Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

Endoscopic sphincterotomy for adults with biliary sphincter of Oddi dysfunction

BACKGROUND

The sphincter of Oddi comprises a muscular complex encircling the distal part of the common bile duct and the pancreatic duct regulating the outflow from these ducts. Sphincter of Oddi dysfunction refers to the abnormal opening and closing of the muscular valve, which impairs the circulation of bile and pancreatic juices.

OBJECTIVES

To evaluate the benefits and harms of any type of endoscopic sphincterotomy compared with a placebo drug, sham operation, or any pharmaceutical treatment, administered orally or endoscopically, alone or in combination, or a different type of endoscopic sphincterotomy in adults with biliary sphincter of Oddi dysfunction.

SEARCH METHODS

We used extensive Cochrane search methods. The latest search date was 16 May 2023.

SELECTION CRITERIA

We included randomised clinical trials assessing any type of endoscopic sphincterotomy versus placebo drug, sham operation, or any pharmaceutical treatment, alone or in combination, or a different type of endoscopic sphincterotomy in adults diagnosed with sphincter of Oddi dysfunction, irrespective of year, language of publication, format, or outcomes reported.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and Review Manager to prepare the review. Our primary outcomes were: proportion of participants without successful treatment; proportion of participants with one or more serious adverse events; and health-related quality of life. Our secondary outcomes were: all-cause mortality; proportion of participants with one or more non-serious adverse events; length of hospital stay; and proportion of participants without improvement in liver function tests. We used the outcome data at the longest follow-up and the random-effects model for our primary analyses. We assessed the risk of bias of the included trials using RoB 2 and the certainty of evidence using GRADE. We planned to present the results of time-to-event outcomes as hazard ratios (HR). We presented dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean difference (MD) with their 95% confidence intervals (CI).

MAIN RESULTS

We included four randomised clinical trials, including 433 participants. Trials were published between 1989 and 2015. The trial participants had sphincter of Oddi dysfunction. Two trials were conducted in the USA, one in Australia, and one in Japan. One was a multicentre trial conducted in seven US centres, and the remaining three were single-centre trials. One trial used a two-stage randomisation, resulting in two comparisons. The number of participants in the four trials ranged from 47 to 214 (median 86), with a median age of 45 years, and the mean proportion of males was 49%. The follow-up duration ranged from one year to four years after the end of treatment. All trials assessed one or more outcomes of interest to our review. The trials provided data for the comparisons and outcomes below, in conformity with our review protocol. The certainty of evidence for all the outcomes was very low. Endoscopic sphincterotomy versus sham Endoscopic sphincterotomy versus sham may have little to no effect on treatment success (RR 1.05, 95% CI 0.66 to 1.66; 3 trials, 340 participants; follow-up range 1 to 4 years); serious adverse events (RR 0.71, 95% CI 0.34 to 1.46; 1 trial, 214 participants; follow-up 1 year), health-related quality of life (Physical scale) (MD -1.00, 95% CI -3.84 to 1.84; 1 trial, 214 participants; follow-up 1 year), health-related quality of life (Mental scale) (MD -1.00, 95% CI -4.16 to 2.16; 1 trial, 214 participants; follow-up 1 year), and no improvement in liver function test (RR 0.89, 95% CI 0.35 to 2.26; 1 trial, 47 participants; follow-up 1 year), but the evidence is very uncertain. Endoscopic sphincterotomy versus endoscopic papillary balloon dilation Endoscopic sphincterotomy versus endoscopic papillary balloon dilationmay have little to no effect on serious adverse events (RR 0.34, 95% CI 0.04 to 3.15; 1 trial, 91 participants; follow-up 1 year), but the evidence is very uncertain. Endoscopic sphincterotomy versus dual endoscopic sphincterotomy Endoscopic sphincterotomy versus dual endoscopic sphincterotomy may have little to no effect on treatment success (RR 0.65, 95% CI 0.32 to 1.31; 1 trial, 99 participants; follow-up 1 year), but the evidence is very uncertain. Funding One trial did not provide any information on sponsorship; one trial was funded by a foundation (the National Institutes of Diabetes and Digestive and Kidney Diseases, NIDDK), and two trials seemed to be funded by the local health institutes or universities where the investigators worked. We did not identify any ongoing randomised clinical trials.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence from the trials included in this review, we do not know if endoscopic sphincterotomy versus sham or versus dual endoscopic sphincterotomy increases, reduces, or makes no difference to the number of people with treatment success; if endoscopic sphincterotomy versus sham or versus endoscopic papillary balloon dilation increases, reduces, or makes no difference to serious adverse events; or if endoscopic sphincterotomy versus sham improves, worsens, or makes no difference to health-related quality of life and liver function tests in adults with biliary sphincter of Oddi dysfunction. Evidence on the effect of endoscopic sphincterotomy compared with sham, endoscopic papillary balloon dilation,or dual endoscopic sphincterotomyon all-cause mortality, non-serious adverse events, and length of hospital stay is lacking. We found no trials comparing endoscopic sphincterotomy versus a placebo drug or versus any other pharmaceutical treatment, alone or in combination. All four trials were underpowered and lacked trial data on clinically important outcomes. We lack randomised clinical trials assessing clinically and patient-relevant outcomes to demonstrate the effects of endoscopic sphincterotomy in adults with biliary sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction that could not be diagnosed with Rome IV: a case report

A 30-year-old female patient presented with monthly episodes of severe intermittent upper abdominal pain, especially after consuming fatty meals. Over a period of 5 years, she visited the emergency department 21 times due to the intensity of the pain. Although the pain appeared consistent with biliary pain, both blood and imaging tests showed no abnormalities. Despite not meeting the Rome IV criteria, we suspected sphincter of Oddi dysfunction (SOD). To further investigate, we conducted hepatobiliary scintigraphy (HBS), which revealed a clear delay in bile excretion. With the patient's informed consent, we performed endoscopic sphincterotomy (EST) and as of 10 months later, there have been no recurrences. This case demonstrates an instance of SOD that could not be diagnosed using the Rome IV criteria alone but was successfully identified through HBS. It underscores the possibility of hidden cases of SOD among patients who regularly experience severe epigastric pain, where routine blood or imaging tests may not provide a diagnosis. HBS may be a useful non-invasive test in confirming the presence of previously undiagnosed SOD. As SOD can be easily treated with EST, updating the current diagnostic criteria to include such types of SOD should be considered in the future.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.

Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.

Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.

Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

The EPISOD study: long-term outcomes

BACKGROUND AND AIMS

The EPISOD (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction) study randomized patients with post-cholecystectomy pain, and little or no objective evidence for biliary obstruction, to sphincterotomy or sham intervention. Results at 1 year showed no benefit for the active treatment. We now report the outcomes at up to 5 years.

METHODS

One hundred three patients completing 1 year, and still blinded to treatment allocation, were enrolled and followed by phone every 6 months for a median of 58 months (range, 17-71 months). Their success was assessed at the final visit by 2 criteria: (1) a low pain score (Recurrent Abdominal Pain and Disability instrument [RAPID] <6) and (2) much or very much improved on the Patients' Global Impression of Change (PGIC) questionnaire (both with no repeat intervention and not taking narcotics).

RESULTS

By the RAPID criteria, success rates for the patients in the sphincterotomy and sham arms were similar: 26/65 (40%) versus 16/38 (42%), respectively. However, by the PGIC criteria, actively treated patients fared worse: 16/43 (37%) versus 16/22 (73%). A total of 75 patients underwent active treatment during the entire study. Their success rate by the RAPID criteria was 31 (41%) compared with 16 (62%) who had no active treatment at any time.

CONCLUSIONS

These data confirm our initial report that endoscopic sphincterotomy is no better than sham intervention in these patients (and, by some criteria, worse), and that ERCP can no longer be recommended. The patients have genuine and often severe symptoms, and further research is needed to establish effective management. (Clinical trial registration number: 00688662 05/3/2008.).

[Recurrent pancreatitis secondary to sphincter of Oddi dysfunction: case report]

Dysfunction of the sphincter of Oddi is a rare disease that causes about 20% of recurrent idiopathic pancreatitis. In order to suspect its existence, it is mandatory to have ruled out all other causes of acute pancreatitis. Then, the disease needs to be classified by degree of dysfunction and have a manometry performed as it is considered the gold standard of diagnosis. Manometry is used to guide treatment and its method of choice is usually an endoscopic sphincterotomy. In this article a case of recurrent pancreatitis is discussed, which after a thorough study that ruled out other etiologies, was diagnosed as a pancreatic-type dysfunction of the sphincter of Oddi. The dysfunction was resolved by endoscopic sphincterotomy and the patient had a favorable course without any recurrence of symptoms.

Sphincter of Oddi Dysfunction

This article reviews the diagnosis and management of sphincter of Oddi dysfunction (SOD), including the various factors to consider before embarking on endoscopic therapy for SOD. Selection starts with patient education to include possible patient misconceptions related to symptoms caused by the pancreaticobiliary sphincter as well as reinforcing the risks associated with the diagnosis and therapy. The likelihood of relief of recurrent abdominal pain attributed to SOD is related to the classification of SOD type and a crucial consideration before considering endoscopic therapy in light of recent evidence.

Endoscopic or laparoscopic approach for hepatolithiasis in the era of endoscopy in China

BACKGROUND

Many endoscopic procedures have been used to treat hepatolithiasis, including as laparoscopic hepatectomy (LH), laparoscopic intrahepatic duct exploration (LIDE), and endoscopic retrograde cholangiopancreatography (ERCP). However, long-term results of such treatments are rarely reported. The series aimed to evaluate the immediate outcomes and long-term results of these treatments and their optimal indications.

METHODS

From January 2002 to April 2010, a total of 124 continuous patients with hepatolithiasis were primarily treated with endoscopic surgery, including LH (LH group, n = 37), LIDE (LIDE group n = 41), and ERCP (ERCP group, n = 46) at our two institutes. These cases were retrospectively reviewed. The patients' demographic variables, operative outcomes, complete clearance rate, and cholangitis recurrence rate were analyzed.

RESULTS

Complete stone clearance was achieved in 94.6 % of LH, 78.0 % of LIDE, and 67.4 % of ERCP patients. After a median follow-up period of 5.0 years (rang 2-8 years), we observed stone recurrence in 26.6 % (33/124) of patients and recurrent cholangitis in 24.2 % (30/124) of patients. Stricture, stones in both lobes, and non-hepatectomy treatments were significant risk factors for incomplete stone clearance on multivariate analysis. In addition, recurrent cholangitis was associated with non-hepatectomy therapy, Sphincter of Oddi dysfunction, residual stones, and intrahepatic bile strictures.

CONCLUSION

In this study with 2-8 years of follow-up, residual stones, biliary stricture, Sphincter of Oddi dysfunction, and ERCP therapy were associated with recurrent stones and/or cholangitis after treatment, indicating that the modification of Sphincter of Oddi function and maintaining its normal pressure are very important.

Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial

IMPORTANCE

Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy.

OBJECTIVE

To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predictive of pain relief.

DESIGN, SETTING, AND PATIENTS

Multicenter, sham-controlled, randomized trial involving 214 patients with pain after cholecystectomy without significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis randomly assigned (August 6, 2008-March 23, 2012) to undergo sphincterotomy or sham therapy at 7 referral medical centers. One-year follow-up was blinded. The final follow-up visit was March 21, 2013.

INTERVENTIONS

After ERCP, patients were randomized 2:1 to sphincterotomy (n = 141) or sham (n = 73) irrespective of manometry findings. Those randomized to sphincterotomy with elevated pancreatic sphincter pressures were randomized again (1:1) to biliary or to both biliary and pancreatic sphincterotomies. Seventy-two were entered into an observational study with conventional ERCP managemeny.

MAIN OUTCOMES AND MEASURES

Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention.

RESULTS

Twenty-seven patients (37%; 95% CI, 25.9%-48.1%) in the sham treatment group vs 32 (23%; 95% CI, 15.8%-29.6%) in the sphincterotomy group experienced successful treatment (adjusted risk difference, -15.6%; 95% CI, -28.0% to -3.3%; P = .01). Of the patients with pancreatic sphincter hypertension, 14 (30%; 95% CI, 16.7%-42.9%) who underwent dual sphincterotomy and 10 (20%; 95% CI, 8.7%-30.5%) who underwent biliary sphincterotomy alone experienced successful treatment. Thirty-seven treated patients (26%; 95% CI,19%-34%) and 25 patients (34%; 95% CI, 23%-45%) in the sham group underwent repeat ERCP interventions (P = .22). Manometry results were not associated with the outcome. No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 15 patients (11%) after primary sphincterotomies and in 11 patients (15%) in the sham group. Of the nonrandomized patients in the observational study group, 5 (24%; 95% CI, 6%-42%) who underwent biliary sphincterotomy, 12 (31%; 95% CI, 16%-45%) who underwent dual sphincterotomy, and 2 (17%; 95% CI, 0%-38%) who did not undergo sphincterotomy had successful treatment.

CONCLUSIONS AND RELEVANCE

In patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy vs sham did not reduce disability due to pain. These findings do not support ERCP and sphincterotomy for these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00688662.

Endoscopic management of acute pancreatitis

Patients presenting with acute pancreatitis can be complex on different levels. Having a multifaceted approach to these patients is often necessary with radiographic, endoscopic, and surgical modalities all working to benefit the patient. Major surgical intervention can often be avoided or augmented by therapeutic and diagnostic endoscopic maneuvers. The diagnostic role of endoscopy in patients presenting with acute idiopathic pancreatitis can help define specific causative factors and ameliorate symptoms by endoscopic maneuvers. Etiologies of an acute pancreatitis episode, such as choledocholithiasis with or without concomitant cholangitis, microlithiasis or biliary sludge, and anatomic anomalies, such as pancreas divisum and pancreatobiliary ductal anomalies, often improve after endoscopic therapy.

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.

Post-endoscopic retrograde cholangio-pancreatography pancreatitis: Is time for a new preventive approach?

Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangio-pancreatography (ERCP) and its incidence may exceed 25% in some high-risk patient subsets. In some patients, pancreatitis may follow a severe course with pancreatic necrosis, multiorgan failure, permanent disability and even death. Hence, approaches which minimize both the incidence and severity of post-ERCP pancreatitis are worth pursuing. Pancreatic stents have been used with some success in the prevention of post-ERCP, while so far pharmacological trials have yielded disappointing results. A recent multicenter, randomized, placebo-controlled, double-blind trial has shown that rectally administered indomethacin is effective in reducing the incidence of post-ERCP pancreatitis, the occurrence of episodes of moderate-to-severe pancreatitis and the length of hospital stay in high-risk patients. These results together with the demonstration that rectal administration of indomethacin is not associated with enhanced risk of bleeding strongly support the use of this drug in the prophylaxis of post-ERCP pancreatitis.

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy

BACKGROUND

Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES.

METHODS

The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted.

RESULTS

Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst.

CONCLUSIONS

TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.

Botulinum toxin may predict the outcome of endoscopic sphincterotomy in episodic functional post-cholecystectomy biliary pain

OBJECTIVE

A retrospective clinical audit was carried out to identify whether relaxation of the sphincter of Oddi (SO) by botulinum toxin (BTX) injection can select patients with episodic functional post-cholecystectomy biliary pain who will benefit from endoscopic sphincterotomy.

PATIENTS AND METHODS

Sixty-four patients complaining of functional post-cholecystectomy biliary pain with a frequency of at least four episodes per month had 100 units of BTX injected into their SO muscle in four aliquots. After review patients with a pain free interval following BTX injection of at least 4 weeks were offered biliary endoscopic sphincterotomy and their outcome assessed.

RESULTS

Of the 64 patients 46 (72%) had at least four pain free weeks after BTX therapy and 44 of these 46 patients (96%) went on to experience pain relief following endoscopic sphincterotomy. Of the 64 patients 41 had sphincter of Oddi manometry prior to BTX injection. Every patient with sphincter of Oddi hypertension defined by manometry and at least 4 weeks' pain relief following BTX (24) had pain relief following sphincterotomy. Fifteen (94%) of the 16 patients who did not undergo manometry but reported at least 4 weeks' pain relief after BTX had pain relief after sphincterotomy.

CONCLUSION

Botulinum toxin relaxation of the SO may be a useful method of predicting the symptom response to endoscopic sphincterotomy in patients who have episodic functional biliary pain.

Mandatory and optional function tests for biliary disorders

Function tests in gastroenterology and hepatology aim to provide criteria for diagnosis of specific disorders and for prediction of patient responses to therapy. This review focuses on the utility of function tests in the management of gallstone disease and functional biliary disorders. In gallstone disease, function tests may be considered in the selection of candidates for nonsurgical therapy of gallbladder stones only. In cases of suspected functional biliary disorders, experts have advocated the use of classical noninvasive tests such as hepatobiliary scintigraphy. However, unequivocal evidence for their utility in diagnosis or patient selection for invasive treatment is yet to be provided. Recently, more advanced noninvasive tests such as real-time ultrasonography or secretin-stimulated magnetic resonance cholangiopancreaticography have been described. Controlled trials using these novel techniques may provide a rationale for the use of function tests in clinical management of calculous and acalculous biliary diseases, but are currently not available.

Pancreatitis after percutaneous ethanol injection into HCC: a minireview of the literature

Deaths after percutaneous ethanol injection (PEI) into hepatocellular carcinoma (HCC) may occur within a few hours to a few days following the procedure because of hemoperitoneum and haemorrhage from oesophageal varices or hepatic insufficiency. Pancreatitis has been recently reported as a rare lethal complication of intra-arterial PEI, another modality for treating HCCs. In this minireview, we analyze the literature concerning the development of acute pancreatitis after PEI. Pathogenesis of pancreatitis from opioids and ethanol is also addressed. Treatment with opioids to reduce the patient's abdominal pain after PEI in combination with the PEI itself may lead to direct toxic effects, thus favouring the development of pancreatitis.

Sphincter of Oddi hypomotility and its relationship with duodenal-biliary reflux, plasma motilin and serum gastrin

AIM: To detect whether patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux by measuring the radioactivity of Tc99m-labeled diethylene triamine penta-acetic acid (DTPA) in the bile and whether the patients with duodenal-biliary reflux have sphincter of Oddi hypomotility, by measuring the level of plasma and serum gastrin of the patients. Finally to if there is close relationship among sphincter of Oddi hypomotility, duodenal-biliary reflux and gastrointestinal peptides.

METHODS: Forty-five patients with a T tube after cholecystectomy and choledochotomy were divided into reflux group and control group. The level of plasma and serum gastrin of the patients and of 12 healthy volunteers were measured by radioimmunoassay. Thirty-four were selected randomly to undergo choledochoscope manometry. Sphincter of Oddi basal pressure (SOBP), amplitude (SOCA), frequency of contractions (SOF), duration of contractions (SOD), duodenal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed.

RESULTS: Sixteen (35.6%) patients were detected to have duodenal-biliary reflux. SOBP, SOCA and CBDP in the reflux group were much lower than the control group (t = 5.254, 3.438 and 3.527, P < 0.001). SOD of the reflux group was shorter than the control group (t = 2.049, P < 0.05). The level of serum gastrin and plasma motilin of the reflux group was much lower than the control group (t = -2.230 and -2.235, P < 0.05). There was positive correlation between the level of plasma motilin and SOBP and between the level of serum gastrin and SOBP and CBDP.

CONCLUSION: About 35.9% of the patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux. Most of them have sphincter of Oddi hypomotility and the decreased level of plasma motilin and serum gastrin. The disorder of gastrointestinal hormone secretion may result in sphincter of Oddi dysfunction. There is a close relationship between sphincter of Oddi hypomotility and duodenal-biliary reflux.

Biliary dyskinesia in the pediatric patient

The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.

Endoscopic management of acute and chronic pancreatitis

Endoscopic therapy has been increasingly recognized as the effective therapy in selected patients with acute pancreatitis and chronic pancreatitis (CP). Utility of endotherapy in various conditions occurring in acute pancreatitis and CP is discussed. Its efficacy, limitations, and alternatives are addressed. For the best management of these complex entities, a multidisciplinary approach involving expertise in all pancreatic specialties is essential to achieve the goal.

Non-alcoholic etiologies of acute pancreatitis - exclusion of other etiologic factors besides alcohol and gallstones

The etiology of an attack of acute pancreatitis (AP) is highly variable. It is important to identify the causing factor, because it can have an effect on the specific treatment of AP. Furthermore, in some cases relapses of AP can be prevented when the causing factor is eliminated. The most common etiology of AP is alcohol abuse and gallstone disease (>80% of all cases). What diagnostic measures should be undertaken before an attack of AP is considered as idiopathic? Important factor in the etiologic diagnostic work-up is the availability, safety, and cost-effectiveness of suitable methods. Further, the relevance of the findings has to be assessed. In some cases also the age of the patient and number of attacks of AP (first vs. recurring) have effects on efforts to detect the causing factor of AP. This review focuses on the search for other etiologic factors once alcohol and gallstones have been excluded.