Sphincter of Oddi dysfunction that could not be diagnosed with Rome IV: a case report.

A 30-year-old female patient presented with monthly episodes of severe intermittent upper abdominal pain, especially after consuming fatty meals. Over a period of 5 years, she visited the emergency department 21 times due to the intensity of the pain. Although the pain appeared consistent with biliary pain, both blood and imaging tests showed no abnormalities. Despite not meeting the Rome IV criteria, we suspected sphincter of Oddi dysfunction (SOD). To further investigate, we conducted hepatobiliary scintigraphy (HBS), which revealed a clear delay in bile excretion. With the patient's informed consent, we performed endoscopic sphincterotomy (EST) and as of 10 months later, there have been no recurrences. This case demonstrates an instance of SOD that could not be diagnosed using the Rome IV criteria alone but was successfully identified through HBS. It underscores the possibility of hidden cases of SOD among patients who regularly experience severe epigastric pain, where routine blood or imaging tests may not provide a diagnosis. HBS may be a useful non-invasive test in confirming the presence of previously undiagnosed SOD. As SOD can be easily treated with EST, updating the current diagnostic criteria to include such types of SOD should be considered in the future.

Biliary type-II sphincter of Oddi dysfunction with a pancreatic duct dilation: a case report and review of the literature.

BACKGROUND: The double-duct sign is defined as dilation of both the common bile duct and pancreatic duct, which usually indicates pancreatic malignancy. However, benign causes have also been reported to cause a double-duct sign. CASE PRESENTATION: We present the case of a 59-year-old Caucasian female patient admitted to the Gastroenterology Department with intermittent right epigastric abdominal pain and an intact gallbladder. A double-duct sign was seen on endoscopic ultrasound. The suspicion of pancreatic malignancy was excluded through follow-up investigations. Biliary type II sphincter of Oddi dysfunction was diagnosed with an association of the double-duct sign. Sphincterotomy was performed to reduce pain, and there was no recurrence of symptoms during follow-up. CONCLUSIONS: This is the third reported case in the literature of the double-duct sign associated with sphincter of Oddi dysfunction. This case emphasizes that the double-duct sign is not always caused by a local malignancy. The literature review of the reported cases has been summarized to help in the diagnosis of future similar cases.

Dorsalgia tras colangiopancreatografía retrógrada endoscópica / Back pain after endoscopic retrograde cholangiopancreatography

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Post-ERCP biliary complications in patients with biliary type sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) has a high risk of post-ERCP pancreatitis. Cholangitis, colicky pain, and jaundice from cholestasis also occur after ERCP. However, these post-ERCP biliary complications have not been sufficiently evaluated in SOD. Thus, the risk factors and post-ERCP biliary complications in biliary-type SOD were evaluated. From December 1996 to January 2017, 72 patients with suspected biliary-type SOD were selected, and 60 patients who underwent ERCP were included in this study. The incidence of biliary complications compared to control group and factors associated with post-ERCP cholangitis were investigated. More frequent biliary complications, including biliary pain and abnormal liver function, occurred in SOD group than in control group, especially in type I SOD patients. Post-ERCP cholangitis occurred significantly more often with bile duct diameter ≥12 mm (26%, 5/19) than with bile duct diameter <11 mm (2.4%, 1/41; p = 0.016). Age ≥75 years was also a risk factor for post-ERCP cholangitis (p = 0.013). Multivariate analysis confirmed that bile duct diameter ≥12 mm was a significant risk factor for post-ERCP cholangitis. Post-ERCP biliary complications occurred frequently in biliary-type SOD, especially type I. Biliary diameter ≥12 mm was an important risk factor for post-ERCP cholangitis.

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.

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.

[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.

Role of endoscopic ultrasonography in the diagnosis of acute and chronic pancreatitis.

Endoscopic ultrasonography (EUS) can be a useful tool for detecting underlying causes of acute pancreatitis and establishing the severity of fibrosis in chronic pancreatitis. Ancillary techniques include fine needle aspiration and core biopsy, bile collection for crystal analysis, pancreatic function testing, and celiac plexus block. This review focuses on the role of EUS in the diagnosis of acute and chronic pancreatitis.

[Criteria of diagnostics of pancreatitis at children's age according to ultrasound research].

In the article new criteria of diagnostics of chronic and reactive pancreatitis due to sonography data are described. Among symptoms of reactive pancreatitis are as follows: presence of pancreatic edema, appearance of hyper echogenic lineal admixtures (visualization of connective tissues jumpers). Among criteria of reactive pancreatitis due to ultrasonography belong all as follows: local (59.7%) or diffuse hyper echogenic (18.8%) parenchyma comparatively to parenchyma of parotic gland, as well as small dots or triangle-like formations - marker of fibrosis. At the same time among signs of long-lasting pancreatitis these symptoms are also characteristic areas of hypoechogenic parenchyma which mimic areas of hyperechogenic structure of pancreas (44.0% of incidences). Widening of pancreatic duct like prominent symptom of chronic pancreatitis they noticed in 1/3 cases of reactive pancreatitis together with local edema of pancreas.

Low but significant yield of endosonography in patients with suspected Sphincter of Oddi Dysfunction Type III with normal imaging studies.

AIM: To determine the yield of endosonography (EUS) in patients with suspected Sphincter of Oddi Dysfunction (SOD) Type III in detecting abdominal abnormalities in those with normal upper endoscopy and imaging studies. METHODS: A retrospective review of patients with suspected SOD who underwent EUS prior to undergoing an ERCP was performed. The inclusion criteria were: 1. patients with right upper quadrant abdominal pain for >/= 3 months; 2. no evidence of abnormalities on upper endoscopy, imaging studies and laboratory tests. Exclusion criteria were: history of acute or chronic pancreatitis, pancreas divisum, jaundice or any significant abnormality detected on prior studies. The main outcome measurements were to determine the diagnostic yield of EUS to diagnose the etiology of abdominal pain and detect clinically significant lesions. RESULTS: We identified 143 patients with suspected SOD type III who had undergone EUS. A diagnosis of the etiology of abdominal pain by EUS was made in 12 of 143 patients (8%) with previously normal endoscopy and imaging studies. EUS identified the following: changes consistent with chronic pancreatitis (n=5), biliary stone (n=1), side-branch intraductal papillary mucinous neoplasms of the pancreas (n=3), benign bile duct stricture (n=1). Papillary stenosis was diagnosed in two patients with common bile duct dilation detected by EUS. CONCLUSIONS: EUS may detect significant abnormalities in a small subset of patients with suspected SOD with previous normal endoscopies and imaging studies. Although the yield of EUS is low, it should be considered in patients with persistent pain and those with a high clinical suspicion for pancreatic pathology.

Quantitative cholescintigraphy with fatty meal in the diagnosis of sphincter of Oddi dysfunction and acalculous cholecystopathy.

To evaluate the role of quantitative cholescintigraphy with fatty meal in the management of biliary dyskinesia and to describe the findings according to Sostre score (SS) criteria in patients with gallbladder (GB) in-situ and biliary pain. We performed a retrospective analysis of the hepatobiliary (HIDA) studies (n = 35) performed for evaluation of biliary dyskinesia either due to biliary pain, opioid induced sphincter of Oddi dysfunction (SOD), recurrent pancreatitis (RP) or post cholecystectomy syndrome (PCS). Gallbladder ejection fraction (GBEF) was calculated from the post fatty meal HIDA images (excluding PCS patients). Studies with GBEF ≤40 % and SS >4 were considered to have cholecystopathy and SOD respectively. Three of the 13 patients with PCS had SS of 6 each, suggestive of SOD. Delayed biliary visualization (>15 min) and activity in common bile duct 60 min > liver 15 min were the specific features in these cases. Opioid induced SOD patients had SS >4 with retrograde refilling of GB in one patient and normalization of the SS parameters after nifedipine challenge in the other patient. Patients with RP and biliary pain were stratified into four groups, normal (GBEF >40 % and SS ≤4), cholecystopathy (GBEF ≤40 % and SS ≤4), normal with SOD (GBEF >40 % and SS >4) and cholecystopathy with SOD (GBEF ≤40 % and SS >4). Four patients with intact GB had cholecystopathy with scintigraphic features of SOD. Quantitative cholescintigraphy with fatty meal and SS scoring identified biliary dyskinesia and SOD in patients with biliary pain, recurrent pancreatitis and post-cholecystectomy syndrome.

Long-term symptomatic relief following surgical sphincteroplasty for sphincter of Oddi dysfunction.

INTRODUCTION: Surgical sphincteroplasty (SS) for sphincter of Oddi dysfunction (SOD) can be performed primarily or following failed endoscopic therapy. The role of SS in an era of endoscopic management is unclear. This study presents long-term follow-up of patients who had undergone SS at a tertiary referral unit. METHODS: Patients were identified from a departmental database and sent post-operative questionnaires to review pain scores and satisfaction with the procedure. Indications, pre-operative interventions and complications were recorded. RESULTS: Seventeen patients underwent SS over 13 years. Thirteen patients had objective features of biliary obstruction (delayed excretion of isotope or elevated sphincter pressures). The positive predictive value, sensitivity and specificity of morphine 99mTc-TBIDA in this series was 100, 100 and 92%, respectively. There were 12 responders of whom all but one had symptomatic improvement. Median follow-up was 5.1 years. Pain was significantly lower following SS (16 ± 9 vs. 67 ± 11; p = 0.003) and median satisfaction with the procedure was high (95%). CONCLUSIONS: Excellent symptomatic pain relief following SS can be achieved in carefully selected patients. Manometry does not appear to be essential for diagnosing SOD and morphine provocation hepatic scintigraphy was used to reliably identify patients who would benefit from SS.

Biliary fascioliasis mimicking sphincter of Oddi dysfunction.

Fasciola hepatica, a liver fluke of livestock, rarely presents as chronic biliary tract infection in humans. We report a 38-year-old woman from Ethiopia who presented with right upper quadrant pain and a dilated common bile duct on ultrasound and magnetic resonance cholangiopancreatography (MRCP) without other abnormalities. She was suspected to have type II sphincter of Oddi dysfunction. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and had a fluke, diagnosed as Fasciola hepatica, in the common hepatic duct. This report confirms the diagnostic and therapeutic role of ERCP in the management of biliary fascioliasis, and highlights the need to include fascioliasis in the differential diagnosis of biliary pain in patients emigrating from areas where this infection is endemic.

Sphincter of Oddi dysfunction in hypercholesterolemic rabbits.

BACKGROUND AND OBJECTIVES: The mechanisms that trigger gallbladder evacuation dysfunction, the key risk factor for gallstone formation, have not yet been fully elucidated. The sphincter of Oddi (SO) plays important roles in the regulation of gallbladder evacuation and maintenance of normal hydraulic pressure of the biliary tract. The aim of our study was to investigate the effects of hypercholesterolemia on the motility function of SO and the underlying mechanisms of SO dysfunction (SOD). METHODS: Forty New Zealand white rabbits were divided randomly into the control group fed with standard chow and the experimental (Ch) group fed with a high-cholesterol diet for 8 weeks. Changes in the maximal gallbladder emptying rate, gallbladder evacuation with cholecystokinin-octapeptide (CCK-8) stimulation and SO functions of both groups were measured in vivo; B ultrasound examination was used for dynamic observation of peristaltic movements in vivo; SO pressure was measured using manometry; morphological characteristics were observed by electronic microscope; laser scanning confocal fluorescence microscopy was used to identify changes in [Ca]i and Ca oscillation in primary SO smooth muscle cells (SMCs). RESULTS: Gallbladder cholestasis was observed during early stages of gallstone formation in Ch rabbits. CCK-8 could not improve the gallbladder cholestatic state in Ch group. Passive dilation of SO significantly improved the cholestatic state in Ch rabbits (P<0.05), although the maximal gallbladder emptying rate was still lower than that of the control group. Manometry data indicted a significant increase in the base pressure of the SO low-pressure ampulla segment and high-pressure segment (P<0.05) in Ch group. laser scanning confocal fluorescence microscopy assay data indicated that [Ca]i in SO cells of Ch group significantly increased and were in a state of overload (P<0.05); Ca oscillation signals in SO cells of Ch group were also abnormal. CONCLUSION: Hypercholesterolemia initially induced SOD, leading to increased gallbladder evacuation resistance and cholestasis. We suggested that [Ca]i overload and/or Ca oscillation abnormality potentially play important roles in the pathogenesis of SOD.

[Diagnosis and endoscopic treatment of stenosing papillitis].

The results of endoscopic papillosphincterotomy (EPST), performed in 2000-2008 yrs in 462 patients for stenosing papillitis, were analyzed. Typical EPST was performed in 166 (35.9%) patients and atypical one--in 296 (64.1%). Complications after performance of typical EPST had occurred in 9 (5.4%) patients and after atypical one--in 12 (4.1%). All the patients are alive.

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.

ERCP in acute pancreatitis.

BACKGROUND: The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute pancreatitis has evolved over years since its introduction in 1968. Its importance in diagnosing the etiology of pancreatitis has steadily declined with the advent of less invasive diagnostic tools. The therapeutic implications of ERCP in acute pancreatitis are many fold and are directed towards management of known etiological factors or its related complications. This article highlights the current status of ERCP in acute pancreatitis. DATA SOURCES: An English literature search using PubMed database was conducted on ERCP in acute pancreatitis, the etiologies and complications of pancreatitis amenable to endotherapy and other related subjects, which were reviewed. RESULTS: ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations, pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. In recurrent acute pancreatitis and smoldering pancreatitis it has a definite therapeutic utility. Complications of acute pancreatitis including pancreatic-duct disruptions or leaks, benign pancreatic-fluid collections and pancreatic necrosis can be beneficially dealt with. Intraductal ultrasound and pancreatoscopy during ERCP are useful in detecting pancreatic malignancy. CONCLUSIONS: The role of ERCP in acute pancreatitis is predominantly therapeutic and occasionally diagnostic. Its role in the management continues to evolve and advanced invasive procedures should be undertaken only in centers dedicated to pancreatic care.

Postcholecystectomy sphincter of oddi dyskinesia--a diagnostic dilemma--role of noninvasive nuclear and invasive manometric and endoscopic aspects.

BACKGROUND: Persistent abdominal pain after cholecystectomy is not uncommon. Sphincter of oddi dysfunction (SOD) is one of the causes for this entity. However, diagnosing SOD is often difficult. Sphincter of oddi manometry (SOM) is the gold standard. Because it is invasive and needs experienced person to perform, simple noninvasive imaging techniques are needed. Other invasive endoscopic methods also play an important role in difficult cases and before therapeutic intervention. METHODS: Retrospective review of the charts of postcholecystectomy patients who presented with persistent abdominal pain and underwent quantitative hepatobiliary studies (QHBS) as per Sostre et al scoring protocol and simultaneous endoscopic retrograde cholangiopancreatography (ERCP) with SOM between 2003 and 2004. Additional 6 studies with SOM data that had routine nonscoring hepatobiliary study (HBS) were later identified and were included in the study. RESULTS: A total of 24 HBS studies (22 patients) were identified, 19 performed with scoring (Sostre) and 5 with nonscoring methods. ERCP results were available for 16 patients. SOM results were available for 10 patients. Of the 19 who had Sostre's QHBS, 3 were positive and 16 were negative. All 3 QHBS positive patents also had ERCP with SOM findings of SOD. Of the 16 negative Sostre's QHBS, 8 had ERCP with SOM of which 6 had SOD, 1 had no SOD, and 1 was inconclusive. Eight patients who had negative QHBS/ HBS did not undergo further invasive gastrointestinal procedures and were followed conservatively. The rest of 5 patients with negative HBS had ERCP with SOM findings of biliary and pancreatic SOD. CONCLUSIONS: From our limited retrospective review, when QHBS by Sostre's is positive there is good correlation to ERCP with SOM. When negative, the agreement with ERCP with SOM is less. However, correlation of Sostre's QHBS is slightly better than nonscoring HBS. Hence, QHBS by Sostre protocol is a simple, noninvasive, and easy to use initial procedure in the management of postcholecystectomy pain syndromes and when positive can guide the gastrointestinal physicians to proceed to invasive ERCP with SOM with confidence.