Pancreatitis recurrente por disquinesia hipertónica del esfínter de oddi: tratamiento endoscópico y seguimiento a largo plazo en un caso clínico / Recurrent pancreatitis caused by oddi sphincter’s hypertonic dyskinesia: case report of endoscopic treatment and long-term follow-up

It is frequently difficult to determine the exact cause of recurrent acute pancreatitis (RAP), which can be life threatening in several cases. Not detected biliary microlithiasis is the most frequent etiology, buthypertonic dyskinesis of Oddi’s sphincter also can cause RAP. Non-invasive diagnosis of this functional disorder is difficult, endoscopic manometry of Oddi’s sphincter allows measuring pressure in the choledochus,in the pancreatic duct and specifically in the sphincter region. Once hypertonic dyskinesis is demonstrated, the treatment option is the partial or total ablation of the sphincter, via endoscopic or surgical methods. This intervention results in an improvement or complete resolution in about 70 percent of the patients, preventing new bouts of acute pancreatitis and eventual progression to chronic disease. In this paper, we describe the history of one of our patients, who consulted more than ten years after cholecystectomy for recurrent abdominal pain and presented three episodes of acute pancreatitis. Endoscopic manometry of Oddi’s sphincter was performed in 1997, with the detection of very high pressure in biliary and pancreatic segments of the sphincter, demonstrating hypertonic dyskinesis involving both segments. A dual endoscopic sphincterotomy was performed, followed by marked reduction in the pressure of biliopancreatic ducts and Oddi’s sphincter and in abolition of choledocho-duodenal and pancreatic-duodenal gradient. She was asymptomatic till 2002, later on, she required endoscopic pneumatic dilatation of the sphincterotomy. She had no more acute pancreatitis episodes and CT scan in 2014 showed a normal pancreas.

Con frecuencia resulta difícil determinar la etiología de la pancreatitis aguda recurrente (PAR), que puede amenazar hasta la vida del paciente. Aparte de la patología litiásica biliar no diagnosticada, la disquinesia hipertónica del esfínter de Oddi (EO) causa con cierta frecuencia PAR. Su diagnóstico no invasivo es difícil, la manometría del esfínter de Oddi permite medir los valores de la presión en la vía biliar, en el conducto pancreático y en la región del esfínter. Una vez que la disquinesia hipertónica se demuestra, su tratamiento es la ablación parcial o total del esfínter, con método endoscópico o quirúrgico, con resolución del cuadro clínico en aproximadamente 70 por ciento de los pacientes, logrando evitar los nuevos brotes de pancreatitis aguda (PA) y la eventual progresión hacia pancreatitis crónica. En este trabajo describimos la historia de una paciente colecistectomizada, quien después de varios años de dolor abdominal recurrente, presentó tres brotes de PA. Manometría de EO fue realizada en 1997, detectando presiones muy elevadas, comprobando disquinesia hipertónica de los segmentos biliar y pancreático del esfínter. Se realizó esfinterotomía endoscópica doble, seguida por gran disminución de los valores de presión, abolición del gradiente colédoco-duodenal y pancreático-duodenal. Estuvo asintomática hasta el 2002, y posteriormente requirió dilatación neumática de los orificios de esfinterotomías. No ha tenido más recaídas de pancreatitis, la tomografía computada de control en noviembre de 2014 mostró un páncreas normal.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5 percent). Sphincter of Oddi dysfunction was found in 18/71 patients (25 percent). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

RACIONAL: Manometria do esfíncter de Oddi é o método padrão-ouro para o diagnóstico da disfunção do esfíncter de Oddi. Atualmente, a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica é desconhecida. OBJETIVOS: Avaliar prospectivamente a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica e estudar a segurança da manometria do esfíncter de Oddi nesses pacientes. MÉTODO: Neste estudo, 110 pacientes encaminhados à colangiopancreatografia retrógrada endoscópica foram submetidos a manometria do esfíncter de Oddi biliar. Com base no número de tentativas de canulação da papila os pacientes foram divididos em dois grupos: até cinco tentativas (canulação fácil) e mais de cinco tentativas (canulação difícil). RESULTADOS: Manometria do esfíncter de Oddi foi realizada com sucesso em 71/110 pacientes (64,5 por cento). Disfunção do esfíncter de Oddi foi encontrada em 18/71 pacientes (25 por cento). Os achados das colangiopancreatografia retrógrada endoscópica foram: estudo normal em 16, coledocolitíase em 39, estenose biliar maligna em 9 e estenose biliar benigna em 7. Não foi observada diferença estatística na prevalência de disfunção do esfíncter de Oddi considerando-se a natureza da doença, sexo ou a dificuldade de canulação. Somente 2/71 pacientes evoluíram com pancreatite pós-procedimento de leve intensidade. CONCLUSÃO: Encontrou-se alta prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica. Sexo, natureza da doença ou dificuldade de canulação não mostraram influência na prevalência da disfunção nestes pacientes. Manometria do esfíncter de Oddi mostrou-se um procedimento seguro na pesquisa de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica.

Percutaneous Transhepatic Biliary Manometry / 대한소화기학회지

Perendoscopic biliary manometry may not represent the overall sphincter of Oddi (SO) motility, as the recording time is relatively short and it is possibly influenced by the presence of an endoscope in duodenum and air inflation. Percutaneous transhepatic biliary manometry of SO permits long-term recordings without patient discomfort and risk of complications. We investigated the change of human SO motility and the correlation between SO motility and migrating motor complex (MMC) of the small bowel in a fasting state by long-term simultaneous manometric examination of SO and small bowel. During long-term manometry, MMC-like cyclic activities of SO were observed, which consiered to be MMC of SO. It coordinated well with MMC of the small bowel, except that SO was not quiescent during phase I MMC of the small bowel. In addition, the basal pressure of SO changed in accordance with the phases of SO motility. Percutaneous transhepatic biliary manometry also permits prolonged manometric studies to investigate normal physiologic reflexes such as gastroduodeno-sphincteric, cholecysto-sphincteric and choledocho-sphincteric reflexes, and the influence of cholecystectomy on SO motility in humans.

The effects of cholecystojejunostomy and biliary drainage on biliary motor / 华中科技大学学报（医学）（英德文版）

Simulating physiological neuronal and hormonal conditions during digestive and interdigestive periods, the study identified the changes of the motility of biliary system including bile duct and sphincter of Oddi (SO) before and after cholecystojejunostomy. Thirty-five rabbits were divided into five groups randomly. The experimental groups received the venous injection of CCK 10 ng/kg, erythromycin 10 mg/kg, atropine 3 micrograms/kg and L-NAME 10 mg/kg respectively. Each rabbit underwent manometry through introducing a three-lumen catheter via the papilla retrogradely, using the low-compliance papillary infusion system. Then the gallbladder and the upper segment of the jejunum was anastomosed and the manometric procedures repeated after one week. SO basal pressure was increased, contraction amplitude decreased, contraction time shortened after cholecystojejunostomy. L-NAME, CCK and erythromycin could all excite SO. L-NAME could increase basal pressure and contraction amplitude, CCK increase basal pressure contraction amplitude and frequency, and erythromycin increase contraction amplitude, respectively. But comparing with that before cholecystojejunostomy, the increasing extent was decreased. The tensional and spontaneous contractions of the SO were under the control of the neural and hormonal mechanism. The anastomosis of gallbladder and jejunum and the drainage of bile made the tensional contraction stronger, but the spontaneous contraction weakened after the operation due to the decreases of the sensitivity of SO to hormonal factors. The clinical symptoms may not be relieved when the patients with SO dysfunction accepted cholecystojejunostomy.

Effect of cholecystectomy on sphincter of oddi motility in dogs

Gallbladder and sphincter of Oddi [SO] function are controlled by a balance of both hormonal and neuronal factors. Neuronal connections pass between the gallbladder and the SO via the cystic duct. It is therefore possible that cholecystectomy may alter SO motility. The present study investigated the effect of cholecystectomy on SO function in anesthetized dogs. Biliary manometry was performed in a group of anesthetized dogs undergoing cholecystectomy and compared with a control group of matched weight and sex. The cholecystectomized dogs compared with the controls showed a significant increase in mean common bile duct [CBD] pressure together with a significant decrease in mean basal SO pressure and SO phasic frequency. There was also a significant increase in the duration of phasic contractions in the cholecystectomy group compared with the control group. No significant change was noticed in the amplitude of phasic contractions and in the duodenal pressure when comparing both groups. These findings show that the gallbladder serves as a reservoir dampening increases in common duct pressure. The increase in intraductal tension following cholecystectomy in the canine model could overcome the choledochoduodenal sphincter resistance resulting in a drop in SO basal pressure associated with a decrease in the frequency of phasic contractions. It is also possible that ductal distension inhibits SO function by local reflexes. Removal of the gallbladder itself may eliminate a significant component of the neural circuity modulating biliary function. Such effects may ultimately lead to the SO manometric abnormalities, which have been described for SO dysfunction

Sphincter of Oddi manometry in various biliary diseases: a report in 20 Thai patients.

This is the first report of sphincter of Oddi manometry study in 20 Thai patients with various biliary diseases. The yield of abnormal SOM in 3 of 17 in our study was low and was comparable to other reports. The successful rate of 85 per cent and complication rate were acceptable. Careful clinical assessment is mandatory before SOM study in order to gain the best benefit and minimize the risk of SOM.

Manometría endoscópica del esfínter de Oddi / Endoscopic manometry of sphincter of Oddi

Background: Endoscopic manometry is the gold standard for the diagnosis of sphincter of Oddi dysfunction. Aim: To report the result of the first 30 endoscopic manometries of sphincter of Oddi performed in a Gastroenterology Service. Patients and methods: Thirty manometries were performed in 28 patients aged 30 to 70 years old (14 females). The papilla was cannulated with a perfused catherter, measuring pressure with external transducers. Results: Deep cannulation of the papilla was achieved in 88 por ciento. Procedure-related complications were not observed in these cases. Normal values were registered in 11 cases with a basal sphincter pressure 15.6ñ10.7 mm Hg, contractions with an amplitude of 92.3ñ35.7 mm Hg and 6.0ñ2.4/ min frequency. The clinical suspicion suspicion of hypertonic dyskinesis was confirmed in 5 cases with an elevated basal pressure of 43.69ñ13.3 mm Hg, an increased frequency of contractions ("tachyoddia") in one, and large spastic contractions of high pressure in other case. In 3 of 5 cases with common bile duct stones, a predominance of retrograde propagation of the contractions was observed with normal pressure. Variable manometric results were observed after endoscopic papillotomy observing a scale from the complete absence of motor activity to normal aphincter function. Conclusions: Endoscopic manometry is a reasonably safe method, of great importance in the diagnosis of fuctional disorders of the sphincter of Oddi

Manometría endoscópica biliar y del esfínter de Oddi / Endoscopic biliary and Oddi's sphincter manometry

Se reportan hallazgos de motilidad del esfínter de Oddi obtenidos en 5 pacientes sometidos a manometría biliar y del esfínter de Oddi. Se trata de 4 mujeres y 1 hombre que fueron referidos a CPRE por sintomatología de la esfera biliopancreática y cuya colangiografía posterior fue normal. Se realizó una duodenoscopía convencional con un equipo Olimpus JFT-20, canulación de la papila de Vater con una sonda BMC-I-93100 Cook la que fue perfundida en forma constante mediante un sistema de infusión neumohidráulico capilar. Una vez en colédoco se efectuó retiro de la sonda con técnica de retirada estacionaria a 2 mm cada 5 segundos. Así se valoró la presión de reposo, longitud y morfología del esfínter y las presiones intraduodenal e intracoledociana. Posteriormente se efectuó una nueva canulación papilar y se localizó la sonda de registro en medio del esfínter. De esta forma se analizó la amplitud y frecuencia de contracciones por minuto. Se constataron las siguientes presiones: intraduodenal=2,4 mmHg, intracoledociana=7,4 mmHg, del esfínter en reposo=14,5 mmHg. Longitud esfinteriana=4,2 mm. Amplitud=100,2 mmHg, duración=4,5 s y 3,3 contracciones por minuto

Manometría directa del esfínter de Oddi: un modelo experimental / Direct manometry of the Oddi's sphincter: experimental model

la evaluación intraoperatoria de las vías biliares es uno de los aspectos que más preocupa al cirujano cuando realiza procedimientos sobre esa área. En el presente trabajo se propone y prueba un modelo experimental de medición directa de la presión del esfínter de Oddi utilizando un catéter con balón inflable, conectado a un transductor. Se utilizaron un total de 5 perros, a los cuales se les realizó cilecistectomía y manometría directa con balón inflable, obteniendo resultados similares a los obtenidos por otros autores con métodos más laboriosos

Función inadecuada del esfinter de ODDI: Tratamiento endoscópico y evaluación a largo plazo / Inadequate function of Oddi-s sphincter. Endoscopic treatment and long term follow up

El síndrome de función inadecuada de esfinter de Oddi, es una entidad clínica de difícil diagnóstico y tratamiento controvertido. El diagnóstico se sospecha con bases clínicas, bioquímicas, ultrasonográficas y endoscópica, pero se corrobora solamente con la manometría. Estudiamos a 35 pacientes, 23 mujeres y 12 hombres con edad promedio de 56.4 años. Todos tenian antecedentes de colecistectomía y continuaban con dolor similar, 33 tenían elevación de la fosfatasa alcalina, en todos se demostro dilatación de la vía biliar mayor a 12 mm y retardo en el vaciamiento del medio de contraste mayor a 45 minutos. La manometría demostró presión elevada de esfinter de Oddi mayor a 30 mmHg. En todos los casos realizamos una esfinterotomía endoscópica amplia sin complicaciones. Hicimos evaluación clínica, bioquímica y endoscópica cada 3 meses durante el primer año y cada 6 meses durante el segundo y tercer año. Treinta y un pacientes (89.6

Disfuncoes do esfincter de Oddi / Oddi's sphincter dysfunction

Desde a primeira descricao de uma estrutura esfincteriana no ducto biliar terminal, em 1681, por Glisson, inumeras publicacoes contribuiram para melhor compreensao da funcao do esfincter de Oddi. Estudos manometricos do esfincter de Oddi abriram novas perspectivas para redefinicao de velhos conceitos como a discinesia biliar e a sindrome pos-colecistectomia, e permitiram uma avaliacao mais racional dos resultados obtidos apos esfincterotomia. Os autores realizaram revisao da literatura no que se refere aos aspectos fisiologicos, farmacologicos, diagnosticos e terapeuticos das disfuncoes do esfincter de Oddi.

Valoración de la esfinteropapilotomia endoscopica (EPE) mediante radiocolangiodebitometria operatoria (RCDM)

Con resultados iniciales de un estudio prospectivo, 5 pacientes con descompresión mediante EPE y posterior cirugía a cielo abierto complementaria son evaluados por RCDM seriada, con débito x = 18.6 cc/minuto ñ 2.3 (V.N. > ou =), el análisis comparativo con 24 EPDT amplios a cielo abierto demuestra comportamientos debitométricos similares (x = 18.3 ñ 2.0 cc/minuto). Se realizan algunas consideraçciones fisiopatológicas de acuerdo a las curvas evolutivas promedio, a verificar con muestras más amplias

Physiopathological evaluation of the sphincter of Oddi

Recentemente, a colangiografia com radioisótopos, a eletromiografia e a manometria endoscópica com o emprego de um cateter de infusäo ou com um microtransdutor têm sido utilizados na avaliaçäo do esfíncter de Oddi. A eletromiografia do esfíncter de Oddi associada à cineradiografia e fluxometria confirmaram que o esfíncter de Oddi do opossum apresenta contraçöes peristáticas e funciona como um aparelho ejaculador. Apesar do mecanismo de fluxo biliar através do esfíncter de Oddi no homem ainda ser controvertido, vários estudos de manometria endoscópica sugerem que o esfíncter de Oddi do homem pode também funcionar como uma bomba. A elevaçäo da pressäo basal do esfíncter de Oddi é a alteraçäo mais comum observada durante a manometria endoscópica de pacientes com estenose papilar e alteraçöes funcionais do esfíncter de Oddi. O valor do teste da morfina-prostigmina no diagnóstico da estenose papilar é controvertido

Radiomanometría transoperatoria de vías biliares / Transoperative radiomanometry of the bile ducts

La radiomanometría (RM) puesta en boga por su autor Jean Caroli desde 1941 en Francia, ha sido poco utilizada fuera de Europa y en pocas ocasiones en México. En el Hospital de Especialidades del I.M.S.S. en Puebla se practica por el autor desde Enero de 1980 usando el aparato de Caroli-Fourés. Fueron documentados 98 resgistros operatorios hasta Julio de 1982, su análisis constituye el contenido de este trabajo. La presión inicial (PI) promdedio (X) fue de 3.58 con una desviación estándar (DE) de ñ 2.72,la presión de paso (PP) necesaria para franquear el esfínter de Oddi X 11.6 y DE ñ 3.97 y la presión residual (PR) resultante de la presión del líquido perfundido y la resistencia del mismo esfínter X 9.68 DE ñ 4.05, consitituyen la parte manométrica del estudio, que se efectua en 7 u 8 minutos. Simultáneamente tres placas radiográficas son impresas para correlacionar ambos procedimientos. Todos los pacientes fueron seguidos por espacio de un mes, mínimo de dos consultas. El estudio fue practicado en 11 pacientes en fase aguda, en quince litiasis de la vía biliar VB, 10 de los cuales no se habían sospechado en el preoperatorio. Se descubrieron tres alteraciones del esfínter del Oddi (Oddipatias) en dos de ellas la RM permitió decidir la esfinteroplastia. Los resultados obtenidos en las cifras, se aproximan bastante a lo informado en la literatura. El aumento de la PR se asoció siempre con alteraciones de la VB. La mortalidad operatoria y hospitalaria fue del 0% y solo hubo tres complicaciones no relacionadas con el procedimiento. Un modelo presonal es presentado, fácil de construir y posiblemente con la misma aplicación que el radiomanómetro francés. La RM es un procedimiento accesible en el transoperatorio para el diagnóstico de las lesiones asociadas de la VB principal en la colecistectomía y para la toma de decisión quirúrgica