review is an attempt to balance the arguments for invasive diagnosis with a pragmatic clinical approach in which papillotomy is performed if clinical suspicion and patient presentation support a dysfunction of the papilla. For patients with biliary or pancreatic type I, endoscopic papillotomy is the treatment of choice. In biliary type II, SO manometry may be helpful for clinical decision making; however, the ratio of risks to benefits is difficult to assess based on the present data. In type III SOD, patient selection and the low predictive value of manometry for treatment success raise questions about the clinical usefulness of SO manometry.

Clinical aspects of sphincter of Oddi function and dysfunction

The sphincter of Oddi (SO) functions to regulate the flow of bile and pancreatic juices as well as to prevent the reflux of duodenal contents into the pancreatobiliary system. When dysfunction of the sphincter occurs, symptoms develop relating to either the biliary or pancreatic portions of the sphincter. The mechanism of this dysfunction remains speculative. SO manometry remains the "gold standard" to correctly diagnose the disorder and stratify therapy. Division of the sphincter is effective for SO stenosis, but there is no proven therapy for SO dyskinesia.

Does intrabiliary pressure predict basal sphincter of Oddi pressure? A study in patients with and without gallbladders

BACKGROUND

The endoscopic measurement of sphincter of Oddi pressure is a technically difficult procedure requiring significant expertise. Intrabiliary pressure is technically easy to measure. Furthermore, since it is believed that the pathogenesis of pain in patients with sphincter of Oddi dysfunction is attributable to increased intrabiliary pressure, its measurement may be more clinically relevant than measurement of sphincter of Oddi pressure.

METHODS

Intrabiliary pressures were blindly measured in 54 patients who had sphincter of Oddi manometry for abdominal pain.

RESULTS

In all patients intrabiliary pressure was significantly higher in patients with sphincter of Oddi dysfunction than those with normal sphincter of Oddi pressure (19.6 +/- 2.2 vs 9.6 +/- 1.2 mm Hg; p < 0.01). These findings were similar when patients were stratified according to presence of intact gallbladder (19.3 +/- 1.6 vs 8.8 +/- 1.4; p < 0.01) and to patients without a gallbladder (20.1 +/- 3.8 vs 12/1 +/- 1.3; p = .034). There was positive correlation between intrabiliary pressure and sphincter of Oddi basal pressure. This correlation was significant both in patients with and without gallbladders.

CONCLUSIONS

These data suggest that increased intrabiliary pressure may be a useful surrogate marker of sphincter of Oddi dysfunction.

Evaluation of results of the prostigmine-morphine test with quantitative hepatobiliary scintigraphy: a new method for the diagnosis of sphincter of Oddi dyskinesia

Attempts have long been made to use the prostigmine-morphine provocation test for the selection of postcholecystectomy patients suffering from sphincter of Oddi (SO) dyskinesia. Since the whole procedure is based upon the evaluation of subjective complaints, this test has frequently been criticized. To improve the diagnostic value of this method, we have visualized SO spasms during prostigmine-morphine provocation by means of quantitative hepatobiliary scintigraphy (QHBS). Twenty-two cholecystectomized patients with typical postprandial biliary pain were included in this study. In the first series of studies, QHBS with technetium-99m 2,6-diethylphenylcarbamoylmethyl-diacetic acid was performed in each patient 2 days before prostigmine-morphine provocation. The time to peak activity (Tmax) and the half-time of excretion (T1/2) over the liver parenchyma (LP), hepatic hilum (HH) and common bile duct (CBD), and the duodenum appearance time (DAT), were determined and served as control values. In the second series of experiments, sphincter spasms were evoked by prostigmine-morphine administration and visualized by means of QHBS. The same parameters were evaluated and serum levels of aspartate aminotransferase (AST) were determined simultaneously at regular intervals. In 12 patients who responded to prostigmine-morphine provocation with typical biliary pain and a significant AST elevation (Nardi positive group) the hepatobiliary scintigram demonstrated a marked biliary obstruction. Tmax and T1/2 over the LP, HH and CBD were significantly increased, while DAT was significantly longer relative to the corresponding data obtained without provocation. Four of the remaining ten patients indicated atypical abdominal pain during prostigmine-morphine provocation, but the AST level remained unchanged in all ten (Nardi negative group).(ABSTRACT TRUNCATED AT 250 WORDS)