Disfunción del esfínter de Oddi (DEO) ¿Qué hay de nuevo? / Sphincter of Oddi Dysfunction (SOD) What's new?

The sphincter of Oddi dysfunction (SOD) is considered a significant cause of post-cholecystectomy biliary pain and recurrent idiopathic pancreatitis, but its diagnosis and treatment have been controversial. Therapeutic options include pharmacological therapy, based on studies with varying efficacy and low levels of evidence, and endoscopic sphincterotomy (ES) in selected patients. The Rome IV expert panel redefined SOD and its treatment. SOD type I is due to organic stenosis of the sphincter, benefiting from ES, while SOD type III is functional pain that should be managed accordingly. The suspicion of SOD (formerly SOD type II) is complex to diagnose due to the overlap of other processes and the lack of definitive diagnostic tests. ES has questio - nable results due to high placebo response rates and associated risks. Current evidence advises against ES in pancreatic SOD for the treatment and prevention of recurrent acute pancreatitis. In biliary SOD, its use remains controversial, although a recent prospective study found that nearly 60% of patients improved with ES. In conclusion, the management of SOD requires a multidisciplinary approach to avoid interventions with limited benefit and high risk

La disfunción del esfínter de Oddi (DEO) se considera una causa importante de dolor biliar poscolecistectomía y pancreatitis recurrente idiopática, pero su diagnóstico y tratamiento han sido controvertidos. Las opciones terapéuticas incluyen la terapia farmacológica, basada en estudios con diferentes eficacias y bajo nivel de evi - dencia, y la terapia endoscópica con esfinterotomía (EE) en pacientes seleccionados. El panel de expertos Roma IV redefinió la DEO y su tratamiento; la DEO tipo I se debe a estenosis orgánica del EO, beneficiándose de la EE, mientras que la DEO tipo III es un dolor de causa funcional que debe manejarse como tal. La sospecha de DEO (antigua DEO tipo II) es compleja de diagnosticar debido a la superposición de otros procesos y la falta de pruebas diagnósticas definitivas. La EE tiene resultados cuestionables debido a las altas tasas de respuesta al placebo y los riesgos asociados. La evidencia actual desaconseja la EE en DEO pancreática como tratamiento y prevención de pancreatitis aguda recurrente. En DEO de tipo biliar, su uso sigue siendo controvertido, aunque un estudio prospectivo reciente encontró que casi el 60% de los pacientes mejoraron con la EE. En conclusión, el manejo de la DEO requiere un enfoque multidisciplinario para evitar intervenciones con poco beneficio y alto riesgo.

The efficacy and safety of endoscopic sphincterotomy in patients with Sphincter of Oddi dysfunction: a systematic review and meta-analysis.

OBJECTIVE: Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. METHODS: The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. RESULTS: Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. CONCLUSION: ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.

[Recurrent acute pancreatitis secondary to sphincter of oddi dysfunction: Case report]. / Pancreatitis aguda recurrente secundaria a disfunción del esfínter de oddi: Reporte de caso.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Disfunción del esfínter de Oddi: un reporte de caso / Sphincter of Oddi dysfunction: Case report

Resumen La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.

Abstract Sphincter of Oddi dysfunction is a clinical syndrome caused by functional (dyskinesia) or structural (stenosis) disease. The estimated prevalence of this condition in the general population is 1%, reaching 20% in patients with persistent pain after cholecystectomy and 70% in patients with idiopathic recurrent acute pancreatitis. It is clinically characterized by the presence of abdominal pain, similar to biliary colic or pancreatic pain in the absence of organic biliary disease. It is also observed in patients with idiopathic recurrent pancreatitis, associated with elevated pancreatic or hepatic enzymes, and bile duct and/or pancreatic duct dilatation. Treatment for sphincter of Oddi dysfunction type I is based on endoscopic sphincterotomy, but there is controversy regarding the management of sphincter of Oddi dysfunction types II and III. This article presents the clinical case of a 67-year-old female patient with a history of cholecystectomy by laparotomy. After the surgical procedure, she reported abdominal pain predominantly in the right hypochondrium, colicky, associated with emesis of biliary characteristics. Cholangioresonance report revealed mild intrahepatic bile duct dilatation, and scintigraphy with HIDA scan showed sphincter of Oddi dysfunction. Endoscopic sphincterotomy was performed. The patient was asymptomatic and the sphincter of Oddi dysfunction had resolved at two-year follow-up.

Quistes del colédoco / Choledochal cysts

Los quistes del colédoco son una condición médica poco frecuente, la cual se caracteriza por presentar dilatación de la vía biliar intrahepática y extrahepática; se postulan en su etiología la anomalía de la unión pancreático-biliar, lo que favorece el reflujo del jugo pancreático al árbol biliar, y la aganglionosis del árbol biliar. Tiene una amplia gama de presentación de síntomas, y entre los principales se encuentran el dolor abdominal, la ictericia y una masa abdominal palpable. Son lesiones premalignas y, por ende, el tratamiento de elección es la resección quirúrgica completa con seguimiento a largo plazo.

Choledochal cysts are rare pathological conditions characterized by dilatation of the intrahepatic and extrahepatic bile ducts. Postulated etiologies are an abnormal pancreato-biliary junction favoring reflux of pancreatic juice to the biliary tree, and aganglionosis of the biliary tree. They have a wide range of presenting symptoms, the main ones being abdominal pain, jaundice and evident abdominal mass. Choledochal cysts are premalignant lesions, and therefore the treatment of choice is complete surgical resection, which demands long-term follow-up.

Effects of cholecystectomy on the changes of motility of Beagle dogs' sphincter of Oddi.

PURPOSE: To observe the effect of cholecystectomy on the changes of motion pattern of Beagle dogs' sphincter of Oddi (SO), and investigate the modulatory role of nitric oxide (NO) and cholecystokinin (CCK) in the regulation of SO. METHODS: Pressure of common bile duct, SO motility, response to bolus injections of cholecystokinin (CCK, 20 ng/kg and 100 ng/kg), basal pressure (BP) and phasic contraction amplitude (PCA) were measured respectively by manometry in six Beagle dogs before and after cholecystectomy. RESULTS: After cholecystectomy, the pressure and diameter of common bile ducts (CBD) was significantly increased (p<0.01); BP and phasic contraction frequency (PCF) were also increased, however, no significant differences were found between the two groups; the SO motilities was not significantly changed. The relaxation responded to physiological dose of CCK (20ng/kg) was decreased, while bolus-dose of CCK (100ng/kg) induced rapid contractions and decreased PCA after cholecystectomy. The regulation pattern of SO pressure modulated by NO and its inhibitor had changed after cholecystectomy. CONCLUSION: After cholecystectomy in Beagle dogs, no obviously change of motion pattern of SO was observed through self-compensation, but these compensations may lead to some changes of regulation pattern of CCK and NO on SO.

Current knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction.

Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and their pathologic implications has experienced tremendous progress during the last few years. This article reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. Many publications with different levels of evidence were found supporting biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. Also, there are many publications supporting the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and sphincter of Oddi dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and their clinical significance, the current evidence does not fully support what has been suggested. The reflux of pancreatic enzymes into the bile tract and gallbladder is a fascinating subject of study which is open to active research. The final demonstration of the pathophysiology and consequences of PBR in NPBL and support by evidence level type I would constitute a major breakthrough in the understanding and eventually in the treatment of gallbladder diseases.

Disfunción del esfínter de Oddi y pancreatitis idiopática / Sphincter of Oddi dysfunction (SOD) and idiopatic pancreatitis

The sphincter of Oddi dysfunction is a little known entity that typically occurs in post-cholecystectomy patients with abdominal pain with biliary or pancreatic characteristics. It represents an important cause of idiopathic recurrent acute pancreatitis. Most of the patients referred for sphincter of Oddi dysfunction study have another disease which explain the symptoms, so a careful history and appropriate physical examination often can identify the true source of the pain. The most used grading score is the Milwaukee classification, based on clinical, laboratory, imaging and cholangiographic findings. In the last decade, new and more applicable criteria have been developed, such as Rome III criteria, which do not require functional tests considered complex and not available in non-specialized centers. The sphincter of Oddimanometry is considered the gold standard for the diagnosis of this entity, allowing for the determination of which patients will benefit from endoscopic therapy (sphincterotomy). There are some noninvasive diagnostic tests that have failed to show strong correlation to displace the sphincter of Oddi. The treatment of this condition is mainly based on endoscopic sphincterotomy, with variable success rates depending on the type of dysfunction. This article presents a review of the most important aspects related to the sphincter of Oddi and its relationship with idiopathic recurrent pancreatitis.

La disfunción del esfínter de Oddi es una entidad poco conocida, que típicamente se presenta en pacientes post-colecistectomía con dolor abdominal de tipo “biliar” o “pancreático”. Representa unaimportante causa de pancreatitis aguda recurrente idiopática. La mayoría de los pacientes derivados para estudio de disfunción del esfínter de Oddi corresponden a otra causa o enfermedad que explica los síntomas, por lo que una cuidadosa historia clínica y un adecuado examen físico, a menudo permiten identificar el verdadero origen del cuadro doloroso. La clasificación más utilizada es la de Milwaukee basada en parámetros clínicos, de laboratorio, imagenológicos y colangiográficos. En la última década, se han elaborado criterios de mayor aplicabilidad clínica como los criterios de Roma III, que no requieren de test funcionales considerados complejos y poco disponibles en centros no especializados. La manometría del esfínter de Oddi es considerado el gold standard en el diagnóstico de esta entidad, permitiendo además, establecer quiénes se beneficiarán con la terapia endoscópica (esfinterotomía). Se han desarrollado una serie de otros métodos diagnósticos no invasivos, que no han logrado demostrar una correlación suficientemente sólida para desplazar a la manometría. El tratamiento de esta condición se basa principalmente en la esfinterotomía endoscópica, con una tasa de éxito variable dependiendo del tipo de disfunción. En el presente artículo se revisarán los aspectos más importantes relacionados con la disfunción del esfínter de Oddi y su relación con pancreatitis recurrente idiopática.

Hallazgos anatomopatológicos en pacientes con disfunción biliar / Pathological findings in patients with biliary dysfunction

Se efectuó un estudio descriptivo, transversal y retrospectivo de 84 pacientes atendidos en el Servicio de Gastroenterología del Hospital General Docente D Juan Bruno Zayas Alfonso de Santiago de Cuba desde enero de 2010 hasta igual mes de 2011, a los cuales se realizó colecistectomía por presentar manifestaciones clínicas de disfunción biliar; pero después de extirparles la vesícula, acudieron a la consulta externa de la especialidad con dolor abdominal y cuadros diarreicos, entre otros síntomas y signos. En busca de datos más precisos, se comparó el diagnóstico preoperatorio con los hallazgos anatomopatológicos, de donde se derivó que a pesar de que en muchos casos no coincidían, ello no obstaculizó la obtención de resultados satisfactorios en los integrantes de la casuística.

A descriptive, cross-sectional, and retrospective study with 84 patients assisted at Gastroenterology Service from Dr Juan Bruno Zayas Alfonso General Teaching Hospital in Santiago de Cuba was carried out from January, 2010 to January, 2011. These patients underwent a colecistectomy for having clinical manifestations of biliary dysfunction. After removing the gallbladder, patients having abdominal pain and diarrhea, among other symptoms and signs, attended the outpatient department related to this speciality. Searching for precise data, the pre-surgical diagnosis was compared to the pathological findings, in which case it was concluded that, in spite of many cases did not match, this fact did not hinder the obtaining of satisfactory results in the case material.

Reflujo pancreáticobiliar en pacientes con colelitiasis y sin colelitiasis: estudio comparativo / Pancreaticobiliary reflux in patients with cholelithiasis and without cholelithiasis: a comparative study

Background. Pancreaticobiliary reflux is a pathologic phenomenon occurring in patients with gallstones. However, the occurrence of pancreaticobiliary reflux has not been studied in patients without gallstones. The objective of this study was to measure the bile levels of amylase and lipase in patients without gallstones submitted to cholecystectomy as part of another surgical procedure, and to compare these values with patients submitted to cholecystectomy for gallstone disease. Patients and Methods. A prospective observational comparative study was designed. A sample of 136 consecutive patients was included. Amylase and lipase levels were measured in bile. Normal serum amylase levels at our institution are 28-100 U/L and for lipase are 13-60 U/L. There are no established normal levels for pancreatic enzymes in bile. However, we considered elevated the bile amylase and lipase levels whenever they were higher than normal plasma levels. Results. One-hundred three patients (76 percent) had gallstones and 33 (24 percent) liad healthy gallbladders without gallstones. According to normal plasma levels for amylase and lipase, these enzymes in bile were elevated in 83.5 percent patients with gallstones, compared to elevated levels of amylase in 6 percent patients and lipase in 3 percent patients without gallstones. Conclusions. Pancreaticobiliary reflux is a common phenomenon in patients with gallstones and occurs sporadically in patients without gallstones.

Introducción. El reflujo pancreáticobiliar es un fenómeno patológico que ocurre en pacientes con colelitiasis. La ocurrencia de este fenómeno no ha sido estudiada en pacientes sin colelitiasis. El presente estudio tiene por objetivo medir los niveles de amilasa y lipasa en la bilis de pacientes sin colelitiasis, colecistectomizados como parte de otro procedimiento quirúrgico y comparar estos valores con pacientes colecistectomizados por colelitiasis. Pacientes y Métodos. Se diseñó un estudio observacional y comparativo. Una muestra de 136 pacientes consecutivos fue incluida. Se midieron los niveles de amilasa y lipasa en la bilis. En nuestra institución los valores normales para amilasa son 28-100 U/L y para lipasa 13-60 U/L. No se han establecido valores normales de enzimas pancreáticas en la bilis. Para efectos del presente estudio, se consideró como elevados los niveles biliares de amilasa y lipasa cuando fueron mayores a los valores plasmáticos normales. Resultados. 103 pacientes (76 por ciento) tenían colelitiasis y 33 (24 por ciento) tenían vesículas normales sin cálculos. De acuerdo a los valores plasmáticos normales de amilasa y lipasa, estas enzimas se encontraron elevadas en 83,5 por ciento de los pacientes con colelitiasis comparados con valores elevados de amilasa en 6 por ciento en pacientes sin colelitiasis y de lipasa en 3 por ciento de estos pacientes. Conclusiones. El reflujo pancreaticobiliar es un fenómeno común en pacientes con colelitiasis y ocurre esporádicamente en pacientes sin colelitiasis.

Fístula colovesical secundaria a la migración de una endoprótesis biliar: reporte de un caso / Colovesical fistula secondary to the migration of a biliary stent: case report

Introducción: la colocación endoscópica de stents para descomprimir una obstrucción biliar es un tratamiento comúnmente utilizado para enfermedades malignas de la vía biliar y para estenosis benignas de la misma. Se han descrito complicaciones inusitadas derivadas de la colocación de endoprótesis biliares, incluyendo la migración. Se presenta un caso clínico con el objetivo de compartir con la comunidad científica una rara complicación y la única publicada, secundaria a la migración de un stent biliar. Caso clínico: mujer de 47 años de edad, con estenosis de ámpula de Vater benigna, a quien se le colocó endoprótesis biliar, con la cual mejoró clínicamente. Posterior a la colocación del stent se le realizó colecistectomía abierta con exploración de vías biliares. Al año y medio posterior a la colocación del stent, la paciente presentó dolor vago en abdomen bajo y disuria; se le practicaron estudios de imagen donde se observó un extremo del stent biliar en colon sigmoides y otro en vejiga. Se realizó intervención quirúrgica encontrando fístula colovesical, la cual se resolvió en un solo tiempo quirúrgico. La paciente fue egresada con resultados satisfactorios.

BACKGROUND: The endoscopic placement of endoprostheses to decompress biliary obstruction is a commonly used treatment for malignant biliary diseases and is also used in the treatment of benign biliary strictures. Unusual complications of endoprosthesis placement have been described and include the migration of the stent. We present a case to share with the scientific community, an unusual complication secondary to the migration of a biliary stent that has not previously been reported to our knowledge. CASE REPORT: We present the case of a 47-year-old female with a diagnosis of benign papillary stenosis. The patient received a biliary endoprosthesis with clinical improvement. Later she underwent open cholecystectomy and common duct exploration. At consultation 18 months later, the patient presents with indistinct lower abdominal pain and dysuria. We performed imaging studies where the biliary stent was observed, partly in the sigmoid colon and partly in the bladder. The patient underwent surgery where a colovesical fistula was found and treated during the same surgical event. The patient was discharged succesfully.

[Colovesical fistula secondary to the migration of a biliary stent. Case report]. / Fístula colovesical secundaria a la migración de una endoprótesis biliar. Reporte de un caso.

BACKGROUND: The endoscopic placement of endoprostheses to decompress biliary obstruction is a commonly used treatment for malignant biliary diseases and is also used in the treatment of benign biliary strictures. Unusual complications of endoprosthesis placement have been described and include the migration of the stent. We present a case to share with the scientific community, an unusual complication secondary to the migration of a biliary stent that has not previously been reported to our knowledge. CASE REPORT: We present the case of a 47-year-old female with a diagnosis of benign papillary stenosis. The patient received a biliary endoprosthesis with clinical improvement. Later she underwent open cholecystectomy and common duct exploration. At consultation 18 months later, the patient presents with indistinct lower abdominal pain and dysuria. We performed imaging studies where the biliary stent was observed, partly in the sigmoid colon and partly in the bladder. The patient underwent surgery where a colovesical fistula was found and treated during the same surgical event. The patient was discharged succesfully.