Proximal oesophagus: the added value in understanding GORD symptoms.

Over the past decade, the approach to the understanding of the mechanisms involved in the aetiology of gastro-oesophageal reflux disease (GORD) symptoms has changed, and growing evidence now supports the concept that visceral hyper-sensitivity to intra-oesophageal stimuli plays a major role. Among the recent advances, one of the more consistent findings is that the contact of the refluxate, either acidic or weakly acidic, with the proximal oesophageal mucosa, is a main determinant of GORD symptoms, particularly in the large majority of patients affected by non-erosive reflux disease. The data reported in the current issue of Neurogastroenterology and Motility by Bredenoord et al., showing only a small proportion of proximal reflux in patients with Barrett's oesophagus, who are less sensitive to gastro-oesophageal reflux, further support the consistency of this finding in the pathogenesis of symptoms. In the light of these results, we shall look forward, in the management of patients, to approaches aimed at restoring the antireflux barrier, hopefully decreasing the amount of reflux and, in turn, its proximal extent.

Presence of gas in the refluxate enhances reflux perception in non-erosive patients with physiological acid exposure of the oesophagus.

OBJECTIVE: The mechanisms underlying symptoms in gastro-oesophageal reflux disease, particularly in non-erosive reflux disease (NERD), remain to be fully elucidated. Weakly acidic reflux and the presence of gas in the refluxate could be relevant in the pathogenesis of symptoms. METHODS: To assess the relationship between symptoms and weakly acidic, acid and mixed (liquid-gas) reflux, 24 h oesophageal pH-impedance monitoring was performed in 32 NERD and in 20 oesophagitis patients. In 12 NERD patients the study was repeated following 4 weeks treatment with a proton pump inhibitor (PPI). Impedance-pH data were compared with those of 10 asymptomatic controls. Heartburn and acid regurgitation were considered in the analysis of symptoms. RESULTS: 15 NERD patients showed a physiological acid exposure time (pH-negative). Weakly acidic reflux was significantly less frequent in patients (25% (2%), mean (SE)) than in controls (54% (4%), p<0.01). Gas was present in 45-55% of reflux events in patient groups and controls, and decreased following PPI treatment. In NERD pH-negative patients, weakly acidic reflux accounted for 32% (10%) (vs 22% (6%) in NERD pH-positive and 12% (8%) in oesophagitis patients) and mixed reflux for more than two-thirds of all symptom-related refluxes. Multivariate logistic analysis showed that in NERD pH-negative patients, the risk of reflux perception was significantly higher when gas was present in the refluxate (odds ratio, 3.2; 95% CI, 1.2 to 10; p<0.01). CONCLUSIONS: The large majority of symptoms, in all patients, are related to acid reflux. In NERD patients, the presence of gas in the refluxate significantly enhances the probability of reflux perception. These patients are also more sensitive to less acidic reflux than oesophagitis patients.

Case report of adult-onset Allgrove syndrome.

Allgrove syndrome is a rare autosomal recessive disorder characterised by childhood onset, alacrima, oesophageal achalasia, adrenocortical insufficiency, neurological and occasionally autonomic involvement. Although the disease has been associated with mutations in the ALADIN gene on chromosome 12q13, it is genetically heterogeneous. The case we report is interesting because of its onset in adulthood, long duration of disease and prominent neurological dysfunctions. After the onset of neurological abnormalities the diagnosis went unrecognised for years until the patient presented for evaluation of dysphagia. The presence of achalasia with dysphagia, adrenal insufficiency, reduced tear production, optic atrophy and peripheral motor-sensory neuropathy with axonal loss led us to clinically diagnose Allgrove syndrome even though a genetic study showed no mutations in the ALADIN gene exons. The case we report shares many clinical features with Allgrove syndrome and, even with the limitations of a single case, underlines the variability in this syndrome and the need for appropriate investigations along with a multidisciplinary approach.

Functional MRI in the evaluation of oesophageal motility: feasibility, MRI patterns of normality, and preliminary experience in subjects with motility disorders.

PURPOSE: The aim of this study was to introduce functional magnetic resonance imaging (fMRI) with T1-weighted turbo fast low-angle shot (FLASH) sequences in the evaluation of oesophageal motility and morphology, to formulate MRI patterns of normality in healthy subjects and to demonstrate the feasibility of the method by obtaining a preliminary experience in the study of subjects affected by oesophageal motility disorders. MATERIALS AND METHODS: Thirty healthy volunteers and seven patients with radiological and manometric diagnoses of oesophageal motility disorders underwent fMRI with dynamic T1- weighted turbo-FLASH (TFL) sequences during the administration of oral contrast material. RESULTS: Evaluation of oesophageal function and morphology proved possible in all subjects, as well as the formulation of normality patterns. In patients with motility disorders, fMRI correctly visualised the typical alterations in agreement with radiological and manometric findings. CONCLUSIONS: Functional MRI sequences acquired during the administration of oral contrast material can evaluate oesophageal transit, providing information on motility and morphology; furthermore, this modality can properly visualise the typical functional and morphological alterations of motility disorders.

Effect of hiatal hernia on proximal oesophageal acid clearance in gastro-oesophageal reflux disease patients.

BACKGROUND: Proximal acid reflux is common in gastro-oesophageal reflux disease and is a determinant of symptoms. Patients with hiatal hernia complain of more symptoms than those without and are less responsive to proton-pump inhibitors. AIM: To evaluate the role of hiatal hernia on spatiotemporal characteristics of acid reflux. METHODS: Thirty seven consecutive gastro-oesophageal reflux disease patients underwent endoscopy, videofluoroscopy, manometry and multichannel 24-h pH test. Data were compared with those of 15 asymptomatic controls. Multivariate linear regression was used for statistical analysis. RESULTS: At videofluoroscopy, hiatal hernia was found in 16 of 37 patients. The mean size of hiatal hernia was 3.4 cm. Patients showed significantly prolonged acid clearance time, both at proximal and distal oesophagus, compared with controls. Hiatal hernia patients showed a significantly delayed acid clearance, along the oesophageal body, compared with non-hiatal hernia patients. The prolonged acid exposure was maintained during upright and supine position. The presence of hiatal hernia significantly predicted acid clearance delay in the distal and proximal oesophagus [at 10 cm below upper oesophageal sphincter: Delta + 2.5 min (95% confidence interval: 0.4-4.5); P < 0.02]. CONCLUSIONS: The presence of hiatal hernia is a strong predictor of more prolonged proximal oesophageal acid exposure and clearance. Hiatal hernia is likely to play a role in the pathophysiology of gastro-oesophageal reflux disease symptoms, and should be taken into greater consideration in the treatment strategies of the disease.

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis.

AIM: To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis. METHODS: This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures. RESULTS: Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab. CONCLUSIONS: These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy.

BACKGROUND: Sphincter of Oddi dysfunction is diagnosed at manometry and, after cholecystectomy, non-invasively at quantitative choledochoscintigraphy. Patients may benefit from endoscopic sphincterotomy. AIMS: The aim of this study was to assess the usefulness of choledochoscintigraphy compared with manometry in predicting outcome of sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction. PATIENTS AND METHODS: Thirty patients with biliary-type pain complying with the Rome diagnostic criteria of sphincter of Oddi dysfunction and belonging to biliary group I and II were subjected to clinical evaluation, choledochoscintigraphic assessment of the hepatic hilum-duodenum transit time, endoscopic retrograde cholangiopancreatography, and perendoscopic manometry. Twenty two biliary group I and II patients with prolonged hepatic hilum-duodenum transit times were invited to undergo sphincterotomy. Fourteen patients underwent sphincterotomy; eight refused. Clinical and scintigraphic assessments were performed at follow up. RESULTS: Hepatic hilum-duodenum transit time was delayed in all patients with manometric evidence of sphincter of Oddi dysfunction, in all biliary group I patients and in 64% of biliary group II patients. At follow up, all patients who underwent sphincterotomy were symptom free and hepatic hilum-duodenum transit time had either normalised or significantly improved. A favourable post sphincterotomy outcome was predicted in 93% of cases at choledochoscintigraphy and in 57% at manometry. CONCLUSIONS: Quantitative choledochoscintigraphy is a useful and non-invasive test to diagnose sphincter of Oddi dysfunction as well as a reliable predictor of sphincterotomy outcome in post cholecystectomy biliary group I and II patients, irrespective of clinical classification and manometric findings.

Increased sphincter of Oddi basal pressure in patients affected by gall stone disease: a role for biliary stasis and colicky pain?

BACKGROUND AND AIMS: Even if the motor activity of the gall bladder and sphincter of Oddi (SO) are integrated, it is not known if the presence of stones in the gall bladder affects SO function. The aim of the study was to compare SO motor activity in patients with and without gall stones. PATIENTS AND METHODS: In a series of 155 patients consecutively submitted to endoscopic retrograde cholangiopancreatography and SO manometry for suspected biliary or pancreatic disease, 23 gall stone patients had recurrent episodes of biliary or pancreatic pain (colicky group); 52 patients had non-biliary/pancreatic-type abdominal pain/discomfort, and of these, 15 had gall stones (non-colicky group), 25 were free of stones (controls), and 12 had undergone cholecystectomy. RESULTS: SO basal pressure in gall stone patients in the colicky or non-colicky group was significantly higher than in controls (p<0.001). SO basal pressure recorded in postcholecystectomy patients did not differ from controls. SO phasic activity did not differ between the patient groups. SO dysfunction was detected in more than 40% of gall stone patients irrespective of associated biliary/pancreatic pain but in none of the control subjects (p<0.001). CONCLUSIONS: Gall stones are frequently associated with increased SO tone which may obstruct bile flow thus acting to facilitate gall bladder stasis, and may play a role as a cofactor in biliary/pancreatic pain.

Chronic neurogenic lesions of the external anal sphincter and abdomino-perineal dyssynergia in chronic constipation.

BACKGROUND: Neuropathy of the pudendal nerves which may be found in constipated patients has been considered the result of pelvic floor descent due to the repetitive acts of straining at stool. However, the relationship between abdominopelvic dyssynergia, which may lead to repetitive acts of straining and neurophysiopathologic alterations of the pelvic floor has not yet been fully elucidated. AIM: Of this study was to assess the relationship between neurophysiologic alterations of the external anal sphincter, patterns of altered evacuation and defaecographic pelvic floor physiology in 32 patients with chronic idiopathic constipation. RESULTS: At electromyography partial muscle denervation, identified as chronic neurogenic lesions of the external anal sphincter, were found in 19% and dyssynergia (co-contraction of external anal sphincter and abdominal muscles) in 34% of the investigated subjects. Patients with different electromyography patterns did not differ as far as concerns symptoms of altered evacuation, bowel frequency, use of digital manoeuvres, age, and duration of symptoms. The presence of neurophysiologic alterations was significantly associated with altered defaecographic findings: reduced ano-rectal angle at rest in chronic neurogenic lesions and abdomino-pelvic dyssynergia (p < 0.01); excessive pelvic floor descent in the presence of chronic neurogenic lesions (p < 0.05). CONCLUSIONS: In chronically constipated patients symptoms of altered defaecation do not appear to be related to abdomino-pelvic dyssynergia and/or chronic neurogenic lesion of the external anal sphincter and do not show any association with defaecographic alterations. These results suggest that straining at evacuation can be induced by additional factors other than abdomino-pelvic dyssynergia and chronic neurogenic lesions and that these two alterations have different pathogenetic mechanisms.

Sequential treatment of chronic constipation in paraplegic subjects.

Chronic constipation is the main gastrointestinal complaint of spinal cord injury (SCI) patients, and has a significant effect on patients' lives, concerning nursing dependence, morbidity and complications. Many therapies have been proposed to treat chronic severe constipation, most of them with limited effect or being unpredictable in their effect or being expensive or very radical. Ten spinal cord injury patients have been submitted to a therapeutic protocol based on a high residue diet, a standardised water intake, and on the use of a sequential schedule of evacuating stimuli. After four weeks of treatment the patients showed an increased frequency of bowel movements per week, a decreased total gastrointestinal transit time, and a decreased need for oral and rectal laxatives. This treatment seems to be effective in modifying patients' bowel habits, and therefore could be considered as a standardised protocol for the management of severe constipation in those who are paraplegic.

Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation.

The present multicenter double-blind placebo-controlled trial evaluates the therapeutic effectiveness of small-volume daily doses of an isosmotic polyethylene glycol (PEG) electrolyte solution in the treatment of chronic nonorganic constipation. After a complete diagnostic investigation, patients still constipated at the end of a four-week placebo-treatment run-in period were enrolled and randomized to receive either placebo or PEG solution 250 ml twice a day for the following eight weeks. Patients were assessed at four and eight weeks of treatment, and they reported frequency and modality of evacuation, use of laxatives, and relevant symptoms daily on a diary card. Oroanal and segmental large-bowel transit times were assessed with radiopaque markers during the fourth week of the run-in period and the last week of the treatment period. During the study period, dietary fiber and liquids were standardized and laxatives were allowed only after five consecutive days without a bowel movement. Of the 55 patients enrolled, five dropped out, three because of adverse events and two for reasons unrelated to therapy; another two were excluded from the efficacy analysis because of protocol violation. Of the remaining 48 patients (37 women, age 42 +/- 15 years, mean +/- SD), 23 were assigned to placebo and 25 to PEG treatment. In comparison to placebo, PEG solution induced a statistically significant increase in weekly bowel frequency at four weeks and at the end of the study (PEG: 4.8 +/- 2.3 vs placebo: 2.8 +/- 1.6; P < 0.002) and a significant decrease in straining at defecation (P < 0.01), stool consistency (P < 0.02), and use of laxatives (P < 0.03). Oroanal, left colon, and rectal transit times were significantly shortened by PEG treatment. There was no difference between controls and PEG-treated patients as far as abdominal symptoms and side effects were concerned. In conclusion, PEG solution at 250 ml twice a day is effective in increasing bowel frequency, accelerating colorectal transit times, and improving difficult evacuation in patients with chronic nonorganic constipation and is devoid of significant side effects.

[Defecography study of outpouchings of the external wall of the rectum: posterior rectocele and ischio-rectal hernia]. / Studio defecografico delle estroflessioni della parete posteriore del retto: rettocele posteriore ed ernia ischio-rettale.

PURPOSE: To report the clinical and defecographic features of posterior rectal wall outpouchings, i.e., posterior rectocele and ischiorectal hernia. MATERIALS AND METHODS: Sixty-six patients with posterior rectal wall outpouching (61 with posterior rectocele and 5 with ischiorectal hernia) were selected among the patients examined in the last two years for defecation disturbance. All patients underwent physical examination, rectoscopy and videodefecography. RESULTS: Posterior rectal wall outpouchings were detected at physical examination in 28 patients and at rectoscopy in 9 patients. Posterior rectocele, more frequent and bigger in men, was usually demonstrated at videodefecography as an outpouching of the lower portion of posterior rectal wall: this finding was visible only in the dynamic phases in 51 patients while it was seen also at rest in 10 patients. In 52 patients, posterior rectocele was associated with other abnormalities--i.e., anterior rectocele (64%), puborectal muscle syndrome (38%), descending perineum (33%), mucosal prolapse (33%) and intussusception (20%). An ischiorectal hernia, defined as a posterolateral ampullar outpouching deeper than 4 cm and already visible at rest, was identified in 5 patients. Descending perineum and anterior rectocele were the most common associated disorders. CONCLUSIONS: We report the clinical and defecographic features of these rectal abnormalities and stress the importance of videodefecography in the real-time study of these morphofunctional disorders.

Effect of wheat bran in treatment of chronic nonorganic constipation. A double-blind controlled trial.

After a two-week basal period, 24 patients were randomly allocated to receive, with a crossover double-blind design, for two consecutive four-week periods, bran (20 g/24 hr) or placebo. The daily intake of water and dietary fibers was standardized. Symptomatology, oroanal transit time, bowel frequency, and stool weight were assessed in basal conditions and at week 4 and 8 of the treatment. Oroanal transit time decreased and bowel frequency and stool weight increased significantly during both bran and placebo administration in comparison with basal period. Bran treatment was more effective than placebo in improving bowel frequency and oroanal transit. During bran treatment oroanal transit time became normal only in patients with slow colonic transit and not in those with slow rectal transit. Neither the occurrence nor the severity of the most frequent accompanying symptoms of chronic constipation differed significantly between placebo and bran treatments.

Hepatoduodenal bile transit in cholecystectomized subjects. Relationship with sphincter of Oddi function and diagnostic value.

The hepatic hilum-duodenum transit time (HHDT) was evaluated in cholecystectomized subjects to assess its relationship with the motor function of the sphincter of Oddi (SO) and its diagnostic accuracy in the detection of SO dysfunction. The study was performed in asymptomatic controls and symptomatic patients with SO dysfunction before and after sphincterotomy. HHDT showed a direct correlation with manometric SO maximal basal pressure (r = 0.77; P < 0.001) but not with SO phasic activity. In sphincterotomized subjects HHDT did not differ from that of the asymptomatic subjects, and HHDT, which was prolonged before sphincterotomy, normalized after sphincterotomy. HHDT had a 100% specificity and an 83% sensitivity in diagnosing SO dysfunction when compared to SO manometry. In conclusion, the cholescintigraphic HHDT is mainly related to the SO maximal basal pressure, presenting an elevated specificity and a satisfactory sensitivity in the diagnosis of SO dysfunction in cholecystectomized subjects.

Role of body position, gender, and age on pelvic floor location and mobility.

The location and mobility of pelvic floor in different body positions and their relation to age and gender was assessed in 117 patients (19 men, 98 women, age range 10-77 years) with chronic nonorganic constipation (defined as less than three bowel movements per week for at least three years) by means of defocography. Eleven females (age range 16-69 years), without gastrointestinal symptoms, affected by noninvasive carcinoma of the cervix represented a control group. Pelvic floor location was measured as the distance in centimeters of the anorectal junction from the pubococcygeal line; pelvic floor mobility was measured during squeezing, straining, and defecation assuming the pelvic location at rest as zero reference. Pelvic floor location and mobility did not differ between controls and constipated patients. In both groups pelvic floor location at rest was significantly higher (P = 0.001) with patients lying down than sitting up, whereas pelvic floor mobility during squeezing was greater with the patients sitting up than lying down (P = 0.003). In both positions, pelvic floor location at rest was significantly lower (P = 0.01) in females than in males. Pelvic floor mobility during squeezing was significantly different between gender. Parity and hysterectomy did not appear to affect pelvic floor location. Data emerging from this study indicate that body position is one of the major determinants of the pelvic floor location.

Quantitative cholescintigraphy in the assessment of choledochoduodenal bile flow.

Quantitative cholescintigraphy has been proposed as a noninvasive method to assess function of the sphincter of Oddi in cholecystectomized subjects. The present study evaluated several quantitative cholescintigraphic variables to assess their time-related variability as well as their capability to detect delay of choledochoduodenal bile flow. Cholescintigraphy with 2,6-diethylphenylcarbahoylmethyl diacetic acid 99mTc was performed in 24 cholecystectomized patients with recurrent biliary-like pain, laboratory evidence of bile stasis, normal hepatocellular function tests, and no evidence of choledocholithiasis. The study was also performed in 26 asymptomatic cholecystectomized subjects and repeated at 2-week intervals during identical experimental conditions in 10 of them. Of the following quantitative cholescintigraphic variables investigated, (a) hepatic T peak, (b) 50% hepatic retention (T peak, 1/2), (c) percent hepatic retention at 30 minutes, (d) percent hepatic retention at 40 minutes, (e) vein-hepatic hilum transit time, (f) vein-duodenum transit time, and (g) hepatic hilum-duodenum transit time, only the hepatic hilum-duodenum transit time showed a statistically significant correlation between the duplicate studies. Only vein-duodenum transit time and hepatic hilum-duodenum transit time discriminated the symptomatic from the asymptomatic patients; of the two variables, however, hepatic hilum-duodenum transit time showed less intrasubject variability and no overlap between the two groups of patients. Hepatic hilum-duodenum transit time showed a positive linear correlation with the maximum diameter of the choledochus. It is concluded that in cholecystectomized patients, the hepatic hilum-duodenum transit time appears to detect a delay of bile flow into the intestine better than any other cholescintigraphic variable. However, in patients with a dilated common bile duct, this variable cannot discriminate bile flow delay due to increased choledochal capacity and/or obstruction of the sphincter of Oddi.

Pressure relationships within the human bile tract. Normal and abnormal physiology.

Bile is secreted continuously, although at various rates, from the liver into the biliary tree; whether bile is then diverted into the gallbladder or the duodenum depends on the relative resistance to flow mainly determined by the contractile state of the gallbladder and the choledochoduodenal junction. The resistance of the sphincter of Oddi is considered the principal factor in the regulation of the intracholedochal pressure and, therefore, of the common bile duct-gallbladder pressure gradient; however, filling of the gallbladder may also take place after total sphincterotomy. During late phase II of the interdigestive period intragallbladder pressure increments favour flow of a small amount of bile into the bile duct and, through the sphincter of Oddi, into the duodenum. During phase III of the interdigestive period maximal frequency of sphincter of Oddi phasic contractions blocks bile flow into the duodenum. After a meal tonic active contraction of the gallbladder causes an increase of the intraluminal pressure followed shortly by volume reduction of the viscus and outflow of bile accompanied by an intracholedochal pressure increment. Gallbladder hypotonia is a relevant factor in the pathogenesis of gallbladder stones. The gallbladder acts as a reservoir, since intracholedochal pressure is higher after than before cholecystectomy, and this may explain post-cholecystectomy choledochal dilatation and biliary pain by obstructed bile flow due to either stenosis or dyskinesia of the sphincter of Oddi.

Effect of glucagon on sphincter of Oddi motor activity.

In this study the effects of glucagon 1-29 peptide and the metabolically inactive portion glucagon 1-21 have been evaluated on sphincter of Oddi (SO) motor activity. A triple lumen catheter perfused by a minimally compliant infusion system was used to record intraoddian pressures at endoscopy. A strictly blind evaluation of tracings was performed. Neither peptide administration appeared to induce any relevant variation of SO resting pressure nor frequency, amplitude and duration of phasic contractions. Data of the present study would not support the use of glucagon whenever a spasmolytic effect on the SO is looked for.

Manometric measurement of human sphincter of Oddi length.

Length of biliary (CBD) and/or pancreatic (PD) sphincter of Oddi (SO) was measured during perendoscopic or intraoperative manometry in 21 control subjects and in 46 patients with biliary disease. When the high resting pressure (HPZ) and the phasic wave zone (PAZ) were considered, SO length was, in the control group, 9.5 +/- 0.5 mm (M +/- SE) and 9.4 +/- 0.6 mm at the level of the CBD-SO, and 7.7 +/- 0.6 mm and 6.9 +/- 0.5 mm at the level of the PD-SO. The physiological sphincter length appeared substantially shorter than the anatomical one, as reported in the literature. No significant differences were found between controls and patients with CBD stones. Endoscopic sphincterotomy without manometry reduced mean sphincter length length of the sphincterotomy was tailored to the manometric findings. Surgical partial sphincterotomy reduced sphincter length by only 46.7 +/- 10.3%.