The influence of variable-stiffness guide wires on basal biliary sphincter of Oddi pressure measured at endoscopic retrograde cholangiopancreatography.

BACKGROUND: Guide wires are commonly utilized to facilitate endoscopic procedures. However, their use may adversely influence the results of sphincter of Oddi manometry, thereby leading to erroneous diagnosis and therapy. The aim of this study was to evaluate the effect of guide wires on the basal pressure of the biliary sphincter of Oddi. METHODS: Forty-five consecutive patients with suspected sphincter of Oddi dysfunction were enrolled. Biliary sphincter of Oddi manometry was performed with and without a guide wire in the conventional retrograde fashion with a low-compliance infusion pump system, an aspirating catheter, and slow station pull-throughs. Three types of guide wires were studied: the Roadrunner (18 patients), the Glidewire (17 patients), and the standard Teflon guide wire (10 patients). The stiffness of the guide wires was tested and reported in Taber Stiffness Units (TSU; higher values represent greater stiffness). RESULTS: Biliary sphincter of Oddi manometry performed with a guide wire revealed higher basal pressure than the same measurement performed without a guide wire (52 +/- 33.4 mmHg vs. 34.4 +/- 20.5 mmHg; P = 0.001). Basal pressure changes induced by guide-wire use were highest in the Roadrunner group (32.9 +/- 33.9 mmHg), lowest in the standard Teflon group (11.6 +/- 8 mmHg; Roadrunner vs. standard Teflon: P = 0.02), and intermediate in the Glidewire group (17.1 +/- 22.1 mmHg). The use of a guide wire resulted in crossover from normal to abnormal basal pressure in 11 cases (Roadrunner, 7; Glidewire, 4) and from abnormal to normal in 2 (Roadrunner, 1; Glidewire, 1). Concordance between recordings obtained with and without guide wire was seen in 32 patients (71 %). Guide-wire stiffness was: Roadrunner: 0.74 TSU; Glidewire: 0.153 TSU; standard Teflon guide wire: 0.077 TSU. CONCLUSION: The use of guide wires frequently alters the basal biliary sphincter pressure, leading to incorrect diagnoses in approximately 40 % of cases. The basal pressure alterations depend on the stiffness of the guide wire used. Hence, the use of guide wires during sphincter of Oddi manometry is strongly discouraged.

[Sphincter of Oddi motility disturbances--etiologic factor or the consequence of choledocholithiasis]. / Zaburzenia motoryki zwieracza Oddiego--czynnik etiologiczny czy skutek przewodowej kamicy zólciowej.

UNLABELLED: Choledocholithiasis is often found in patients after cholecystectomy done previously for cholelithiasis. AIM: To evaluate the effects of cholecystectomy and common bile stones' presence on sphincter of Oddi (SO) motility. MATERIAL: 13 patients with common bile duct stones (2 men and 11 women, age 54 to 85 yrs) were studied. They were divided in two groups: A--6 pts age 54 to 85 yrs (with biliary lithiasis) and group B of 7 pts age 55-71 after cholecystectomy. Cholecystectomized group was further divided into 2 groups according to administration (B1 group) or not (B2) a premedication. METHOD: Sphincter of Oddi manometry was done in all patients as the part of routine ERCP. A water-perfused, low-compliance, triple-lumen manometric system (Synectics Medical Sweden) was used to record the SO tonic and phasic activity. Common bile duct (CBD) pressure, basal SO pressure, SO phasic contractions frequency, duration and amplitude as well as direction of propagation peristaltic waves, motility index (MI) and AuC (area under curve) were measured. RESULTS: The CBD pressure, the basal SO pressure and the frequency of phasic SO waves tended to be lower in patients after cholecystectomy (p > 0.05). We observed profound changes in the motility pattern of SO phasic activity. There was significantly less anterograde and more retrograde waves in patients from group B than A (18.9% vs. 68.8%; p < 0.01 and 52.4% vs. 10.4% respectively; p = 0.01). In the group B1 comparing with group B2 we found significant decrease of frequency (1.8/min +/- 0.53 vs. 3.3/min +/- 0.77; p < 0.05) and increase of the mean amplitude of phasic SO activity (223.2 mmHg +/- 22.9 vs. 137.3 mmHg +/- 25.0; p < 0.01). The duration of pressure waves was prolonged (with long "plateau" or multipeaked) with rapid pressure increase, what resulted in high AuC index (1155.61 +/- 100.42 vs. 515.23 +/- 210.9; p < 0.01). However no difference in MI was observed. CONCLUSION: Our results confirm hypothesis that cholecystectomy influences the pattern of phasic SO motility. Moreover increased percent of retrograde propagation of SO phasic contractions probably contributes to subsequent common duct stones development rather than being the consequences of their presence.

Immediate effects of endoscopic sphincterotomy on sphincter of Oddi motility.

The evidence exists that incomplete sphincterotomy in patients with biliary tract diseases may result in early symptoms reoccurrence or lack of improvement. Sphincter of Oddi manometry (SOM) can be used to verify the completeness of the procedure. The purpose of the study was to investigate the immediate effects of biliary endoscopic sphincterotomy (BES) and common bile duct stones (CBDS) clearance on biliary sphincter of Oddi (SO) motility. Moreover the percentage of incomplete sphincterotomies was estimated. 26 patients (6 male, 20 female, 24-93 years) with confirmed choledocholithiasis were investigated. All underwent BES followed by CBDS extraction, and then SO manometry (SOM) was performed. Moreover 6 patients underwent SOM prior to BES. SOM was performed with a triple lumen 5 Fr catheter attached to the water perfused low compliance system. Immediately after sphincterotomy and extraction of the CBDS common bile duct pressure dropped from a mean of 10.9 mmHg to 2.9 mmHg (p < 0.05). Similarly basal biliary sphincter pressure decreased from 22.7 mmHg to 7.3 mmHg (p < 0.05). 20 patients presented duodeno-choledochal gradient of less than 5 mmHg. However only 10 patients had also basal sphincter pressure lower than 5 mmHg. The phasic sphincter activity was abolished in 16 patients, whereas phasic contractions persisted in 10 patients. Seven patients displayed uncoordinated, low amplitude contractility. BES significantly decreases SO and CBD pressures, but when performed for CBDS extraction, commonly does not abolish SO motor activity nor ablate choledocho-duodenal gradient. Therefore to confirm the completeness of sphincterotomy, SO manometry is recommended.

[Disturbances of the autonomic nervous system in gastroesophageal reflux disease]. / Zaburzenia ukladu autonomicznego w chorobie refluksowej przelyku.

GERD (Gastroesophageal Reflux Disease) is a common clinical problem, which affects the upper part of the gastrointestinal tract. The pathophysiology of GERD is associated with dysfunction of the various mechanisms called "the anti-reflux barrier". Lately, the disturbances of the autonomic nervous system (ANS) have been stressed in the pathogenesis of the different diseases (including GERD). The HRV examination (Heart Rate Variability) seems to be the best non-invasive method to evaluate the disturbances of ANS. The aim of our study was to detect possible ANS disturbances in GERD patients. 23 persons (healthy volunteers and GERD patients) took part in the examinations. 24-h-esophageal pH-metry and the resting, "deep breathing" (DB) test, as a short-term measurement of heart rate variability, were performed in every person. The results proved that the GERD patients have abnormal low values of the basic components that make up the HRV spectrum (LF and HF obtained from rest record and HF from record during DB). We demonstrated the evidence of functional ANS disturbances, which may be responsible for the changing the HRV parameters of the frequency domain analysis in GERD patients. The disturbances mentioned above are supposed to influence the normal modulation of the X (vagus) nerve, which plays an important role in the maintaining the physiological LES function.

Helicobacter pylori infection in pathogenesis of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) refers to the very common and constantly increasing conditions where reflux of gastric contents into the esophagus leads to development of characteristic symptoms. The esophagus, LES and stomach can be envisioned as single functional unit controlled by neuro-hormonal factors. The abnormalities that contribute to GERD can start in any component of this unit, resulting particularly from disturbances in their control system. It is extremely important to identify factors and mechanisms leading to functional failure of this system so that causative therapy can be effectively applied. The key-role has been attributed to parasympathetic dysfunction, which may adversely affect motor activity of this area by increasing transient LES relaxation number and impairing LES pressure, esophageal acid clearance and motility of the proximal stomach. Recently, numerous investigations have been performed to elucidate the role of Helicobacter pylori (Hp) infection in GERD pathogenesis with the most concern given to its potency to increase gastric acid secretion. However, it appeared that this infection leads to much more complex changes in gastric mucosa including modification of afferent neural signals and specific gastric hormones release. Plasma ghrelin level is low in subjects infected and increases significantly after eradication. Since ghrelin, beside potency to increase gastric secretion has strong prokinetic action on LES functional unit, this phenomenon together with impaired vagal control may contribute to the Hp infection or eradication - related GERD development. Thus, ghrelin and vagal activity could be the missing links that partially explains relationship between GERD and Hp infection.

Influence of cholangiography on biliary sphincter of Oddi manometric parameters.

BACKGROUND: When sphincter of Oddi manometry (SOM) and endoscopic retrograde cholangiopancreatography are performed at the same session, SOM is usually performed immediately before ductography because of concern about the accuracy of the manometric recording after contrast medium injection. However, it would be preferable to inject contrast medium first to identify other causes for a patient's symptoms, allowing selective use of SOM. The aim of this study was to evaluate the effect of cholangiography on sphincter of Oddi (SO) basal pressure. METHODS: Twenty-five patients with suspected SO dysfunction were prospectively studied. Conventional station pull-through manometry of the biliary part of the sphincter was performed before and after cholangiography. The intraductal pressure and basal sphincter pressure were evaluated. RESULTS: The mean intraductal pressure was 8+/-5.5 mm Hg before and 13.3+/-6.8 mm Hg after contrast medium injection (p< 0.01). However, the basal sphincter pressure was not significantly altered (52.9+/-42.1 mm Hg vs. 55.1+/-38.1 mm Hg, p = 0.52). Concordance (normal vs. abnormal) between the basal sphincter pressure before and after ductography was seen in 24 of 25 patients (96%). CONCLUSIONS: Intraductal installation of contrast medium immediately before SOM infrequently alters SO basal pressure in a clinically significant manner. We therefore believe that this sequence can be utilized in clinical practice.