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Risk Stratification for the Development of Post-ERCP Pancreatitis by Sphincter of Oddi Dysfunction Classification. South Med J 2013; 106:298-302. [DOI: 10.1097/smj.0b013e318290c6be] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi. Gastrointest Endosc Clin N Am 2013; 23:405-34. [PMID: 23540967 DOI: 10.1016/j.giec.2012.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- M T McLoughlin
- Department of Gastroenterology, Belfast City Hospital, Northern Ireland
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Canlas KR, Branch MS. Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis. World J Gastroenterol 2008. [PMID: 18081218 DOI: 10.3748/wjg.13.6314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Affiliation(s)
- Karen R Canlas
- Division of Gastroenterology and Hepatology, Duke University Medical Center, DUMC Box 3662, Durham, NC 27710, United States
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5
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Abstract
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.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Petersen BT. Sphincter of Oddi dysfunction, part 2: Evidence-based review of the presentations, with "objective" pancreatic findings (types I and II) and of presumptive type III. Gastrointest Endosc 2004; 59:670-87. [PMID: 15114311 DOI: 10.1016/s0016-5107(04)00297-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo College of Medicine, Rochester, Minnesota 55905, USA
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Piccinni G, Angrisano A, Testini M, Bonomo GM. Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation. J Clin Gastroenterol 2004; 38:350-9. [PMID: 15087695 DOI: 10.1097/00004836-200404000-00010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Giuseppe Piccinni
- Department of Applications in Surgery of Innovative Technologies, University of Bari, School of Medicine, Bari, Italy.
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Sherman S. What is the role of ERCP in the setting of abdominal pain of pancreatic or biliary origin (suspected sphincter of Oddi dysfunction)? Gastrointest Endosc 2002. [PMID: 12447279 DOI: 10.1016/s0016-5107(02)70023-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Stuart Sherman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana 46202-5000, USA
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Linder JD, Geels W, Wilcox CM. Prevalence of sphincter of Oddi dysfunction: can results from specialized centers be generalized? Dig Dis Sci 2002; 47:2411-5. [PMID: 12452371 DOI: 10.1023/a:1020611302852] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Recent studies suggest a high prevalence of sphincter of Oddi dysfunction (SOD) in patients referred to specialized centers for sphincter of Oddi manometry (SOM). Whether these results can be generalized to other centers is unknown. From September 1998 to April 2000, patients undergoing SOM were prospectively identified. Patients were classified as having either biliary or pancreatic SOD, according to the modified Milwaukee classification, and underwent SOM of either the biliary or pancreatic sphincter based on clinical history. SOD was diagnosed when the mean basal sphincter pressure was >40 mm Hg. Standard cholangiography and/or pancreatography were performed following manometry. Fifty-one patients were studied (43 women, median age 46 years, range 7-74 years). Prior to SOM, patients were classified by the modified Milwaukee classification as biliary type I in 1 patient, type II in 8, and type III in 20; pancreatic type I in 4 patients, type II in 14, and type III in 3; and biliary type III and pancreatic type III in 1 patient. Indications for SOM included abdominal pain in 35 patients (69%), recurrent idiopathic pancreatitis in 12 (24%), chronic pancreatitis in 3 (7%), and acute pancreatitis in 1 (2%). Overall, 30 patients (59%; 95% CI 41.1-76.9%) were found to have SOD; abnormal biliary sphincter pressure in 16 of 29 patients (55%) undergoing biliary manometry, and abnormal pancreatic sphincter pressures in 14 of 21 patients (67%) undergoing pancreatic sphincter manometry, and abnormal biliary and pancreatic sphincter pressures in 1. SOD was diagnosed in 1 biliary type I patient (100%), 4 type II patients (50%), and 11 type III patients (52.4%) with a mean pressures of 92, 47, and 80 mm Hg, respectively. SOD was identified in 4 pancreatic type I patients (100%), 7 type II patients (50%), and 3 type III patients (100%) with mean sphincter pressures of 83 mm Hg, 96 mm Hg, and 102 mm Hg, respectively. In conclusion, the prevalence of SOD in patients with suspected biliary disease was 55%, suspected pancreatic disease 66%, yielding an overall prevalence of SOD of 59%. These results confirm the high prevalence of SOD in patients referred for SOM.
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Affiliation(s)
- Jeffrey D Linder
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Alabama at Birmingham, 35294-0007, USA
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Devereaux BM, Sherman S, Lehman GA. Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis. Curr Gastroenterol Rep 2002; 4:153-9. [PMID: 11900681 DOI: 10.1007/s11894-002-0053-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two- to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.
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Affiliation(s)
- Benedict M Devereaux
- Indiana University Medical Center, 550 North University Boulevard, Suite 2300, Indianapolis, IN 46202, USA
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Abstract
Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.
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Affiliation(s)
- M J Levy
- The Mayo Clinic, Rochester, Minnesota 55905, USA
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Cohen SA, Siegel JH. Endoscopic retrograde cholangiopancreatography and the pancreas: when and why? Surg Clin North Am 2001; 81:321-8, x. [PMID: 11392419 DOI: 10.1016/s0039-6109(05)70120-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Historically, endoscopic retrograde cholangeopancreatography (ERCP) has played a unique role as a diagnostic and therapeutic modality for diseases of the pancreas. Despite the advent of new imaging techniques, ERCP continues to play a central role in the evaluation and treatment of pancreatitis of various causes. Endoscopic cholangiography and stenting remain mainstays in the palliation of inoperable obstructive jaundice in patients with cancer of the pancreas.
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Affiliation(s)
- S A Cohen
- Columbia University College of Physicians and Surgeons, and Division of Gastroenterology, St Lukes-Roosevelt Hospital Center, New York, New York, USA
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Silverman WB, Slivka A, Rabinovitz M, Wilson J. Hybrid classification of sphincter of Oddi dysfunction based on simplified Milwaukee criteria: effect of marginal serum liver and pancreas test elevations. Dig Dis Sci 2001; 46:278-81. [PMID: 11281175 DOI: 10.1023/a:1005692530034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
To date, when using the Milwaukee classification for sphincter of Oddi dysfunction (SOD), one cannot accurately classify patients with marginal elevations in laboratory tests; ie, < 1.5 x the upper limit of normal (ULN). Since subsequent treatment may depend on how they are classified, we sought to determine whether these patients should be considered as type II or type III. Between January 1993 and October 1996, 113 consecutive patients (82 females and 31 males; ages 12-87 years) without prior sphincterotomy were referred to consider a diagnosis of SOD type II or III. SOD II patients had pancreaticobiliary-type pain and laboratory elevations >1.5 x ULN or dilated ducts, while SOD III patients had pain only. Hybrid patients had pain and marginal laboratory elevations <1.5 x ULN, with normal duct diameters. Drainage times, frequency, duration, and propagation were not assessed. Sphincter of Oddi manometry (SOM) was performed in each case, and the frequency of abnormal biliary and/or pancreatic basal sphincter pressure was compared, with respect to type II, III, and hybrid SOD. Successful SOM was obtained in 113/114 patients: Abnormal basal sphincter pressure was found in 65, 89, and 43% of type II, hybrid, and type III SOD, respectively. We found no statistical difference between type II and hybrid patients. In contrast, there was statistical difference between types II and III patients and between type III and hybrid patients. In conclusion, there was no significant difference in the frequency of elevated basal sphincter pressure in SOD type II versus hybrid, and thus they should be considered as one group.
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Affiliation(s)
- W B Silverman
- Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City 52242-1081, USA
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Wehrmann T, Schmitt TH, Arndt A, Lembcke B, Caspary WF, Seifert H. Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction. Aliment Pharmacol Ther 2000; 14:1469-77. [PMID: 11069318 DOI: 10.1046/j.1365-2036.2000.00814.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the technical feasibility, safety, and short-term efficacy of botulinum toxin injection for pancreatic sphincter of Oddi dysfunction and to analyse whether the symptomatic response to botulinum toxin might be a predictor of outcome for endoscopic sphincterotomy. METHODS Fifteen consecutive patients (nine female, aged 38 +/- 12 years) with frequent attacks (median four) of acute pancreatitis within 6 months, and manometrically proven pancreatic sphincter of Oddi dysfunction underwent endoscopic injection of 100 units of botulinum toxin into the major papilla. All patients underwent prospective follow-up thereafter and in cases of recurrent pancreatitis manometry this was repeated and pancreatic sphincterotomy was performed. RESULTS No side-effects occurred after botulinum toxin injection in any patient. Within 3 months after botulinum toxin treatment, 12 out of 15 patients remained asymptomatic (80% primary response). Only one out of three patients without symptomatic benefit showed continued elevated pancreatic sphincter pressure at manometry and only this patient benefited from pancreatic sphincterotomy later on. Eleven of the 12 patients initially responding to botulinum toxin injection developed a symptomatic relapse 6 +/- 2 months after botulinum toxin treatment. These patients then achieved long-term clinical remission from pancreatic or combined (biliary and pancreatic, n=5) sphincterotomy (median follow-up, 15 months). CONCLUSION Endoscopic botulinum toxin injection into the papilla of Vater is a safe procedure for treatment of pancreatic sphincter of Oddi dysfunction that may provide short-term relief in about 80% of the patients. Those patients who respond to botulinum toxin may subsequently gain definitive cure from sphincterotomy.
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Affiliation(s)
- T Wehrmann
- Department of Internal Medicine II, J.W. Goethe-University Hospital, Frankfurt am Main, Germany.
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Aymerich RR, Prakash C, Aliperti G. Sphincter of oddi manometry: is it necessary to measure both biliary and pancreatic sphincter pressures? Gastrointest Endosc 2000; 52:183-6. [PMID: 10922088 DOI: 10.1067/mge.2000.105985] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Data are scant on the miss rate of sphincter of Oddi dysfunction if basal pressure in both biliary and pancreatic sphincter segments is not measured during manometry. METHODS Motility tracings with basal pressure measurements of both sphincter segments were retrospectively analyzed. Basal sphincter pressure greater than 40 mm Hg was considered abnormal in either sphincter segment. RESULTS The study population consisted of 73 subjects (64 women, 9 men; age 45.3 +/- 1.6 yr). The basal pressures in the 2 sphincter segments were highly discordant (correlation coefficient = 0.2, p = 0.04). Basal pressures were normal in both segments in 19%, abnormal in both segments in 40%, and abnormal in 1 segment but normal in the other in 41%. The negative predictive value of normal biliary sphincter pressure in excluding sphincter dysfunction was 0. 42; when the pancreatic sphincter pressure was normal, the negative predictive value was 0.58. The incidence of pancreatitis with dual duct manometry was comparable to the institutional experience with all sphincter studies. CONCLUSIONS Although the clinical relevance of individually elevated sphincter pressures remains uncertain, there is significant discordance of basal pressures between the biliary and pancreatic sphincter segments. If only the biliary sphincter pressure were to be measured, one fourth of abnormal sphincter pressures would be missed. Therefore, if the first sphincter segment has a normal basal pressure, the other segment should also be evaluated.
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Affiliation(s)
- R R Aymerich
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Arendt T, Mönig H, Stüber E, Katsoulis S, Fölsch UR. Gallstones, the choledochoduodenal junction and initiation of acute pancreatitis: are two stones the culprits rather than one stone? Med Hypotheses 2000; 54:570-3. [PMID: 10859640 DOI: 10.1054/mehy.1998.0896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reflux of biliary secretions into the pancreatic duct following gallstone obstruction of the common biliary pancreatic ampulla has been implicated as a cause of acute pancreatitis. However, the pancreatic duct pressure is higher than the biliary pressure and, therefore, the simple obstruction of the choledochoduodenal junction by one gallstone does not result in biliary pancreatic reflux. We propose a mechanism whereby simultaneous migration and sequential impaction above and below the common biliary pancreatic ampulla of two gallstones allows for the creation of a toxic bile-pancreatic juice mixture in the common bile duct, subsequent reversal of the pressure gradient and reflux of the toxic secretions into the pancreatic duct.
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Affiliation(s)
- T Arendt
- First Department of Medicine, Christian-Albrechts-University, Kiel, Germany
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Eversman D, Fogel EL, Rusche M, Sherman S, Lehman GA. Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction. Gastrointest Endosc 1999; 50:637-41. [PMID: 10536318 DOI: 10.1016/s0016-5107(99)80011-x] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sphincter of Oddi manometry as performed at ERCP is the most accepted method to evaluate for sphincter of Oddi dysfunction. To fully assess for sphincter of Oddi dysfunction, both the pancreatic and the bile ducts must be evaluated. We assessed the frequency of pancreatic and biliary sphincter abnormalities in a large series of patients. METHODS A total of 593 patients underwent manometry of the biliary and pancreatic ducts at one endoscopic retrograde cholangiopancreatography session. Basal sphincter pressure greater than or equal to 40 mm Hg was considered abnormal. Phasic waves were not evaluated. Manometric abnormalities were correlated with the clinical presentation as categorized using a modified Geenen/Hogan classification. RESULTS Of 360 patients with intact sphincters, 18.9% had abnormal pancreatic sphincter basal pressure alone, 11.4% had abnormal biliary basal sphincter pressure alone, and in 31.4% the basal pressure was abnormal for both sphincters; thus, 60.1% of the patients had sphincter dysfunction. The frequency of sphincter of Oddi dysfunction did not differ whether typed by biliary or pancreatic criteria: approximately 65% type II and 59% type III. Of patients without pancreatitis, 55.9% had an abnormal basal sphincter pressure, whereas sphincter dysfunction was present in 72.3% of those with idiopathic pancreatitis and 53.9% of patients with chronic pancreatitis. Of patients with an ablated biliary sphincter, 45.9% had abnormal basal pancreatic sphincter pressure and only 0.6% had an abnormal biliary sphincter pressure alone. Abnormal pressure in both sphincters was found in 9.3%. CONCLUSION If both portions of the sphincter of Oddi are studied simultaneously, abnormalities are found very commonly (55% to 72%). Assessment of both sides of the sphincter is necessary. Classifying patients according to both pancreatic and biliary sphincter segments is cumbersome, and may be replaced by an overall type. Using this modified classification, the frequency of sphincter of Oddi dysfunction is similar in both type II and type III patients (59% to 67%).
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Affiliation(s)
- D Eversman
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis 46202, Indiana, USA
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Tarnasky PR, Palesch YY, Cunningham JT, Mauldin PD, Cotton PB, Hawes RH. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 1998; 115:1518-24. [PMID: 9834280 DOI: 10.1016/s0016-5085(98)70031-9] [Citation(s) in RCA: 267] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. METHODS Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3). CONCLUSIONS Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.
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Affiliation(s)
- P R Tarnasky
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
UNLABELLED BACKGROUND Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives. METHODS A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject. RESULTS AND CONCLUSION Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.
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Affiliation(s)
- G Tzovaras
- Department of Surgery, The Queen's University of Belfast, UK
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Lehman GA, Sherman S. Sphincter of Oddi dysfunction. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1996; 20:11-25. [PMID: 8872520 DOI: 10.1007/bf02787372] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Evidence continues to accumulate indicating that sphincter of Oddi dysfunction may give rise to cholestasis, pancreatitis, or upper abdominal pain syndromes. Diagnosis of such dysfunction may be inferred from noninvasive tests or more precisely defined by manometric studies. Both the biliary and pancreatic sphincters are commonly involved. If medical therapy is ineffective, sphincter ablation via endoscopy or laparotomy should be considered for highly symptomatic patients. Complication rates of invasive techniques remain relatively high and risk:benefit ratio should be carefully considered. Future research as to etiology, more defined pathophysiology, more accurate noninvasive evaluation, and optimal therapies are awaited.
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Affiliation(s)
- G A Lehman
- Department of Medicine, Indiana University Medical Center, Indianapolis 46202-5000, USA.
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Abstract
BACKGROUND In recent years, applications of electromyographic, cineradiographic, scintilographic, and endoscopic manometric techniques have improved our knowledge of normal and abnormal motility of Oddi's sphincter. This sphincter coordinates the time and rate of secretion of about 3 liters of bile and pancreatic juice into the duodenum daily. METHODS Oddi's sphincter may be evaluated by endoscopic manometry, ultrasound, dynamic hepatobiliary scintigraphy, and laboratory tests. Endoscopic manometry is the best method for evaluating the function Oddi's sphincter. RESULTS The basal pressure of Oddi's sphincter is usually 5 to 15 mm Hg greater than the bile and pancreatic duct pressures. Phasic contractions of 50 to 150 mm Hg in amplitude and 3 to 8 contractions per minute in frequency are superimposed on the basal pressure. A small percentage of patients with gastrointestinal symptoms after cholecystectomy has sphincter of Oddi dysfunction, which may have structural abnormality (papillary stenosis) or functional abnormality (Oddi's sphincter dyskinesia). CONCLUSIONS Elevated basal pressure ( > 40 mm Hg) is the most important manometric finding of Oddi's sphincter dysfunction. Endoscopic sphincterotomy is the treatment of choice for patients with Oddi's sphincter dysfunction and elevated basal sphincter pressure.
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Affiliation(s)
- J C Coelho
- Department of Surgery, Federal University of Parana, Curitiba, Brazil
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Lehman GA, Sherman S, Hawes RH. Endoscopic management of recurrent and chronic pancreatitis. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1995; 208:81-9. [PMID: 7777810 DOI: 10.3109/00365529509107767] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Endoscopic therapy is now being utilized in the setting of recurrent acute and chronic pancreatitis. This review analyzes the current state of the art of these new applications of endoscopy. Selection of appropriate candidates for the various treatment modalities appears important for optimal results of therapy. Patients with gallstone pancreatitis, pancreas divisum, obstructing main pancreatic duct stones, and bulging pseudocysts appear to be the best candidates for endoscopic therapy.
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Affiliation(s)
- G A Lehman
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis 46202, USA
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