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Beheshti Namdar A, AkbariRad M, Farzaneh Far M, Ahadi M, Hosseini SM, Firoozi A, Shoraka O, Ataee Karizmeh M, Moodi Ghalibaf A. Addiction and the Risk of Common Bile Duct Stones: A 4-Year Retrospective Population-Based Study in Mashhad, Iran. ADDICTION & HEALTH 2023; 15:100-104. [PMID: 37560391 PMCID: PMC10408761 DOI: 10.34172/ahj.2023.1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/12/2022] [Indexed: 08/11/2023]
Abstract
BACKGROUND As a common digestive disorder, choledocholithiasis can have serious consequences, including death. Given that opioids have been shown to contribute to the spasm of Oddi's sphincter, which results in biliary stasis in the common bile duct (CBD), it is likely that opioids can also raise the prevalence of choledocholithiasis. In this regard, this study aimed to investigate how common opium addiction was among choledocholithiasis patients in Mashhad, Iran. METHODS The current retrospective observational study was conducted on 599 patients with choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP), utilizing information gathered at the Ghaem hospital in Mashhad, Iran, between 2011 and 2015. Patient data were collected from files and records using certain criteria such as gender, opium addiction, hepatic enzymes (AST, ALT, ALP), plasma levels of total bilirubin, and direct bilirubin. The size of the CBD stones as well as the correlation between the gallbladder and CBD stones were calculated. FINDINGS From among 599 patients included, 345 (57.6%) were female and 254 (42.4%) were male. Moreover, 195 patients (32.2%) had opiate addictions. The size of the CBD stone was correlated with the patient's age (r=0.17, P=0.001). The average stone measured 12.22±3.32 mm. There were notable differences in the mean size of the CBD stone (P<0.001) between addicted and non-addicted cases; specifically, the mean CBD stone size in addicted cases was 12.715.13 mm while it was 12.34.33 mm in non-addicted cases. CONCLUSION This study showed patients with CBD stones have a higher rate of opium addiction compared to the general population, indicating a possible link between the two conditions.
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Affiliation(s)
- Ali Beheshti Namdar
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mina AkbariRad
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammadreza Farzaneh Far
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mitra Ahadi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mousalreza Hosseini
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdollah Firoozi
- Pharmacist, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Shoraka
- Medical Doctor, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Ataee Karizmeh
- Student Research Committee, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - AmirAli Moodi Ghalibaf
- Student Research Committee, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
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Abstract
The pancreatic enzymes lipase and amylase serve important functions in digestion/absorption of fats and polysaccharides. Measurement of these enzymes is often used in the emergency department to rule out acute pancreatitis in patients with nonspecific abdominal pain. In acute pancreatitis, serial measurements of plasma lipase and amylase typically follow a predictable temporal pattern of rise-and-fall kinetics: lipase levels rise within 4 to 8 hours, crest at 2× to 50× the upper reference limit at 24 hours, and decline to normal concentrations in 7 to 14 days. In situations in which the duration and magnitude of pancreatic enzyme elevation are more transient, clinicians should consider alternative causes for enzyme elevation. In this case report, incidental discovery of elevated lipase in an African American baby girl who ingested oxycodone resulted in additional laboratory and radiological work-up. Stronger awareness of exogenous influences on gastrointestinal motility may have prevented the need for further testing in this patient.
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Affiliation(s)
- Iván González
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri
| | - Stephen Roper
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri
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Liao WC, Tu TC, Lee KC, Tseng JH, Chen MJ, Sun CK, Wang SY, Chang WK, Chang PY, Wu MS, Lin TJ, Lee HL, Chen JH, Yuan KC, Liu NJ, Wu HC, Liang PC, Wang HP, Hwang TL, Lee CL. Taiwanese consensus recommendations for acute pancreatitis. J Formos Med Assoc 2020; 119:1343-1352. [PMID: 31395463 DOI: 10.1016/j.jfma.2019.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/11/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.
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Affiliation(s)
- Wei-Chih Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tien-Chien Tu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jseng-Hwei Tseng
- Department of Imaging & Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheuk-Kay Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shang-Yu Wang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taiwan
| | - Pi-Yi Chang
- Department of Radiology, Taichung Veterans General Hospital, Taiwan
| | - Ming-Shun Wu
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Jung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
| | - Hsiang-Lin Lee
- Department of Surgery, Chung Shan Medical University Hospital, Institute of Medicine4, Chung Shan Medical University, Taichung, Taiwan
| | - Jiann-Hwa Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Kuo-Ching Yuan
- Division of Acute Care Surgery and Trauma, Department of Surgery, Taipei Medical University Hospital, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsing-Chien Wu
- Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taiwan
| | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taiwan
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taiwan
| | - Chia-Long Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan.
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Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol 2017; 15:1338-1349. [PMID: 28529168 PMCID: PMC5565678 DOI: 10.1016/j.cgh.2017.05.014] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023]
Abstract
The use of opioid medications on both an acute and chronic basis is ubiquitous in the United States. As opioid receptors densely populate the gastrointestinal tract, symptoms and side effects can be expected in these patients. In the esophagus, dysmotility may result, manifesting with dysphagia and a syndrome indistinguishable from primary achalasia. In the stomach, a marked delay in gastric emptying may occur with postprandial nausea and early satiety. Postoperatively, particularly with abdominal surgery, opioid-induced ileus may ensue. In the colon, opioid-induced constipation is common. A unique syndrome termed narcotic bowel syndrome is characterized by chronic abdominal pain often accompanied by nausea and vomiting in the absence of other identifiable causes. With the recognition of the important role of opioids on gastrointestinal function, novel drugs have been developed that use this physiology. These medications include peripheral acting opioid agonists to treat opioid-induced constipation and combination agonist and antagonists used for diarrhea-predominant irritable bowel syndrome. This review summarizes the most recent data in these areas.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anthony Lembo
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Boothby LA, Wang LJ, Mayhew S, Chestnutt L. Academic Detailing of Meperidine at a Teaching Hospital. Hosp Pharm 2017. [DOI: 10.1177/001857870303800111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Meperidine (Demerol) is an opiate analgesic that is not considered first-line therapy for most pain management indications because of concerns about its safety and efficacy. Inpatient data from a 417-bed community teaching hospital revealed high use of meperidine in oral, IM, and IV forms. A multifaceted academic detailing approach was employed to change prescribing behavior and decrease meperidine use. This approach included conducting two concurrent Medication Use Evaluations; Grand Rounds presentations for pharmacy staff, nurses, and medical residents; solicitation of opinion leaders; pocket and table-top cards; newsletter articles; and provision of pharmaceutical care. Comparing the number of meperidine doses dispensed per adjusted patient day before and after the intervention, use was reduced by 0.0966 doses per patient (P < 0.05: 95% CI, 0.0955 to 0.0977). The number of patients receiving meperidine was reduced by 2.43% (P < 0.05: 95% CI, 1.97 to 2.88). This translates into a relative reduction of 29.5% in patients receiving meperidine and a relative reduction of 31% in meperidine doses dispensed per patient after academic detailing initiatives vs before. Eighty-five percent of standard orders were changed to improve therapy; these changes included converting meperidine to morphine or hydromorphone, decreasing cumulative acetaminophen daily dosages, using controlled-release and immediate-release opioids for pain management when oral therapy was tolerated, and combining modalities with different mechanisms of action for synergy and to decrease potential adverse effects from larger dosages of single entities. Academic detailing of meperidine resulted in short-term changes in prescribing patterns and decreased meperidine use at this institution. Long-term implications for pain management have not yet been assessed.
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Affiliation(s)
- Lisa A Boothby
- Drug Information, Columbus Regional Drug Information Center, Columbus Regional Healthcare System
| | - Lih-Jen Wang
- Clinical Pharmacy Services, Department of Pharmacy, Columbus Regional Healthcare System
| | - Susan Mayhew
- Pharmacy Education, Department of Pharmacy, Columbus Regional Healthcare System
| | - Lynn Chestnutt
- Quality Management, Department of Pharmacy, Columbus Regional Healthcare System
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Afghani E, Lo SK, Covington PS, Cash BD, Pandol SJ. Sphincter of Oddi Function and Risk Factors for Dysfunction. Front Nutr 2017; 4:1. [PMID: 28194398 PMCID: PMC5276812 DOI: 10.3389/fnut.2017.00001] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
| | - Simon K. Lo
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Wang AY, Strand DS, Shami VM. Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques. Clin Gastroenterol Hepatol 2016; 14:1521-1532.e3. [PMID: 27237430 DOI: 10.1016/j.cgh.2016.05.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
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8
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Kakuyama S, Nobutani K, Masuda A, Shiomi H, Sanuki T, Sugimoto M, Yoshida M, Arisaka Y, Fujita T, Hayakumo T, Azuma T, Kutsumi H. Sphincter of Oddi manometry using guide-wire-type manometer is feasible for examination of sphincter of Oddi motility. J Gastroenterol 2013. [PMID: 23179609 DOI: 10.1007/s00535-012-0710-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sphincter of Oddi manometry (SOM) is recognized as the standard diagnostic modality for sphincter of Oddi dysfunction (SOD). However, SOM is not commonly performed because of its technical difficulty and the high incidence of post-procedural pancreatitis. To diminish post-procedural pancreatitis, we tried to develop a new method of SOM. This study examined the feasibility of SOM with a guide-wire-type manometer, which is commonly used to measure the arterial pressure for coronary angiography, for the assessment of SO motility. METHODS A total of 35 procedures were performed in 8 patients with biliary type III SOD and 14 patients with other disease. We performed SOM using the guide-wire-type manometer on SOD cases and other cases [amplitude, duration, frequency and the area under the curve (AUC) of SO contractions]. RESULTS The mean time required for the measurement was 7.5 ± 4.1 min. The amplitude, frequency and AUC of SO contractions were significantly larger in the SOD cases than in other diseases (147.2 vs. 92.8 mmHg, p = 0.042; 10 vs. 5/min, p = 0.007; 2,837 vs. 1,122 mmHg s, p = 0.003, respectively). In 6 patients who underwent endoscopic sphincterotomy (EST), the SO amplitude decreased dramatically after EST. In this study, mild pancreatitis was observed in only one patient. CONCLUSIONS SOM using a guide-wire-type manometer is safe, reliable and easy to apply for the clinical assessment of SO motility. The guide-wire-type manometer may become a new method to measure SO function for the diagnosis of SOD.
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Affiliation(s)
- Saori Kakuyama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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9
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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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Imler TD, Sherman S, McHenry L, Fogel EL, Watkins JL, Lehman GA. Low yield of significant findings on endoscopic retrograde cholangiopancreatography in patients with pancreatobiliary pain and no objective findings. Dig Dis Sci 2012; 57:3252-7. [PMID: 22661251 DOI: 10.1007/s10620-012-2250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/07/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Due to the challenging nature of the type III sphincter of the Oddi dysfunction (SOD) patient, the suspected low diagnostic yield from endoscopic retrograde cholangiopancreatography (ERCP), the high complication rate, and the potential for litigation it is surprising that diagnostic ERCP continues to be performed in this patient population. AIMS The purpose of this study was to determine the incidence of significant findings on ERCP alone in patients with disabling abdominal pain of suspected pancreatobiliary origin and no objective findings. METHODS Entry criteria of this study included: (1) ERCP with attempt at visualization of both the biliary tree and pancreatic duct, (2) suspected of having abdominal pain of pancreatobiliary origin, (3) biliary or pancreatic type III by the modified Geenen-Hogan classification, (4) never undergone sphincterotomy, (5) attempted manometry of both sphincters. A total of 265 patients met entry criteria. RESULTS Significant findings were found in seven patients (2.6 %): choledococoele (1), anomalous pancreatobiliary ductal union (2), mild-moderate chronic pancreatitis (2), and pancreatic duct filling defect suspicious for IPMN (2). Potentially significant in 25 patients (9.4 %) were: equivocal chronic pancreatitis (1), incomplete (4) and complete pancreas divisum (20). SOD was diagnosed in 77.7 %. 11.3 % had undergone a previous diagnostic ERCP. CONCLUSION ERCP in this high-risk population requires detailed informed consent, availability of SOM to increase the diagnostic yield, and skills in placing prophylactic pancreatic stents. It is our belief that patients without objective findings of pancreatobiliary disease that would explain their subjective complaints should not undergo diagnostic ERCP.
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Affiliation(s)
- Timothy D Imler
- Division of Gastroenterology, Indiana University School of Medicine, 1050 Wishard Blvd, RG 4100, Indianapolis, IN 46202-2872, USA.
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Cheon YK. How to interpret a functional or motility test - sphincter of oddi manometry. J Neurogastroenterol Motil 2012; 18:211-7. [PMID: 22523732 PMCID: PMC3325308 DOI: 10.5056/jnm.2012.18.2.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/24/2012] [Accepted: 03/04/2012] [Indexed: 12/23/2022] Open
Abstract
To date, endoscopic manometry is the best method for evaluating the function of the sphincter. Sphincter of Oddi manometry (SOM) remains the gold standard to correctly diagnose the sphincter of Oddi dysfunction (SOD) and stratify therapy. Several dynamic abnormalities relating to the intensity, frequency, and propagation of sphincter contractions have been described. However, their clinical use generally has been abandoned in favor of basal sphincter pressure alone, because this measurement is stable over time, and has stronger interobserver reliablility, reproducibility on repeating testing, and is associated with the responsiveness to therapy. A significant elevated risk of pancreatitis was attributed to the technique. The risk of pancreatitits associated with manometric evaluation of the pancreatic sphincter is markedly reduced when manometry is performed with continous aspiration from the pancreatic duct via one of the 3 catheter lumens. This section reviews indications, conscious sedative drugs, techniques, and the appropriate interpretations of SOM.
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Affiliation(s)
- Young Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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12
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Koo HC, Moon JH, Choi HJ, Hwang KH, Maeng HJ, Kim HK, Park JK, Hong SJ, Cheon YK, Cho YD, Lee JS, Lee MS. Effect of transdermal fentanyl patches on the motility of the sphincter of oddi. Gut Liver 2010; 4:368-72. [PMID: 20981215 DOI: 10.5009/gnl.2010.4.3.368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/31/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS Pain is one of the most troublesome symptoms of pancreatitis. Transdermal fentanyl patches (TFPs) are long-acting analgesics with a reduced risk of dependency. This prospective study evaluated the effect of TFPs on sphincter of Oddi (SO) motility for the management of pain in pancreatitis. METHODS SO manometry (SOM) was performed using triple-lumen catheters anterogradely inserted through the percutaneous transhepatic route during cholangioscopy in 16 patients. The basal pressure, amplitude, and frequency of the SO were assessed before and after applying a TFP at 24 hour at doses of 25 and 12.5µg/hr, respectively. RESULTS Two of 16 patients receiving a 25µg/hr. TFP were excluded because of adverse side effects (headache and/or nausea). The mean basal pressure, amplitude, and frequency of SOM did not change significantly in the 25µg/hr TFP group (n=4 patients). Parameters of SO function also did not significantly change in the 12.5µg/hr TFP group (n=11 patients). CONCLUSIONS TFPs below a dose of 25µg/hr may not affect the motility of the SO. Administration of TFPs at lower dosages seems to be a safe analgesic treatment for the pain control of patients with pancreatitis without affecting the function of the SO.
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Affiliation(s)
- Hyun Cheol Koo
- Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon and Seoul, Korea
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13
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Varadarajulu S, Tamhane A, Wilcox CM. Prospective evaluation of adjunctive ketamine on sphincter of Oddi motility in humans. J Gastroenterol Hepatol 2008; 23:e405-9. [PMID: 17593222 DOI: 10.1111/j.1440-1746.2007.05024.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIM Performance of sphincter of Oddi manometry (SOM) at endoscopic retrograde cholangio-pancreatogram (ERCP) is technically demanding and requires that the patient be well sedated. Droperidol is used as an adjunctive agent in patients who are difficult to sedate. Concerns regarding the safety profile of droperidol and its effects on sphincter of Oddi motility has resulted in the search for other potent sedative agents that do not influence SOM readings. Ketamine, a dissociative anesthetic, is increasingly being used as an adjunctive agent for conscious sedation. This study evaluates the effect of ketamine on sphincter of Oddi motility when used as an adjunctive sedative agent during ERCP. PATIENTS AND METHODS This is a prospective study of 30 consecutive patients undergoing SOM who were difficult to sedate and required adjunctive ketamine. Manometry was initially performed with intravenous administration of diazepam plus meperidine or a combination of diazepam plus meperidine and midazolam. After the initial two pull-throughs, 20 mg of ketamine was administered intravenously and the measurements were repeated 5 min later. RESULTS The basal pressures of the biliary sphincter and of the pancreatic sphincter were not significantly altered by ketamine. By using a definition for sphincter of Oddi dysfunction of a basal pressure >or=40 mmHg, concordance (normal vs abnormal) between the basal sphincter pressure before and after ketamine was seen in 28 patients (93%). Ketamine also did not lead to a difference in phasic wave amplitude, duration, or frequency. No complication was associated with ketamine use. CONCLUSIONS Ketamine at 20 mg did not significantly affect SOM parameters. Further studies are required to confirm our preliminary findings before ketamine can be added to the armamentarium of agents used for performance of sphincter of Oddi manometry.
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Affiliation(s)
- Shyam Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama 35294, USA.
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14
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Cappell MS. Acute pancreatitis: etiology, clinical presentation, diagnosis, and therapy. Med Clin North Am 2008; 92:889-923, ix-x. [PMID: 18570947 DOI: 10.1016/j.mcna.2008.04.013] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis is a relatively common disease that affects about 300,000 patients per annum in America with a mortality of about 7%. About 75% of pancreatitis is caused by gallstones or alcohol. Other important causes include hypertriglyceridemia, medication toxicity, trauma from endoscopic retrograde cholangiopancreatography, hypercalcemia, abdominal trauma, various infections, autoimmune, ischemia, and hereditary causes. In about 15% of cases the cause remains unknown after thorough investigation. This article discusses the causes, diagnosis, imaging findings, therapy, and complications of acute pancreatitis.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3535 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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15
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[Occurrence and risk factor for development of pancreatitis and asymptomatic hyperamylasemia following endoscopic retrograde cholangiopancreatography--our experiences]. ACTA ACUST UNITED AC 2008; 55:17-24. [PMID: 18510057 DOI: 10.2298/aci0801017l] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Chronic pancreatitis is defined as chronic inflammatory lesion of pancreatic parenchyma leading to destruction and fibrosis of exocrine pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive and specific method for detection of morphological alterations in chronic pancreatitis. ERCP is inevitably associated to post-ERCP acute pancreatitis, as well as hyperamilasemia. STUDY AIM This study aims to determine frequency of post-ERPC pancreatitis and asymptomatic hyperamilasemia. STUDY METHODS We have studied 160 patients who underwent ERCP in Institute of Digestive Diseases, Clinical Centre of Serbia in Belgrade. Data regarding cholecystectomy, papillotomy, peripapillary diverticulosis, Oddi's sphincter hypertension, choledoch canulation and diameter, Wirsung duct canulation, minor duodenal papilla patency, anomalies of BP junction, as well as chronic pancreatitis has been analysed and correlated with eventual development of post-ERCP pancreatitis and asymptomatic hyperamilasemia. RESULTS Asymptomatic hyperamilasemia was determined in 51 subjects (31.9%), while pancreatitis has been developed in 5 patients (3.1%) subsequent to ERCP. It has been proofed that Wirsung duct canulation plays significant role in development of post-ERCP complications. CONCLUSION Although numerous factors may potentially contribute to development of post-ERCP pancreatitis, none of them, with the exception of Wirsung duct canulation, has been determined to play significant role in development of these complications.
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Peiró AM, Martínez J, Martínez E, de Madaria E, Llorens P, Horga JF, Pérez-Mateo M. Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain. Pancreatology 2008; 8:25-9. [PMID: 18235213 DOI: 10.1159/000114852] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 08/10/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction. However, scientific evidence supporting a deleterious influence on the clinical course is absent. This pilot study was undertaken to evaluate the efficacy and adverse events of metamizole versus morphine in acute pancreatitis. METHODS 16 patients with acute pancreatitis were randomized to receive 10 mg/4 h s.c. (n = 8) morphine or 2 g/8 h i.v. (n = 8) metamizole. Pain scores were recorded every 4 h during 48 h after admission by a Visual Analogue Scale. Pethidine was additionally administered as a rescue therapy. RESULTS 75% of patients achieved pain relief in the metamizole group versus 37.5% in the morphine group within 24 h of hospitalization (6/8 vs. 3/8; p: n.s.). The mean time to achieve pain relief was shorter in the metamizole group (10 +/- 6.6 vs. 17 +/- 18.3 h; p: n.s.). At the end of the study, 75% of patients achieved pain relief in the metamizole group versus 50% in the morphine group. Three patients in each group needed pethidine: 2 out of 3 achieved pain control in the metamizole group vs. 0 out of 3 in the morphine group. CONCLUSIONS Intravenous metamizole shows a non-significant association with a quicker pain relief than morphine s.c. in acute pancreatitis. A larger randomized controlled trial should be desirable to confirm this result. and IAP.
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Affiliation(s)
- A M Peiró
- Clinical Pharmacology Unit, Hospital General Universitario de Alicante, Alicante, Spain
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Turan M, Bagcivan I, Gursoy S, Sarac B, Duman M, Kaya T. In vitro effects of intravenous anesthetics on the sphincter of Oddi strips of sheep. Pancreatology 2005; 5:215-9. [PMID: 15855818 DOI: 10.1159/000085274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Accepted: 07/29/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intravenous anesthetics are often used for conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincter of Oddi (SO) manometry. This study was designed to investigate the direct effects of some intravenous anesthetics on SO in sheep. METHODS In sheep SO rings, changes in isometric tension in response to cumulative concentrations of intravenous anesthetics were determined, and values for Emax (mean maximal inhibition) and pD2 (i.e. the negative logarithm of the concentration for the half-maximal response, EC50) were compared. RESULTS Meperidine (10(-7) to 3 x 10(-5) M), fentanyl (10(-7) to 3 x 10(-5) M), midazolam (10(-7) to 3 x 10(-5) M) and propofol (10(-7) to 3 x 10(-4) M) induced concentration-dependent relaxations on SO precontracted with carbachol (10(-6) M). Emax and pD2 values following meperidine, fentanyl and midazolam administration were significantly greater than after propofol (p < 0.05). There were no significant differences in Emax and pD2 values for meperidine, fentanyl and midazolam. CONCLUSION These results suggest that meperidine, fentanyl and midazolam are equipotent relaxants in the sheep SO in vitro. The relaxatory effect of propofol was 10 times less potent compared to the above agents, and it can be beneficial during SO manometry in controlled clinical human studies.
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Affiliation(s)
- Mustafa Turan
- Department of General Surgery, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey.
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Wu SD, Zhang ZH, Jin JZ, Kong J, Wang W, Zhang Q, Li DY, Wang MF. Effects of narcotic analgesic drugs on human Oddi’s sphincter motility. World J Gastroenterol 2004; 10:2901-4. [PMID: 15334697 PMCID: PMC4572129 DOI: 10.3748/wjg.v10.i19.2901] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To assess the effects of intramuscular analgesics (morphine, Ap-237, pethidine and tramadol) on human Oddi's sphincter motility with choledochoscope manometry.
METHODS: A total of 70 patients having T tubes after cholecystectomy and choledochotomy were assessed by choledochoscope manometry. They were randomly divided into morphine group, Ap-237 group, pethidine group and tramadol group. Basal pressure of Oddi's sphincter (BPOS), amplitude of phasic contractions (SOCA), frequency of phasic contractions (SOF), duration of phasic contractions (SOD), duodenal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed. All narcotic analgesic drugs were administered intramuscularly.
RESULTS: Levels of BPOS, SOCA and SOF were increased after injection of morphine and Ap-237 (P < 0.05), level of CBDP was increased from 4.97 ± 3.87 mmHg to 8.62 ± 7.43 mmHg (10 min later) and 7.32 ± 5.95 mmHg (20 min later) after injection of morphine (P < 0.01). No apparent change occurred after intramuscular injection of pethidine. Level of BPOS was increased from 7.01 ± 5.50 mmHg to 2.87 ± 2.78 mmHg 10 min after injection of tramadol and SOCA was decreased from 63.34 ± 35.29 mmHg to 45.90 ± 27.86 mmHg (10 min later, P < 0.05) and 35.97 ± 24.30 (20 min later, P < 0.01) after administration of tramadol.
CONCLUSION: All these findings indicate that Oddi’s sphincter manometry via choledochoscope is a practical and new way to study the dynamics of Oddi’ s sphincter. The regular dose of morphine and Ap-237 could increase BPOS, SOF and SOCA. Morphine could increase the level of CBDP, demonstrating an excitatory effect on the sphincter of Oddi. Pethidine had no effect on Oddi's sphincter motility. Tramadol shows an inhibitory effect on the motility of the sphincter of Oddi and decreases levels of BPOS and SOCA.
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Affiliation(s)
- Shuo-Dong Wu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
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Abstract
BACKGROUND Endoscopic interventions have limited efficacy in sphincter of Oddi dysfunction (SOD) Type 3. Improved predictors of response to treatment are needed. METHODS Patients with postcholecystectomy pain underwent a standardized history and physical examination and were then managed individually. Long-term outcome was determined by record review and telephone interview. Initial predictors of response to treatment were assessed. RESULTS Mean follow-up for the 74 subjects was 36 months. Fifty were improved, and 24 had persistent pain. Patients were likely to respond to sphincterotomy if their pain was not continuous, if it was accompanied by nausea or vomiting, and if there had been a pain free interval after cholecystectomy of at least 1 year. When 2 or 3 of these predictors were present, 85% of SOD Type 2 patients and 56% of Type 3 patients had a good response. Initial history and examination features also predicted response to treatment of neuropathic pain. CONCLUSION Among patients with postcholecystectomy pain, specific features of the initial history and examination predict response to treatment with higher accuracy than the SOD grade. These predictors identify a subset of Type 3 patients likely to respond to sphincterotomy.
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Affiliation(s)
- Mark Topazian
- Department of Internal Medicine, Yale University School of Medicine, CT, USA.
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Abstract
With the introduction of endoscopic retrograde cholangiopancreatography (ERCP) manometry, the characteristics of sphincter of Oddi (SO) motor activity have been described. SO manometry is the only available method to measure SO motor activity directly and is usually performed at the time of ERCP. SO manometry is considered to be the gold standard for evaluating patients for sphincter dysfunction. This review reports the technique of SO manometry and normal values for SO manometry. SO motility is characterized by prominent phasic contractions superimposed on a tonic pressure. Elevated basal SO pressure is the most consistent and reliable criteria to diagnose SO dysfunction. Basal pressures obtained from the biliary sphincter are similar to the basal pressure obtained from the pancreatic sphincter. Abnormal SO manometric values are shown. Factors that influence SO pressures, and interpretation of SO manometric tracing are discussed. The most common and serious complication of SO manometry is post-manometry pancreatitis. In healthy volunteers with normal sphincter function, pancreatitis is almost never seen. However, in patients with SO dysfunction, the incidence of pancreatitis is high. The use of new nonperfused microtransducers may reduce this complication.
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Affiliation(s)
- Kinnari Kher
- Division of Gastroenterology, Tufts University School of Medicine, Tufts New England Medical Center, 750 Washington Street, Box 233, Boston, MA 02111, USA
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21
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Petersen BT. An evidence-based review of sphincter of Oddi dysfunction: part I, presentations with "objective" biliary findings (types I and II). Gastrointest Endosc 2004; 59:525-34. [PMID: 15044889 DOI: 10.1016/s0016-5107(04)00012-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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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23
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Abstract
SOD is a challenging condition that is difficult to diagnose and treat. The high failure rate of endoscopic and surgical treatment reflects the difficulties in establishing accurate diagnosis and the lack of specific objective criteria by which appropriate therapy could be determined. In general, sphincter ablation should be offered for type I patients. An initial trial of medical therapy is appropriate for type II patients with mild-to-moderate symptoms and for all type III patients. SOM is highly recommended for type II patients and is mandatory for all type III patients if sphincter ablation is contemplated. Other causes of abdominal pain such as chronic pancreatitis or functional disorders should be considered in patients not benefiting from sphincter ablation. All procedures on the sphincter should be undertaken with caution after meticulous investigation, and patient selection should be based on strict objective criteria.
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Affiliation(s)
- Shyam Varadarajulu
- Medical University of South Carolina Digestive Disease Center, Charleston 29425, USA.
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Fogel EL, Sherman S, Bucksot L, Shelly L, Lehman GA. Effects of droperidol on the pancreatic and biliary sphincters. Gastrointest Endosc 2003; 58:488-92. [PMID: 14520278 DOI: 10.1067/s0016-5107(03)01541-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Performance of sphincter of Oddi manometry at ERCP is technically demanding and requires that the patient be well sedated. Droperidol is frequently administered when adequate sedation cannot be achieved with a benzodiazepine and meperidine. This study examined the effects of droperidol on the biliary and pancreatic sphincters. METHODS A total of 31 patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous administration of diazepam alone, diazepam plus meperidine or midazolam plus meperidine. Manometry was then repeated 5 minutes after droperidol was administered. RESULTS The basal pressure of the biliary sphincter and of the pancreatic sphincter were not significantly altered by droperidol. Concordance (normal vs. abnormal) between the basal sphincter pressure before and after droperidol was seen in 30 patients (97%). Droperidol also did not lead to a difference in phasic wave amplitude, duration, or frequency. Thirteen manometry tracings (42%) were judged as being qualitatively better after droperidol, whereas two (6.5%; </= p 0.001) were qualitatively better before droperidol administration. CONCLUSIONS Droperidol does not significantly affect sphincter of Oddi manometric parameters. It appears that it can be added to the armamentarium of agents needed for performance of sphincter of Oddi manometry. However, further study is needed to determine whether recent safety concerns with droperidol use are valid.
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Affiliation(s)
- Evan L Fogel
- Indiana University Medical Center, Indianapolis, Indiana, USA
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Khalid A, Peterson M, Slivka A. Secretin-stimulated magnetic resonance pancreaticogram to assess pancreatic duct outflow obstruction in evaluation of idiopathic acute recurrent pancreatitis: a pilot study. Dig Dis Sci 2003; 48:1475-81. [PMID: 12924639 DOI: 10.1023/a:1024747319606] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Magnetic resonance pancreatography is a new modality to visualize the pancreatic duct. Prolonged dilation of the pancreatic duct following secretin administration may suggest obstruction at the level of the pancreatic duct orifice. We describe 10 patients with idiopathic acute recurrent pancreatitis who underwent secretin-stimulated magnetic resonance pancreatography with subsequent endoscopic retrograde pancreatogram with or without manometry. All patients had complete visualization of the main pancreatic duct and no evidence of chronic duct disease. Two patients had pancreas divisum. Three had prolonged dilation of the pancreatic duct on secretin-stimulated magnetic resonance pancreatography and evidence of pancreatic duct outflow obstruction. Four additional patients with pancreatic duct outflow obstruction had normal secretin-stimulated magnetic resonance pancreatography. In conclusion, secretin stimulated magnetic resonance pancreatography provides high quality pancreatic duct images and has high specificity but low sensitivity for diagnosing pancreatic duct outflow obstruction using manometric/clinical criteria.
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Affiliation(s)
- Asif Khalid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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26
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Park SH, Watkins JL, Fogel EL, Sherman S, Lazzell L, Bucksot L, Lehman GA. Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram. Gastrointest Endosc 2003; 57:483-91. [PMID: 12665757 DOI: 10.1067/mge.2003.138] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND For patients with sphincter of Oddi dysfunction and abnormal pancreatic basal sphincter pressure, additional pancreatic sphincterotomy has been recommended. The outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction was evaluated. METHODS An ERCP database was searched for data entered from January 1995 to November 2000 on patients with sphincter of Oddi dysfunction who met the following parameters: sphincter of Oddi manometry of both ducts, abnormal pressure for at least 1 sphincter (> or =40 mm Hg), no evidence of chronic pancreatitis, and endoscopic dual pancreatobiliary sphincterotomy. Patients were offered reintervention by repeat ERCP if clinical symptoms were not improved. The frequency of reintervention was analyzed according to ducts with abnormal basal sphincter pressure, previous cholecystectomy, sphincter of Oddi dysfunction type, and endoscopic dual pancreatobiliary sphincterotomy method. RESULTS A total of 313 patients were followed for a mean of 43.1 months (median, 41.0 months; interquartile range: 29.8-60.0 months). Immediate postendoscopic dual pancreatobiliary sphincterotomy complications occurred in 15% of patients. Reintervention was required in 24.6% of patients at a median follow-up (interquartile range) of 8.0 (5.5-22.5) months. The frequency of reintervention was similar irrespective of ducts with abnormal basal sphincter pressure, previous cholecystectomy, or endoscopic dual pancreatobiliary sphincterotomy method. Of patients with type III sphincter of Oddi dysfunction, 28.3% underwent reintervention compared with 20.4% with combined types I and II sphincter of Oddi dysfunction (p = 0.105). When compared with endoscopic biliary sphincterotomy alone in historical control patients from our unit, endoscopic dual pancreatobiliary sphincterotomy had a lower reintervention rate in patients with pancreatic sphincter of Oddi dysfuntion alone and a comparable outcome in those with sphincter of Oddi dysfunction of both ducts. CONCLUSION Endoscopic dual pancreatobiliary sphincterotomy is useful in patients with pancreatic sphincter of Oddi dysfunction. Prospective randomized trials of endoscopic biliary sphincterotomy alone versus endoscopic dual pancreatobiliary sphincterotomy based on sphincter of Oddi manometry findings are in progress.
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Affiliation(s)
- Sang-Heum Park
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis 46202, USA
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Affiliation(s)
- Gary C Vitale
- Director of Interventional Endoscopy of the Center for Advanced Surgical Technologies, Norton Hospital Surgical Director, Digestive Disease Center, University of Louisville, Louisville, Kentucky, USA
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Ury WA, Rahn M, Tolentino V, Pignotti MG, Yoon J, McKegney P, Sulmasy DP. Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents? J Gen Intern Med 2002; 17:625-31. [PMID: 12213144 PMCID: PMC1495092 DOI: 10.1046/j.1525-1497.2002.10837.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices. DESIGN Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars. MEASUREMENTS Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs). MAIN RESULTS The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline. CONCLUSIONS This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.
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Affiliation(s)
- Wayne A Ury
- Saint Vincent's Catholic Medical Centers of New York, Manhattan Campus, New York, NY 10011, USA.
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Abstract
Meperidine was initially synthesized as an anticholinergic agent but was soon discovered to have analgesic properties. Although meperidine's anticholinergic effects were demonstrated in vivo, the anticholinergic effects on the biliary and renal tracts have not been demonstrated in vivo. Studies have clearly demonstrated that meperidine is no more efficacious in treating biliary or renal tract spasm than comparative mu opioids. The initial studies demonstrating the analgesic efficacy of meperidine were mostly case reports and not double-blind, randomized, controlled trials in specific populations. Subsequent comparative studies failed to demonstrate any advantages of meperidine over comparable doses of other analgesics. Meperidine was portrayed in practice and teaching as having unique clinical advantages. The analgesic effects of meperidine are not pronounced, and, in addition, meperidine use is complicated by unique side effects including serotonergic crisis and normeperidine toxicity. Meperidine's poor efficacy, toxicity, and multiple drug interactions have resulted in a movement to replace meperidine with more efficacious and less toxic opioid analgesics.
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Affiliation(s)
- Kenneth S Latta
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Howerton DH. Sphincter of Oddi manometry: is timing everything? Am J Gastroenterol 2001; 96:1933-4. [PMID: 11419856 DOI: 10.1111/j.1572-0241.2001.03900.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- D H Howerton
- Eastern Virginia School of Medicine, Norfolk, USA
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Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol 2001; 96:1266-72. [PMID: 11316181 DOI: 10.1111/j.1572-0241.2001.03536.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO. METHODS A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed. RESULTS Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis. CONCLUSIONS Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.
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Affiliation(s)
- D R Thompson
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA
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Blaut U, Sherman S, Fogel E, Lehman GA. Influence of cholangiography on biliary sphincter of Oddi manometric parameters. Gastrointest Endosc 2000; 52:624-9. [PMID: 11060186 DOI: 10.1067/mge.2000.108717] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND When sphincter of Oddi manometry (SOM) and endoscopic retrograde cholangiopancreatography are performed at the same session, SOM is usually performed immediately before ductography because of concern about the accuracy of the manometric recording after contrast medium injection. However, it would be preferable to inject contrast medium first to identify other causes for a patient's symptoms, allowing selective use of SOM. The aim of this study was to evaluate the effect of cholangiography on sphincter of Oddi (SO) basal pressure. METHODS Twenty-five patients with suspected SO dysfunction were prospectively studied. Conventional station pull-through manometry of the biliary part of the sphincter was performed before and after cholangiography. The intraductal pressure and basal sphincter pressure were evaluated. RESULTS The mean intraductal pressure was 8+/-5.5 mm Hg before and 13.3+/-6.8 mm Hg after contrast medium injection (p< 0.01). However, the basal sphincter pressure was not significantly altered (52.9+/-42.1 mm Hg vs. 55.1+/-38.1 mm Hg, p = 0.52). Concordance (normal vs. abnormal) between the basal sphincter pressure before and after ductography was seen in 24 of 25 patients (96%). CONCLUSIONS Intraductal installation of contrast medium immediately before SOM infrequently alters SO basal pressure in a clinically significant manner. We therefore believe that this sequence can be utilized in clinical practice.
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Affiliation(s)
- U Blaut
- Department of Pathophysiology, Faculty of Medicine, Jagiellonian University, Cracow, Poland
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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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Desautels SG, Slivka A, Hutson WR, Chun A, Mitrani C, DiLorenzo C, Wald A. Postcholecystectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III. Gastroenterology 1999; 116:900-5. [PMID: 10092312 DOI: 10.1016/s0016-5085(99)70073-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND & AIMS Persistent abdominal pain occurs in many patients after cholecystectomy, some of whom are described as having sphincter of Oddi dysfunction (SOD). Pain in SOD type III is thought to be of biliary origin with little objective data, and treatment is often unsatisfactory. Chronic abdominal pain without a biological disease marker is similar to irritable bowel syndrome, in which many patients exhibit visceral hyperalgesia. This study tested the hypothesis that duodenal-specific visceral afferent sensitivity exists in patients with SOD type III. METHODS Eleven patients with chronic abdominal pain after cholecystectomy and 10 controls underwent duodenal and rectal barostat studies to evaluate visceral pain perception measured with a visual analog scale. All subjects underwent psychological testing. RESULTS Patients with SOD type III exhibited duodenal but not rectal hyperalgesia compared with controls. There were no differences in duodenal compliance between the groups. Duodenal distention reproduced symptoms in all but 1 patient. Patients showed high levels of somatization, depression, obsessive-compulsive behavior, and anxiety. CONCLUSIONS Patients with SOD type III exhibited duodenal-specific visceral hyperalgesia, and duodenal distention reproduced symptoms in all but 1 patient. Abdominal pain in these patients may not originate exclusively from the biliary tree.
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Affiliation(s)
- S G Desautels
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Abstract
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.
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Affiliation(s)
- J Toouli
- Gastrontestinal Surgical Unit, Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, 5042, Australia
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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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