Influence of cholangiography on biliary sphincter of Oddi manometric parameters

[Sphincter of Oddi dyskinesia]

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

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation

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.

Key issues in sphincter of Oddi dysfunction

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.

Idiopathic acute pancreatitis

After routine investigations, including a thorough history, routine laboratory study, and noninvasive imaging with transcutaneous ultrasonogram, 10% to 25% of cases of acute pancreatitis have no readily identifiable cause and are termed idiopathic. But modern medicine has made notable advances in uncovering various causes of acute pancreatitis, and several new diagnostic tools that allow clinicians to less invasively approach the patient without sacrificing the diagnostic yield have been introduced. By being knowledgeable of these new changes and by their proper use in a proper circumstances, clinicians will be able to find the cause more accurately and earlier. This better management will not only improve the well-being of the patients but also reduce the number of "true" idiopathic acute pancreatitis to a minimum.

The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog

AIM: To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regulatory effect of gallbladder.

METHODS: Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed.

RESULTS: According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0 ± 2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8 ± 0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P < 0.01) in the interval period of bile draining, but significant difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8 ± 0.5 mmHg) and the bile flowing period (15.9 ± 0.9 mmHg) (P > 0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling.

CONCLUSION: During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.

Clinical significance of sphincter of Oddi dyskinesia

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

Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis

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%.