Effects of droperidol on the pancreatic and biliary sphincters

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.

Low yield of significant findings on endoscopic retrograde cholangiopancreatography in patients with pancreatobiliary pain and no objective findings

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.

How to interpret a functional or motility test - sphincter of oddi manometry

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.

Effect of four medications associated with gastrointestinal motility on Oddi sphincter in the rabbit

AIM

Modulatory drugs of gastrointestinal (GI) motility are a possibility for use to relieve the main clinical presentation of sphincter of Oddi (SO) dysfunctions which are not easily distinguished from those occurring in high prevalence functional GI disorders. The aim of this study was to investigate the effects of GI motility modulators including pinaverium, domperidone, trimebutine, and tegaserod on the contractile activity of SO stimulated by carbachol in the rabbit.

METHODS

The contraction responses precontracted by carbachol (0.1 microM) of in vitro rabbit SO rings were evaluated before and after the addition of a series concentration (10(-13) to 10(-3)M) of pinaverium, domperidone, trimebutine, and tegaserod.

RESULTS

Pinaverium induced a concentration-dependent relaxation of isolated SO rings (10(-13) vs. 10(-7) vs. 10(-3)M = 16.6 +/- 4.8 vs. 47.1 +/- 5.5 vs. 81.2 +/- 6.2%, p < 0.001 by ANOVA) precontracted with carbachol (0.1 microM). Tegaserod did not significantly effect (10(-13) vs. 10(-7) vs. 10(-3)M = 2.3 +/- 2.2 vs. 6.7+/- 2.1 vs. 10.1 +/- 2.3%, p > 0.05 by ANOVA) SO motility, but domperidone seemed to stimulate SO contractions (10(-12) vs. 10(-7) vs. 10(-3)M = -2.2 +/- 1.5 vs. -13.9 +/- 2.0 vs. -21.0 +/- 2.7%, p < 0.05 by ANOVA). At low doses (10(-13) to 10(-7)M), trimebutine stimulated SO contraction (-8.7 +/- 1.4 vs. -9.3 +/- 2.0%); however, high doses (10(-6) to 10(-3)M) of trimebutine inhibited SO motility (-5.9 +/- 1.7 vs. 14.5 +/- 2.0%, p < 0.05 by ANOVA).

CONCLUSION

Pinaverium totally inhibits contractions induced by carbachol and tegaserod has no effect on carbachol-induced contractions. Domperidone stimulates contractions induced by carbachol. Trimebutine could either stimulate or inhibit SO contractions depending on its dosage.

Prospective evaluation of adjunctive ketamine on sphincter of Oddi motility in humans

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.

Normal sphincter of oddi motor function

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.