Sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) is a benign non-tumoral disorder of the major papilla. It occurs mainly after cholecystectomy but can also occur before surgery. Biliary pain and biliary colic are the most frequent symptoms although recurrent pancreatic pain or pancreatitis can also be presenting symptoms. In about half of the cases, there is a fibrotic stricture of the sphincter of Oddi, probably secondary to the passage of biliary stones, while in the remaining half, the syndrome is due to ampullary motility disorders. The diagnosis of SOD first requires exclusion of choledocholithiasis or ampullary tumor, by means of ERCP, endoscopic ultrasound or magnetic resonance imaging. Findings on biliary manometry will establish the diagnosis, but this technique is performed less and less often because its high risk of inducing pancreatitis discourages its use as a diagnostic procedure. Biliary scintigraphy offers a risk-free alternative albeit with lower sensitivity. Medical treatment relies on the administration of trimebutine and nitroglycerine when pain occurs. Their efficacy is moderate. Sometimes patients are referred for endoscopic sphincterotomy. Endoscopic treatment should be performed only for patients with biliary pain associated with hepatic function disorders and/or bile duct dilatation. Practicians and patients should be aware that endoscopic sphincterotomy in this clinical setting is associated with a high risk of pancreatitis and its efficacy is limited in patients with pain but without laboratory anomalies or dilatation of the biliary duct (type III Milwaukee classification). Patients with Milwaukee classification type III disorders have mostly functional complaints or psychosocial disabilities and require only medical management.

Functional Pancreatic Sphincter Dysfunction in Children: Recommendations for Diagnosis and Management.

OBJECTIVE: Functional pancreatic sphincter dysfunction (FPSD), previously characterized as pancreatic sphincter of Oddi dysfunction, is a rarely described cause of pancreatitis. Most studies are reported in adults with alcohol or smoking as confounders, which are uncommon risk factors in children. There are no tests to reliably diagnose FPSD in pediatrics and it is unclear to what degree this disorder contributes to childhood pancreatitis. METHODS: We conducted a literature review of the diagnostic and treatment approaches for FPSD, including unique challenges applicable to pediatrics. We identified best practices in the management of children with suspected FPSD and formed a consensus expert opinion. RESULTS: In children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP), we recommend that other risk factors, specifically obstructive factors, be ruled out before considering FPSD as the underlying etiology. In children with ARP/CP, FPSD may be the etiology behind a persistently dilated pancreatic duct in the absence of an alternative obstructive process. Endoscopic retrograde cholangiopancreatography with sphincterotomy should be considered in a select group of children with ARP/CP when FPSD is highly suspected and other etiologies have been effectively ruled out. The family and patient should be thoroughly counseled regarding the risks and advantages of endoscopic intervention. Endoscopic retrograde cholangiopancreatography for suspected FPSD should be considered with caution in children with ARP/CP when pancreatic ductal dilatation is absent. CONCLUSIONS: Our consensus expert guidelines provide a uniform approach to the diagnosis and treatment of pediatric FPSD. Further research is necessary to determine the full contribution of FPSD to pediatric pancreatitis.

Sphincter of Oddi Dysfunction After Gastric Bypass: Surgical or Endoscopic Therapy?

BACKGROUND: Management of Sphincter of Oddi Dysfunction (SOD) requires advanced techniques (endoscopic retrograde cholangiopancreatography via gastrostomy [GERCP]) after Roux-en-Y gastric bypass (RYGB) for obesity. Transduodenal sphincteroplasty (TS) is also performed yet carries the risks of surgery. We hypothesized that TS would have increased morbidity and mortality but provide a more durable remission of symptoms. METHODS: All patients between 2005 and 2016 with RYGB for obesity undergoing endoscopic or surgical management for type I or II SOD were included in the study. Patients with type III SOD, or who underwent RYGB for nonobesity indications, were excluded. RESULTS: Thirty-eight patients were identified. GERCP was initially performed in 17 patients, whereas TS was performed in 21. Thirty-day mortality was 0% in our cohort, and 30-d morbidity was similar between GERCP and TS (29% versus 10%; P = 0.207). Resolution of symptoms after initial therapy was seen in 41% of GERCP (7/17) and 67% of TS (14/21) (P = 0.190), respectively, and overall after 35% (8/23) and 64% (16/24) of procedures performed (P = 0.042). Symptom resolution, as defined by the median ratio of days of total remission by total days of observed follow-up, was shorter after initial and all interventions with GERCP compared with TS (0.67 versus 1.00, P = 0.036 and 0.52 versus 1.00, P = 0.028, respectively). CONCLUSIONS: Endoscopic and surgical treatment of SOD had similar morbidity and mortality. However, treatment success and duration of remission was higher in those treated with surgery.

The Role of Endotherapy in Recurrent Acute Pancreatitis.

Patients with recurrent acute pancreatitis (RAP) have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. At present, endotherapy is typically pursued as a means to achieve symptom remission and reduce rates of recurrence, hospitalization, abdominal pain, narcotic use, and surgical intervention. However, evidence that endotherapy effectively alters the natural history of disease remains limited. This article reviews the recent literature on the efficacy of endoscopic intervention in the treatment RAP with a focus on high-quality prospective randomized controlled studies. Additional studies are needed to corroborate these findings.

Sphincter of Oddi dysfunction: sphincter of Oddi dysfunction or discordance? What is the state of the art in 2018?

PURPOSE OF REVIEW: To review important manuscripts published over the previous 2 years relative to sphincter of Oddi dysfunction (SOD). RECENT FINDINGS: The long-term outcomes of the Evaluating Predictors and Interventions of SOD (EPISOD) trial further substantiated results from the initial EPISOD study, reinforcing that neither endoscopic retrograde cholangiopancreatography-manometry nor endoscopic sphincterotomy are appropriate for SOD type III. Pain management in the latter patients has reverted to neuromodulating agents, and recent studies have suggested a role for duloxetine and potentially acupuncture. The functional role of the sphincter of Oddi has been reiterated with a report demonstrating a higher clinically significant pancreatic fistula rate in distal pancreatectomy patients treated with higher doses of postoperative narcotics. Moreover, the injection of periampullary botulinum toxin preoperatively has been shown to decrease these fistulas in a pilot trial. Additional studies have reinforced that eluxadoline can cause sphincter of Oddi spasm and pancreatitis. In contrast to approaching patients with acute relapsing pancreatitis using endoscopic retrograde cholangiopancreatography and manometry, previous and current studies suggest that endoscopic ultrasound should be done first and the role of SOD in idiopathic acute relapsing pancreatitis remains controversial. Finally, there remain widespread disparities in practice patterns in the approach to patients currently classified as SOD type II. SUMMARY: In contrast to historical manuscripts which stress the classical definitions of three types of SOD and their consequences, more recent manuscripts on this topic have focused on improving surgical outcomes based on the physiologic role of sphincter of Oddi, as well as the pharmacologic causes and treatments of SOD. The simplistic view that SOD, however it has been diagnosed, requires biliary or dual sphincterotomy is just that, simplistic and potentially misguided.

Biliary Complications in Recipients of Living-Donor Liver Transplant: A Single-Center Review of 120 Patients.

OBJECTIVES: Biliary complications are common after living-donor liver transplant. This retrospective study reviewed our experience with biliary complications in recipients of living-donor liver transplant. MATERIALS AND METHODS: Over our 9-year study period, 120 patients underwent living-donor liver transplant. Patients were divided into 2 groups, with group A having biliary complications and group B without biliary complications. Both groups were compared, and different treatment modalities for biliary complications were evaluated. RESULTS: Group A included 45 patients (37.5%), whereas group B included 75 patients (62.5%). Biliary complications included bile leak in 17 patients (14.2%), biliary stricture in 11 patients (9.2%), combined biliary stricture with bile leak in 15 patients (12.5%), and sphincter of Oddi dysfunction and cholangitis in 1 patient each (0.8%). Cold ischemia time was significantly longer in group A (P = .002). External biliary drainage was less frequently used in group A (P = .031). Technical success rates of endoscopic biliary drainage and percutaneous transhepatic biliary drainage were 68.3% and 41.7%. Survival rate following relaparotomy for biliary complications was 62.5%. CONCLUSIONS: Graft ischemia is an important risk factor for biliary complications. Bile leaks can predispose to anastomotic strictures. The use of external biliary drainage seems to reduce the incidence of biliary complications. Endoscopic and percutaneous trans-hepatic approaches can successfully treat more than two-thirds of biliary complications. Relaparotomy can improve survival outcomes and is usually reserved for patients with intractable biliary complications.

Prospective Endoscopic Ultrasound-Based Approach to the Evaluation of Idiopathic Pancreatitis: Causes, Response to Therapy, and Long-term Outcome.

OBJECTIVES: Although idiopathic pancreatitis is common, the natural history is not well studied, and the best diagnostic approach to both single and multiple attacks remains undefined. METHODS: We prospectively evaluated patients with idiopathic pancreatitis over a 10-year period, and clinical information for each episode was reviewed. Endoscopic ultrasound (EUS) was performed in all patients. Patients with microlithiasis or bile duct stones were referred for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP), respectively. For those with a single attack, if EUS was normal or chronic pancreatitis or pancreas divisum was diagnosed, the patient was followed up for recurrence. For those with multiple attacks and a negative EUS, ERCP and sphincter of Oddi manometry with endoscopic therapy as appropriate were recommended. All patients were followed up in the long term to evaluate for recurrent pancreatitis, the primary study end point. RESULTS: Over the study period, 201 patients were identified (80 single attack, 121 multiple attacks; mean age 53 years, range 17-95 years, s.d. 16.3 years; and 53% female). After EUS, 54% of patients with a single attack were categorized as idiopathic, and for multiple attacks sphincter of Oddi dysfunction (SOD) was the most common diagnosis (41%). Long-term follow-up (median 37 months; interquartile range 19-70 months) documented recurrence of pancreatitis in 15 (24%; 95% confidence interval (CI), 15-38%) patients with a single attack and in 48 (49%; 95% CI, 38-62%) patients with multiple attacks. Despite endoscopic therapy, patients with pancreas divisum and SOD had relapse rates of 50% (95% CI, 35 to 68%) and 55% (95% CI, 31 to 82%), respectively. CONCLUSIONS: Following a single idiopathic attack of pancreatitis and a negative EUS examination, relapse was infrequent. Despite endoscopic therapy, patients with multiple attacks, especially those attributed to pancreas divisum and SOD, had high rates of recurrence. EUS may be a useful, minimally invasive tool for the diagnostic evaluation of idiopathic pancreatitis. The study was listed in Clinicaltrials.gov NCT00609726.

The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases.

Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.

ENDOSCOPIC METHODS OF DIAGNOSTICS AND TREATMENT OF PAPILLOSTENOSIS.

Differential diagnostics of papillospasm and papillostenosis should be based on the complex of clinical and instrumental researches with the priority to endoscopic technologies. Conservative therapy should be considered as optimal option of treatment for the patients with papillospasm. Preference of endoscopic operations have to be in case of revealed papillostenosis of different degree. Similar differentiated diagnostics and treatment management justified in 90% of cases and led to improvement of patient's conditions and their recovery.

[DIFFERENTIAL MANAGEMENT AT THE SPHINCTER OF ODDI DYSFUNCTION AFTER CHOLECYSTECTOMY].

Aim: Develop a differential management at the patients with suspected sphincter of Oddi dysfunction after cholecystectomy. Materials and methods: 169 patients after cholecystectomy, divided into 2 groups. 1st group - 60 patients after repeated surgery formed as a comparison group. They multivariate analysis of clinical, laboratory and ultrasonic data revealed the most significant signs of organic causes of cholestasis, expressed in scores. 2nd group - 109 patients with a suspected sphincter of Oddi dysfunction, who did not have symptoms of organic pathology. Types of bile outflow were assessed by hepatobiliary scintigraphy (GBSG). In cases of doubtful diagnoses computer tomography, magnetic resonance cholangiopancreatography, and/or retrograde cholangiopancreatography are performed. Results: According to the scoring system, patients 1st group scored 4 or more (8,7 ± 3,87) points. GBSG performed only in 7 (11.6%) patients, and in all cases the cholestatic type of bile outflow was detected. The amount of estimated points in the 2nd group was 2-3 points (2,43 ± 0,34; p < 0.05). GBSG performed in all patients and three types of bile outflow were revealed: normal - in 21 (19.2%) patients, cholestatic in 8 (7.3%), and accelerated - in 80 (73.3%) patients. When refining the diagnosis in 10 (9%) patients had hidden organic disorders of bile outflow, served as an indication for surgery. Conclusion: Scoring system for the assessment of the suspected sphincter of Oddi dysfunction allows to differentiate of patients for invasive research and surgery. In our study group of 109 patients received less than 4 points, they have dominated the functional disorders, but the results of a detailed examination, 9% of patients had latent organic changes that have become indications for surgical treatment.

Sphincter of Oddi Dysfunction: Updates from the Recent Literature.

Sphincter of Oddi dysfunction (SOD) has long been a controversial topic, starting with whether it even exists, as a sphincterotomy-responsive entity to treat, for either: (1) post-cholecystectomy abdominal pain and/or (2) idiopathic recurrent acute pancreatitis (IRAP). Many of its aspects had required further research to better prove or refute its existence and to provide proper recommendations for physicians to diagnose and treat this condition. Fortunately, there has been major advancement in our knowledge in several areas over the past few years. New studies on challenging the classification, exploring alternative diagnostic methods, and quantifying the role of sphincterotomy in treatment of SOD for post-cholecystectomy pain and for IRAP were recently published, including a randomized trial in each of the two areas. The goal of this paper is to review recent literature on selected important questions and to summarize the results of major trials in this field.

Sphincter of Oddi dysfunction Type III: New studies suggest new approaches are needed.

Sphincter of Oddi dysfunction (SOD) has been classified into three types based upon the presence or absence of objective findings including liver test abnormalities and bile duct dilatation. Type III is the most controversial and is classified as biliary type pain in the absence of any these objective findings. Many prior studies have shown that the clinical response to endoscopic therapy is higher based upon the presence of these objective criteria. However, there has been variable correlation of the manometry findings to outcome after endoscopic therapy. Nevertheless, manometry and sphincterotomy has been recommended for Type III patients given the overall response rate of 33%, although the reported response rates are highly variable. However, all of the prior data was non-blinded and non-randomized with variable follow-up. The evaluating predictors in SOD study - a prospective randomized blinded sham controlled one year outcome study showed no correlation between manometric findings and outcome after sphincterotomy. Furthermore, patients receiving sham therapy had a statistically significantly better outcome than those undergoing biliary or dual sphincterotomy. This study calls into question the whole concept of SOD Type III and, based upon prior physiologic studies, one can suggest that SOD Type III likely represents a right upper quadrant functional abdominal pain syndrome and should be treated as such.

[Sphincter of Oddi dyskinesia]. / Sphinkter-Oddi-Dyskinesie.

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

Symptomatic cholelithiasis and functional disorders of the biliary tract.

Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.

Sphincter of Oddi dysfunction: an evidence-based review.

Sphincter of Oddi dysfunction is a painful syndrome that presents as recurrent episodes of right upper quadrant biliary pain, or recurrent idiopathic pancreatitis. It is a disease process that has been a subject of controversy, in part because its natural history, disease course and treatment outcomes have not been clearly defined in large controlled studies with long-term follow-up. This review is aimed at clarifying the state-of-the-art with an evidence-based summary of the current diagnostic and therapeutic approaches and modalities for sphincter of Oddi dysfunction.

Self-administered electroacupuncture provides symptomatic relief in a patient with sphincter of Oddi dysfunction: a patient's report.

A 46-year-old woman with differentially diagnosed sphincter of Oddi dysfunction (SOD) type III is described. After two and a half years of managing the condition with a conventional medical/pharmacological approach, the patient's symptoms worsened and she sought complementary approaches, starting traditional acupuncture treatment before receiving training from a practitioner of Western medical acupuncture to self-administer electroacupuncture. The frequency and intensity of severe night-time pain attacks reduced and, additionally, self-administered manual acupuncture during pain attacks resulted in quick, lasting, complete symptomatic pain resolution. This is the first published case report using electroacupuncture in the clinical management of this condition. It shows patient-administered electroacupuncture as a low-risk well-tolerated procedure which provided effective pain relief and reduced the frequency and severity of pain attacks. Self-administered acupuncture could be considered as a potential complementary medical approach for patients with SOD type III before resorting to endoscopic SO manometry and sphincterotomy which carry significant associated risks of pancreatitis.

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.