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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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.

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.

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.

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.

Aspectos biométricos y morfológicos del pericardio fibroso y diafragma en el hombre / Biometric and morphological charachteristics of the fibrous pericardium and the diaphragm in man

El pericardio es una membrana fibro-serosa que envuelve al corazón y a la porción yuxtacardíaca de los grandes vasos. Realizamos un estudio del pericardio y del diafragma, registrando sus dimensiones, sus relaciones, así como también, establecer el tipo de conexiones existente entre ambas estructuras. Fueron disecadas 142 regiones mediastínicas de cadáveres sin fijación o con fijación en formaldehído al 10 por ciento, brasileños, adultos, de ambos sexos, de edades comprendidas entre los 18 y 70 años, fallecidos de diferentes causas. Para el estudio histológico, del conjunto pericardio y diafragma fueron retirados cinco fragmentos de diferentes regiones: anterior próxima al esternón (región 1), lateral izquierda próxima al ápice del corazón (región 2), posterior (región 3), lateral derecha próxima al paso de la vena cava inferior (región 4) y central (región 5). El promedio de los diámetros latero-lateral y antero-posterior del pericardio fueron de 103,3 +/- 6,7 y 66,0 +/- 2,3 mm, respectivamente y del diafragma de 309,4 +/- 27,4 y 152,5 +/- 24,9 mm, respectivamente. El área del diafragma fue en promedio de 37. 260 +/- 2.324 mm2. El área de la base del pericardio sobre el diafragma fue de 6.042 +/- 367 mm2. El espesor del diafragma fue en promedio: parte derecha, 2,42 +/- 0,34 mm; parte izquierda, 2,38 +/- 0,71 mm y la parte anterior, 2,52 +/- 0,66 mm. El promedio del espesor del pericardio separado del diafragma fue de 0,26 +/- 0,02 mm. En la región 2 ambas estructuras fueron separadas con facilidad en 47,2 mm; en la región 5 ambas estructuras se encuentran fusionadas. Los resultados obtenidos en este trabajo complementarán los conocimientos morfológicos sobre el pericardio fibroso y sus relaciones con el diafragma.

The pericardium is a fibrous and serous membrane that surround the heart and the juxta- cardiac portion of the great vessels. We studied the pericardium and diaphragm and we recorded different measurements, relations and connection between both. We dissected 142 mediastinal regions from 10 percent formaldehyde ¡ fixed or fresh individual cadavers, Brazilian adults, of both sexes, from 18-70 years of age. For the histology study from both structures were sectioned five fragments of different regions: anterior, next to sternum (region 1), left lateral, next to heart apex (region 2), posterior (region 3), right lateral, next to course of inferior vena cava (region 4) and central(region 5). The average of transversal and anterior-posterior diameters of pericardium were 103.3 +/- 6.7 mm and 66.0 +/- 2.3 mm, respectively; the same diameters of diaphragm were 309.4 +/- 27.4 mm and 152.5 +/- 24.9 mm, respectively. The diaphragm area was 37,260 +/- 2,324 mm² and the area of pericardium base over the diaphragm was 6,042 +/- 367 mm² . The thickness of diaphragm was 2.42 +/- 0.34 mm in right part, 2.38 +/- 0.71 mm in left part and 2.52 +/- 0.66 mm in anterior part. The thickness of pericardium was 0.26 +/- 0.02 mm. In region 2 both structures were easily separated in 47.2 mm; in the region 4 both structures are fused. The results of this study will complement the morphologic knowledges about fibrous pericardium and its relationships with the diaphragm.

Regional histomorphometry of the hepatic inferior vena cava; a possible sphincteric mechanism / Histomorfometría regional de la vena cava inferior hepática; un posible mecanismo de esfínter

This study was aimed at identifying the changes in diameter and structural composition of the Hepatic Inferior Vena Cava in its infrahepatic, intrahepatic and suprahepatic portions. Eighty adult liver specimens from the Chiromo and Nairobi City mortuaries were used for morphometry, while twenty of them were processed for light microscopy. A constriction was noted in the mid-portion of the HIVC, while structurally; the intrahepatic portion had thicker fibromuscular adventitia. It is plausible that these are sphincteric apparatus to prevent backflow of blood in the Hepatic Inferior Vena Cava.

Este estudio tiene por objetivo identificar los cambios en el diámetro y la composición estructural de la vena cava inferior hepática en sus porciones infrahepática, intrahepática y suprahepática. Ochenta hígados de especímenes adultos de los depósitos de cadáveres de la ciudad de Nairobi y Chiromo fueron usadas para morfometría, mientras que veinte de ellos fueron procesados para microscopía de luz. Se observó una constricción en el medio de la HIVC, mientras que estructuralmente, la porción intrahepática había una gruesa adventicia fibromuscular. Es posible que este sea un aparato esfinteriano para evitar el reflujo de sangre en la vena cava inferior hepática.

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.

The functional sphincter of Oddi disorder.

The sphincter of Oddi disorder (SOD) has been a controversial subject for many years, about which a lot has been written. However, new findings mainly using Endoscopic Retrograde Cholangiopancreatography (ERCP) and sphincter of Oddi manometry (SOM) demonstrate the fact of this diagnostic. SOD is just a part of a larger pathology, the tfunctional gastrointestinal disorders, which have been reconsidered as an important part of gastrointestinal diseases. For a better understanding, the American Gastroenterology Association Institute created a new classification of The Functional Gastrointestinal Disorders in 2006, Rome III Classification, in which the SOD is grouped in the functional biliary disorders (category E). The term SOD is used to define manometric abnormalities in patients who have signs and symptoms consistent with a biliary or pancreatic ductal origin. Based on the pathogenic mechanism and manometry findings, the SOD is separated into two groups: a group characterized by a stenotic pattern (anatomical abnormality) and a second group with a dyskinetic pattern functional abnormality). The purpose of this article is to construct a short presentation of the main aspects regarding tfunctional SOD (E2 and E3 after Rome III Classificatio).

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.

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.

Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment.

Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.

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.

The relationship of bile duct crystals to sphincter of Oddi dysfunction.

Bile duct crystals collected either from the duodenum after gallbladder contraction or directly from bile duct aspiration are surrogates for gallbladder stones and microlithiasis. Whether bile crystals also serve as surrogates for bile duct stones or microlithiasis that forms in the bile duct after cholecystectomy is not known based on current data. Sphincter of Oddi dysfunction (SOD), due either to muscular spasm or sphincter fibrosis, is a cause of bile duct obstruction. Almost all of the literature on SOD involves patients who have had a prior cholecystectomy. Intuitively, obstruction at the SO following cholecystectomy would seem to lead to biliary stasis and predispose patients to bile duct microlithiasis. However, a recent study did not find bile duct crystals in patients with manometrically diagnosed SOD. The reason for this is unknown, although we hypothesize that cholesterol and bilirubinate crystals are not surrogates for brown pigment stones commonly found in patients following cholecystectomy.

Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis.

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two- to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.

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.

Morphometric study of the sphincter of oddi (hepatopancreatic) and configuration of the submucosal portion of the sphincteric muscle mass.

The sphincter of Oddi (SO) hepatopancreatic sphincter from 114 Japanese adults, especially the sphincteric muscle mass lying in the duodenal mucosal layer (the submucosal portion of the SO: SMSO), was measured macroscopically under a binocular microscope. The SMSO was classified into two types according to shape. The horizontal type (95/114) usually displayed a rod-like shape (6.0 mm at average diameter at the root) directed toward the anus and was situated on the duodenal muscle wall with the papillary orifice at or near the tip (anal side) of the SMSO. The horizontal type SMSO followed the underlying muscle wall widely ranging from 5.0 mm to 17.9 mm length (9.8 mm at average) and was attached to the wall by the loose connective tissue along the entire length. In the horizontal type, the extramural portion (the portion penetrating and outside of duodenal muscle of the SO) of the SO was very small. The vertical type (19/114) erected on the muscle wall vertically into the lumen of the duodenum. The average length and average maximum diameter of the vertical type were 6.0 mm and 6.2 mm, respectively. The extramural portion of the SO was thicker and tighter in the vertical type, which suggested that endoscopic sphincterotomy might preserve the length of the SO longer than endoscopic papillary balloon dilation (EPBD). Of the individuals in our study, 18% (19/114) had SO diameters <5 mm, a finding that may have implications for selection of balloon size in EPBD.

[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.

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.