Major duodenal papilla and its normal anatomy.

The major duodenal papilla (papilla of Vater) is the point where the dilated junction of the bile and pancreatic ducts (ampulla of Vater) enter the duodenum. The ampulla is surrounded by the sphincter of Oddi, which not only controls the flow of bile and pancreatic juice into the duodenum, but also prevents the reflux of duodenal contents, bile and pancreatic juice into the bile and pancreatic ducts.

Ruggero Oddi: 120 years after the description of the eponymous sphincter: a story to be remembered.

This article presents a short account of theories, methods, and experimental data formulated and carried out 120 years ago, by Ruggero Oddi, then a 4th-year student in medicine, about the identification of the common bile duct sphincter. A historical picture emerges which leads us to think that Oddi not only discovered the bile duct sphincter, but also described bile duct dilation after cholecystectomy and performed biliary manometry for the first time. The role of serendipity and the almost unknown contribution of Arturo Marcacci, Oddi's "maestro" are also mentioned.

Motor function of the opossum sphincter of Oddi.

We studied the opossum sphincter of Oddi (SO) because in this species the SO is approximately 3 cm in length and its extraduodenal location permits recording of motor activity with negligible interference from duodenal motor activity. The SO segment of 120 animals was evaluated by one or more of the following: (a) intraluminal manometry; (b) electromyography; (c) common bile duct (CBD) flow monitored by a drop counter; (d) cineradiography of intraductal contrast medium; and (e) histologic examination. SO pull-throughs using an infused catheter of 0.6-mm o.d. invariably showed a high pressure zone (HPZ) of 18 +/- 3 SE mm Hg in the terminal 4-5 mm of the SO segment. This HPZ had a narrow lumen, 0.5-0.7 mm in diam, and prominent circular muscle. The HPZ in the terminal SO had both active and passive components. HPZ with minimal amplitude and a paucity of underlying smooth muscle were present inconstantly at the junction of the SO segment with the CBD and pancreatic duct, respectively. The dominant feature of the SO segment was rhythmic peristaltic contractions that originated in the proximal SO and propagated toward the duodenum. These contractions occurred spontaneously at a rate of 2-8/min, ranged up to 200 mm Hg in magnitude, had a duration of approximately 5 s and were not abolished by tetrodotoxin. Concurrent myoelectric and manometric recordings showed that each phasic contraction was immediately preceded by an electrical spike burst. Simultaneous recordings of cineradiography, CBD inflow of contrast medium, SO manometry, and SO electromyography indicated that rhythmic peristaltic contractions stripped contrast medium from the SO into the duodenum. During SO systole, CBD emptying was transiently interrupted, whereas SO filling occurred during the diastolic interval between SO peristaltic contractions. SO distention increased the frequency of SO peristalsis. We conclude that (a) the dominant feature of the opossum SO is rhythmic peristaltic contractions that originate in the proximal SO and propagate toward the duodenum; (b) these forceful SO peristaltic contractions are myogenic in origin and serve as a peristaltic pump that actively empties the SO segment; (c) CBD outflow occurs passively during SO diastole, but is interrupted transiently during each SO peristaltic contraction; and (d) a short HPZ with active as well as passive components exists in the distal SO segment and acts as a variable resistor to SO outflow.

Innervation of Extrahepatic Biliary Tract, With Special Reference to the Direct Bidirectional Neural Connections of the Gall Bladder, Sphincter of Oddi and Duodenum in Suncus murinus, in Whole-Mount Immunohistochemical Study.

Sphincter of Oddi dysfunction is one of the most important symptoms in post-cholecystectomy syndrome. Using either electrical or mechanical stimulation and retrogradely transported neuronal dyes, it has been demonstrated that there are direct neural pathways connecting gall bladder and the sphincter of Oddi in the Australian opossum and the golden hamster. In the present study, we employed whole-mount immunohistochemistry staining to observe and verify that there are two different plexuses of the extrahepatic biliary tract in Suncus murinus. One, named Pathway One, showed a fine, irregular but dense network plexus that ran adhesively and resided on/in the extrahepatic biliary tract wall, and the plexus extended into the intrahepatic area. On the other hand, named Pathway Two, exhibiting simple, thicker and straight neural bundles, ran parallel to the surface of the extrahepatic biliary tract and passed between the gall bladder and duodenum, but did not give off any branches to the liver. Pathway Two was considered to involve direct bidirectional neural connections between the duodenum and the biliary tract system. For the first time, morphologically, we demonstrated direct neural connections between gall bladder and duodenum in S. murinus. Malfunction of the sphincter of Oddi may be caused by injury of the direct neural pathways between gall bladder and duodenum by cholecystectomy. From the viewpoint of preserving the function of the major duodenal papilla and common bile duct, we emphasize the importance of avoiding kocherization of the common bile duct so as to preserve the direct neural connections between gall bladder and sphincter of Oddi.

The sphincter of Oddi: understanding its control and function.

The most common functional disorders of the biliary tract and pancreas are associated with disordered motility of the sphincter of Oddi (SO). The SO is a neuromuscular structure located at the junction of the bile and pancreatic ducts with the duodenum. The primary functions of the SO are to regulate the delivery of bile and pancreatic juice into the duodenum, and to prevent the reflux of duodenal contents into the biliary and pancreatic systems. Disordered motility of the SO leads to the common and painful clinical conditions of SO dysfunction and acute pancreatitis. In order to understand normal SO motility, studies have been performed addressing SO function, control of spontaneous SO activity, responses to bioactive agents, SO innervation, and reflexes with other gastrointestinal organs. These studies have led to the current understanding of how the SO functions and may permit the development of targeted therapy for SO dysfunction and acute pancreatitis. This review summarizes the current knowledge regarding the control and regulation of SO motility, highlighting laboratory based and clinical research performed over the last 5 years.

Benign anatomical mistakes: "ampulla of Vater" and "papilla of Vater".

The anatomy of the ampullary termination of the bile and pancreatic ducts is complex; appropriate terminology for this area is confusing and inaccurate. We examine the terms "ampulla of Vater" and "papilla of Vater" for anatomical and historical correctness. The term "ampulla" refers to a dilated part of a duct or other channel. Thus, this word is topographically correct to describe the dilatation at the confluence of the bile and main pancreatic ducts; historically, however, there is considerable reason to believe that its first description was by Santorini rather than Vater. The eponymous term "papilla of Vater" is also incorrect historically. The use of eponyms is firmly entrenched in the medical literature, but some are so problematic that they should be discarded. The eponymous terms for both the ampulla and the papilla should be replaced with the terms "hepatopancreatic ampulla" (or "biliaropancreatic ampulla") and "major [or "greater"] duodenal papilla," respectively.

Galanin modulates sphincter of Oddi function in the Australian brush-tailed possum.

The neuropeptide galantin (GAL) is found in neurons in the biliary tract of several species. We mapped the distribution of GAL-like immunoreactive nerve (GAL-LI) fibers in the sphincter of Oddi of the Australian brush-tailed possum by immunohistochemistry. The pharmacological effects of GAL in vitro and in vivo were studied by measuring sphincter of Oddi muscle strip contractility and transsphincteric flow, respectively. Muscle layers, and ganglionated and perivascular plexuses, contained GAL-LI nerve fibers. Exogenous GAL caused a concentration-dependent (10(9)-10(-6)M) increase in the spontaneous longitudinal but not circular muscle contractions. At 10(-6) M GAL, contractile activity was elevated two- to fourfold. This response was tetrodotoxin insensitive but competitively inhibited by galantide (10(-8)-10(-7) M). In vivo, intra-arterial bolus injections of GAL (1001000 ng/kg), decreased transsphincteric flow, with a maximum reduction to 80.2 +/- 6.8% of control. In conclusion, GAL appears to selectively stimulate longitudinally oriented sphincter of Oddi smooth muscle via a direct mechanism, which results in a modest reduction in transsphincteric flow.

Distribution and morphological features of nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) activity in intrinsic neurons of the Oddi sphincter of the cat.

To clarify the role of nitric oxide (NO) in the sphincter of Oddi, we histochemically investigated the distribution of nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d), a marker for NO synthase, in the cat. NADPH-diaphorase activity was localized in two neuronal subtypes: large neurons with many dendrites and smaller with one process. Most of the nerve cell bodies (99%) in the wall of the sphincter of Oddi showed strong activity for this enzyme. The nerve fibers with NADPH-d activity were observed in all layers, chiefly in the muscle layers. These results suggest that NO may play a very important role in the neuronal regulation of sphincter of Oddi.

Vector manometric study of the sphincter of Oddi in the dog: functional and morphological correlation.

The relationship between sphincter of Oddi pressure and the morphological structure of the sphincter was studied in eight dogs prepared with a duodenal cannula. Sphincter of Oddi manometry was performed in awake animals in three directions, ventral, left dorsal, and right dorsal, using a catheter with three radial side holes for recording at one level. The pressure in the ventral direction (26.6+/-1.06 mmHg) (mean+/-SEM) was significantly lower than that in the left and right dorsal directions (30.6+/-1.42 and 31.2+/-1.23 mmHg, respectively). This functional manometric difference in the three directions correlated closely with the morphological structure of the sphincter of Oddi; the sum of the thickness of the sphincter of Oddi muscle and duodenal proper muscle was greater on the dorsal than on the ventral side. To our knowledge, this is the first report of axial asymmetry in sphincter of Oddi pressure.

Physiology of motor function of the sphincter of Oddi.

Human and experimental studies of the sphincter of Oddi have established that the sphincter is not a simple and passive smooth muscle portion of the biliary system; rather, it plays an active role in modulating bile flow into the duodenum in both the fasted and the postprandial states. The sphincter of Oddi in the opossum, and likely in man, demonstrates spontaneous phasic and perhaps peristaltic activity that affects bile flow into the duodenum. The sphincter appears to be under the control of a smooth muscle pacemaking-like region in the proximal sphincter that controls the frequency and direction of propagation of the phasic contractions. Immunohistochemical studies have documented the presence of dense concentrations of neuropeptide-containing myenteric nerves in the sphincter of Oddi. Physiologic studies have confirmed that these peptides, in combination with the classic gastrointestinal hormones, exert significant effects on biliary motility. Experimental studies of the motor physiology of the sphincter of Oddi have advanced our understanding of human biliary motility and dysmotility. A subset of patients experiences biliary-like pain after cholecystectomy. This pain may be attributable to either mechanical stenosis of the papilla or dysfunction of the sphincter of Oddi. No definitive test currently exists to establish the diagnosis with adequate sensitivity or specificity. It is hoped that further development of ultrasonographic, scintigraphic, manometric, or electromyographic techniques will allow a clearer definition of patients who truly have sphincter dysfunction and who might benefit from medical, endoscopic, or surgical therapy.

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 regularizing 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 significative 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.

Surgical anatomy of the papilla of Vater and biliopancreatic ducts.

The present research was aimed at defining the surgical anatomy of the biliopancreatic ducts and of Oddi's sphincter. The numerous anatomic variations of the papilla, the millimetric distribution of its muscle fibres, and any morphological detail of clinical significance have been investigated. An integrated analysis of radiographic, tridimensional (casts), and histologic findings has been carried out in 49 of 64 autoptic bilio-duodenopancreatic specimens. Exact limits of the choledocus and Wirsung sphincters were defined. A consistent accumulation of circular muscle fibres could be seen, on the choledocus duct side, up to a mean distance of 13.6 mm from the papillary pore. However, more rarefied fibres were present up to 20.5 mm. Muscle fibres were seen to stop roughly on the pancreatic duct side at 7.3 mm from the papillary pore. The beginning of the sphincter was observed 2-3 mm above the papillary pore. There was no evidence suggesting the presence of upper, middle, and lower biliary sphincters. Five anatomic diversities of the Wirsung-choledocus confluence were found. The Y type was the most frequent (61.2%), followed by the U type (22.4%), V (14.3%), and II (2.1%). Santorini's duct with a normal papilla was present in 16 per cent of the cases. These data along with other interesting observations on antireflux mechanisms (Santorini's valves) and on the ductal space orientation appear to be useful guidelines for a physiopathological understanding of bilio-pancreatic diseases and for any therapeutic procedure on these structures.

Oddi sphincter and common channel: evaluation with pharmacodynamic MR cholangiopancreatography using fatty meal and secretin stimulation.

PURPOSE: This study was performed to assess the usefulness of pharmacodynamic MR cholangiopancreatography (MRCP) in depicting the segment covered by the Oddi sphincter. MATERIALS AND METHODS: Twelve volunteers were studied by pharmacodynamic MRCP. After stimulation by the oral intake of a fatty meal and an intravenous injection of secretin, a single-shot rapid acquisition relaxation enhancement (RARE) sequence was used to obtain consecutive images of the segment covered by the Oddi sphincter. The contraction range of the Oddi sphincter and the lengths of the common channel were measured on the MR console by comparing the most contracted image of the sphincter with the most relaxed image. RESULTS: Pharmacodynamic MRCP showed periodic contraction of the Oddi sphincter in all cases. The range of sphincteric contraction over the biliary duct was 8-19 mm (11.8+/-3.2 mm, mean +/- standard deviation) and over the pancreatic duct 8-23 mm (10.0+/-1.5 mm). In 11 of the 12 cases, the common channel was depicted and its length ranged from 3-8 mm (5.2+/-1.3 mm). CONCLUSION: Pharmacodynamic MRCP clearly depicted the range of contraction of the Oddi sphincter and the common channel, which are not usually revealed by conventional MRCP.

Sphincter of Oddi motility.

BACKGROUND: Technical improvement in endoscopic and manometric technique has allowed direct manometry of the human sphincter of Oddi (SO). The aim of the present review is to describe the present status of physiologic and clinical knowledge of the SO, with emphasis on contributions from Danish Gastroenterology. RESULTS: The SO is a zone with an elevated basal pressure with superimposed phasic contractions. It acts mainly as a resistor in the regulation of bile flow. Neurohormonal regulation influences the motility pattern. The contractions are under the control of slow waves. Clinical subgroups show abnormalcy in SO manometric pattern especially in patients with biliary or pancreatic pain without demonstrable organic substrate. Evidence suggests that endoscopic sphincterotomy may be of benefit in these patients.

[The microsurgical anatomy of the major duodenal papilla and of the sphincter of the hepatopancreatic ampulla]. / Mikrokhirurgicheskaia anatomiia bol'shogo duodenal'nogo sosochka i sfinktera pechenochno-podzheludochnoi ampuly.

Morphometrical parameters of the anterior, posterior, superior and inferior walls of gastroduodenal passage have been investigated in 26 preparations. Three anatomical forms of the pyloric sphincter were distinguished. Histotopography of vessels and nerves in gastroduodenal passage and their distribution in the walls of the passage have been investigated.

[Manometric study of the biliary sphincter zone: a comparison between the length of phasic activity and the narrow distal segment].

Motor activity of the sphincter of Oddi has been evaluated in 26 patients who underwent ERCP examination. Manometric recordings from the common bile duct and the sphincter of Oddi were performed with a single end-lumen perfused catheter. The number of successive 3 mm spaced black marks, observed during the pull-through from the first appearance of the proximal sphincter activity to that of duodenal pressure, was used to measure the length of the sphincter zone. In 14 of 26 patients, the length of phasic activity zone of the sphincter of Oddi was 9 mm. However, the narrow distal segment of the common bile duct was 15.1 +/- 3.6 mm in length. In same patients, the length of phasic activity zone was shorter than the anatomical one. The mean sphincter of Oddi pressure (SOP) at the distance of 6 mm from the papillary pore (77.8 +/- 22.1 mmHg) was greater than that of 9 mm (58.4 +/- 27.0 mmHg) and 12 mm (51.0 +/- 16.9 mmHg). These results suggest that the location of the orifice of catheter should be taken into consideration when comparing the SOP.

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.

Fetal intraluminal portion of the sphincter of Oddi: a histological study using human fetuses

The sphincter of Oddi surrounds a common duct after joining of the bile and pancreatic ducts in the adult ampulla of Vater, but the fetal development of the submucosal portion of the sphincter is still obscure possibly because previous studies used horizontal or frontal sections. We examined serial sagittal histological sections of 12 human fetuses with 36-65 mm crown rump length or CRL (approximately 9-11 weeks) and semi-serial sections of the other 3 fetuses with 210-250 mm (25-30 weeks). Except for 1 fetus (36 mm CRL), fourteen fetuses carried the "intraluminal portion" protruding and floating in the duodenal lumen. Twelve of them had the sphincter extending to the anal side in the duodenal lumen, whereas two extended to the stomach side. The distal end of the sphincter seemed to detach from the duodenal mucosa at and around 9 weeks, and subsequently the common duct seemed to elongate freely without mucosal attachment in mid-term fetuses and, finally, become embedded again in the duodenal mucosa in the postnatal life. A possible discrepancy in growth rate between the sphincter muscle and duodenal mucosa was likely to allow the specific intermediate morphology, i.e., the intraluminal common duct. The fetal accessory papilla did not show such morphology. A minority of cases whose common duct extended to the stomach side might connect with abnormal union of the bile and pancreatic ducts

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Role of neurocrine somatostatin on sphincter of Oddi contractility and intestinal ischemia reperfusion-induced acute pancreatitis in macaques.

BACKGROUND: Intestinal ischemia-reperfusion (IIR) is implicated in the pathogenesis of severe acute pancreatitis (SAP). This study investigates the impact of neurocrine somatostatin (SST) on the contraction of sphincter of Oddi (SO) during IIR. METHODS: Intestinal ischemia-reperfusion model in macaques was induced by occluding the superior mesenteric artery. Pancreatitis was confirmed by pancreatic histology and serum levels of amylase and lipase. SST and its receptors (SSTRs) in SO were visualized by immunohistochemistry. Effects of SST on the contraction of the isolated SO were recorded in vitro. KEY RESULTS: Inflammatory scores of the pancreas and serum levels of amylase or lipase in the macaques that underwent IIR were significantly higher than those in the control group. The frequency and amplitude of phasic contraction of the circular muscle in SO was increased by SST in a concentration-dependent manner. Compared with the control group, SST innervation or SSTR2 expression in SO of macaques treated with IIR was increased 5.2 fold or 5.6 fold respectively. Prophylactic infusion of SST before IIR significantly reduced SST immunoreactive fibers in SO as compared to those in the IIR group and remarkably alleviated the pathophysiologic changes due to IIR. CONCLUSIONS & INFERENCES: Increased SST innervation in SO during the early phase of IIR associated with the contraction of circular muscle of SO, which might be one of the promoting factors associated with the development of SAP. Prevention of IIR or intervention of SO contraction after occurrence of acute pancreatitis might be beneficial for preventing SAP.