Endoscopic Papillary Balloon Dilation/Endoscopic Papillary Large Balloon Dilation / 대한췌담도학회지

Endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) have been performed all around the world over several decades for the treatment of common bile duct stone. EPBD using small dilation balloon catheter can preserve sphincter of Oddi function and reduce the recurrence rate of bile duct stone compared to endoscopic sphincterotomy (EST). EPBD is a procedure with low risk of bleeding, which is appropriate for patients with coagulopathy, hepatic cirrhosis, end-stage of renal disease, and surgically altered anatomy such as Billroth II gastrectomy and periampullary diverticulum. However, it has a higher risk of postprocedure pancreatitis than EST. EPLBD using large balloon catheter (12 mm or more of diameter) is proper for more than 10 mm of common bile duct stone. The advantages of EPLBD are reduced need for mechanical lithotripsy with decreased procedure time and radiation exposure time irrespective of the precedence of EST. EPLBD also requires fewer endoscopic retrograde cholangiopancreatography sessions and is more cost-effective. The incidence of post-procedure pancreatitis is lower in EPLBD than EST. If EPBD and EPLBD are done under the guidelines, these would be safe and effective and may be alternatives to EST for common bile duct stone.

Evaluation of Recurrent or Idiopathic Pancreatitis / 대한췌담도학회지

Recurrent acute pancreatitis (RAP) is defined as two or more true episodes of acute pancreatitis and about 20% of patients with acute pancreatitis experience at least one episode of recurrence. In about 10% of RAP, no definite etiology is found despite extensive evaluation. This entity is called idiopathic acute pancreatitis (IAP). Toxic-metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, obstructive (TIGAR-O) classification is commonly used to identify risk factors for RAP. Modalities employed to find causes of RAP and IAP include meticulous history taking, blood tests, diagnostic imaging, genetic testing, bile crystal analysis, endoscopic ultrasonography, and endoscopic retrograde cholangiopancreatography with/without sphincter of Oddi manometry. Each modality is briefly reviewed in this review.

Understanding the Biliary Dyspepsia / 대한췌담도학회지

Functional dyspepsia is a very common disease and there are two types of dyspepsia. One is functional dyspepsia in the gastrointestinal tract and the other is pancreatobiliary dyspepsia. Biliary dyspepsia is caused by biliary tract disease and can even cause biliary pain. Acalculous biliary pain (ABP) is biliary colic without gallstones, it is caused by functional biliary disorder or structural disorders such as microlithiasis, sludges or parasitic infestation like Clonorchiasis. The endoscopic ultrasonography is helpful tool for differential diagnosis of ABP. Although sphincter of Oddi manometry (SOM) is performed for the confirmative diagnosis of sphincter of Oddi dysfunction (SOD), several non-invasive tests have been studied because of some practical limitations and invasiveness of SOM itself. In fact, the most clinically used easy test to diagnose functional biliary disorder is quantitative hepatobiliary scintigraphy and it can distinguish gallbladder dyskinesia, SOD, or combined type. Initial treatment of functional biliary disorder is adequate dietary control and medication, but if the symptoms worsened or recurred frequently, laparoscopic cholecystectomy could be performed with gallbladder dyskinesia. If SOD is suspected, additional SOM should be considered and endoscopic sphincterotomy (EST) can be done according to the outcome. If the SOM is not available, the patient could be diagnosed by stimulated ultrasound.

Cólico biliar inducido por morfina / Morphine induced biliary pain: case report

Morphine produces contraction of Oddi’s sphincter, which can be severe and of longer duration in some pathological conditions. This exaggerated response can manifest as a colicky biliary pain, frequently accompanied by a dramatic increase in hepatic enzymes. We report a 32 years old female who consulted in the emergency room for severe low abdominal pain of gynecologic origin, which was completely controlled by morphine. However, she presented a sudden epigastric colicky pain irradiating in the back, which persisted for several hours in spite of the repeated administration of analgesics. Transaminases elevated from previously normal value to over 1,000 U/L, and returned to the normal level without further treatment after several days. Magnetic resonance cholangiography showed normal fine bile duct, without stones. This transient increase in hepatic enzymes was considered as a consequence of high biliary pressure secondary to morphine-induced spastic contraction of Oddi’s sphincter and a consecutive hepatocellular necrosis.

Sphincter of Oddi Manometry: Reproducibility of Measurements and Effect of Sphincterotomy in the EPISOD Study

BACKGROUND/AIMS: The reproducibility of sphincter of Oddi manometry (SOM) measurements and results of SOM after sphincterotomy has not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. METHODS: The recently published Evaluating Predictors and Interventions in sphincter of Oddi dysfunction (EPISOD) study included 214 subjects with post-cholecystectomy pain, and fit the criteria of sphincter of Oddi dysfunction type III. They were randomized into 3 arms, irrespective of manometric findings: sham (no sphincterotomy), biliary sphincterotomy, and dual (biliary and pancreatic). Thirty-eight subjects had both biliary and pancreatic manometries performed twice, at baseline and at repeat endoscopic retrograde cholangiopancreatography after 1-11 months. Sham arm was examined to assess the reproducibility of manometry, and the treatment arms to assess whether the sphincterotomies were complete (elevated pressures were normalized). RESULTS: Biliary and pancreatic measurements were reproduced in 7/14 (50%) untreated subjects. All 12 patients with initially elevated biliary pressures in biliary and dual sphincterotomy groups normalized after biliary sphincterotomy. However, 2 of 8 subjects with elevated pancreatic pressures in the dual sphincterotomy group remained abnormal after pancreatic sphincterotomy. Paradoxically, normal biliary pressures became abnormal in 1 of 15 subjects after biliary sphincterotomy, and normal pancreatic pressures became abnormal in 5 of 15 patients after biliary sphincterotomy, and in 1 of 9 after pancreatic sphincterotomy. CONCLUSIONS: Our data suggest that SOM measurements are poorly reproducible, and question whether we could adequately perform pancreatic sphincterotomy.

Sphincter of Oddi Manometry: Methodological Issues in Reproducibility of Measurements

No abstract available.

Sphincter of Oddi Manometry: Methodological Issues in Reproducibility of Measurements

No abstract available.

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.

Diagnostic Approach to Recurrent Idiopathic Pancreatitis / 대한내과학회지

Acute recurrent pancreatitis (ARP) most commonly results from alcohol abuse or gallstone disease. Nevertheless, the initial evaluation fails to detect the cause of ARP in 20% to 30% of patients, who are thus diagnosed with idiopathic pancreatitis. Further evaluation is indicated in patients with a severe initial attack of acute pancreatitis or those with two or more attacks. This evaluation might include one or more of the following procedures: specialized laboratory studies, endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP). Based on our experience, the initial step in this evaluation should be MRCP or EUS because of the high safety and diagnostic yield of these techniques. If MRCP or EUS is negative, then ERCP with sphincter of Oddi manometry, intraductal ultrasonography (IDUS), or bile analysis should be considered.

Problems of Pathologic T Staging in Ampullary Neoplasm / 대한췌담도학회지

Ampulla of Vater (AoV) is a small dilated duct less than 1.5 cm long, formed by the union of pancreatic duct and common bile duct. AoV has also anatomic layer of mucosa, sphincter of Oddi, perisphincteric or duodenal submucosa, and duodenal proper muscle, which corresponds to mucosa, muscularis mucosa, submucosa, and proper muscle layer of other gastrointestinal tract organs, respectively. Because of its small compact size and variation of anatomic structure, it is sometimes difficult to identify layering architecture of AoV. This anatomic difficulty may cause some problem in T classification of ampullary carcinoma (AC). The most confusing point in T classification is the vague definition of T2, "Tumor invades duodenal wall". It seems that duodenal wall includes duodenal mucosa, submucosa, and proper muscle layer. However there is no precise description or definition about duodenal wall that might lead personal variation in T classification of AC staging. We found that clinical course of AC with perisphincteric and/or duodenal submucosal invasion is more close to AC with T2 than T1. Although it is described as T1b according to T classification scheme of ordinary gastrointestinal tract cancer, we thought AC with T1b may have more high-grade malignant potential than those of other gastrointestinal (GI) tract malignancy. AC showed various clinicopatholgic findings that represent heterogeneous tumor groups within category of AC. Recently site-specific classification of AC was introduced, and it showed relatively well-categorized clinical prognosis. It may be reasonable to understand site-specific tumorigenesis in AC. The standard gross protocol is needed to evaluate pathologic T classification of AC. In conclusion, ampullary neoplasm is composed of various subtypes, which require a separate approach according to anatomic epicenter of ampullary neoplasm. Although submucosal invasion in AC was classified into pT1b, its' biologic behavior is more close to pT2.

Right upper quadrant pain with normal hepatobiliary ultrasound: can hepatobiliary scintigraphy define the cause?

The objective of this study was to assess the value of hepatobiliary scintigraphy [HS] for the diagnosis of right upper quadrant [RUQ] abdominal pain in patients with normal hepatobiliary ultrasound [HU]. This is an observational study with a retrospective analysis of data from March 2008 to August 2010. We reviewed the HS results of 30 patients, aged 29-69 years [average 45.8 years]; 12 male and 18 female patients. Patient selection to perform the HS was RUQ abdominal pain, suspected hepatobiliary disorder, and negative HU. All patients had gone through the standard procedure of HS. Based on predefined interpretation criteria, HS results were divided into 2 patterns: Normal [n=8, 25.8%] and abnormal [n=22, 73%]: 18 patients [81.8%] having early gallbladder [GB] and common bile duct visualization, and delayed transit to small bowel [SB], which can be seen only after a fatty meal with normal or abnormal GB ejection fraction [GBEF] pattern characteristic of Oddi's sphincter dyskinesia. The remaining 4 patients [8.18%] had acalculous cholycystitis pattern: Delayed GB visualization with activity appearing in SB before GB. HS with fatty meal stimulation and GBEF estimation seems to be a reliable test, which may reveal a biliary cause in more than 70% of patients with RUQ abdominal pain and normal HU. Normal results exclude functional biliary cause. The decision for invasive or noninvasive therapeutic approach may depend on the results of HS

How to Interpret a Functional or Motility Test: Sphincter of Oddi Manometry

To date, endoscopic manometry is the best method for evaluating the function of the sphincter. Sphincter of Oddi manometry (SOM) remains the gold standard to correctly diagnose the sphincter of Oddi dysfunction (SOD) and stratify therapy. Several dynamic abnormalities relating to the intensity, frequency, and propagation of sphincter contractions have been described. However, their clinical use generally has been abandoned in favor of basal sphincter pressure alone, because this measurement is stable over time, and has stronger interobserver reliablility, reproducibility on repeating testing, and is associated with the responsiveness to therapy. A significant elevated risk of pancreatitis was attributed to the technique. The risk of pancreatitits associated with manometric evaluation of the pancreatic sphincter is markedly reduced when manometry is performed with continous aspiration from the pancreatic duct via one of the 3 catheter lumens. This section reviews indications, conscious sedative drugs, techniques, and the appropriate interpretations of SOM.

Endoscopic Papillary Balloon Dilation for Removal of Choledocholithiasis: Indications, Advantages, Complications, and Long-Term Follow-Up Results

Endoscopic papillary balloon dilation (EPBD) is an alternative method of endoscopic sphincterotomy (EST). Although concerns regarding post-procedure pancreatitis have been expressed, EPBD has come to be recognized as an effective and safe method for stone removal in specific cases. To analyze the proper indications, ideal methods, complications, and long-term follow-up results for EPBD, we reviewed articles about EPBD located through a search of the PubMed data base. We analyzed the ballooning methods, indications, results and complications of EPBD among the articles found and compared the results with those of EST. We considered the authors' own clinical experience and knowledge in developing recommendations for EPBD. EPBD showed similar efficacy and safety for the removal of choledocholithiasis to that of EST. Although large or multiple stones were difficult to remove by EPBD, it was safer and easier to apply in patients with coagulopathy or abnormal anatomy. To prevent severe pancreatitis, excessive ballooning and impractical cannulation should be avoided, and precut sphincterotomy or adjuvant prophylaxis should be considered. Due to its preservation of the sphincter of Oddi, EPBD is expected to have fewer long-term complications, such as stone recurrence, cholangitis and cholecystitis. In conclusion, EPBD appears to be safe and effective for the treatment of choledocholithiasis with proper selection of ballooning methods and patients.

Endoscopic Therapy in Chronic Pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

Effect of Transdermal Fentanyl Patches on the Motility of the Sphincter of Oddi

BACKGROUND/AIMS: Pain is one of the most troublesome symptoms of pancreatitis. Transdermal fentanyl patches (TFPs) are long-acting analgesics with a reduced risk of dependency. This prospective study evaluated the effect of TFPs on sphincter of Oddi (SO) motility for the management of pain in pancreatitis. METHODS: SO manometry (SOM) was performed using triple-lumen catheters anterogradely inserted through the percutaneous transhepatic route during cholangioscopy in 16 patients. The basal pressure, amplitude, and frequency of the SO were assessed before and after applying a TFP at 24 hour at doses of 25 and 12.5microgram/hr, respectively. RESULTS: Two of 16 patients receiving a 25microgram/hr. TFP were excluded because of adverse side effects (headache and/or nausea). The mean basal pressure, amplitude, and frequency of SOM did not change significantly in the 25microgram/hr TFP group (n=4 patients). Parameters of SO function also did not significantly change in the 12.5microgram/hr TFP group (n=11 patients). CONCLUSIONS: TFPs below a dose of 25microgram/hr may not affect the motility of the SO. Administration of TFPs at lower dosages seems to be a safe analgesic treatment for the pain control of patients with pancreatitis without affecting the function of the SO.

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.

Variaciones anormales en la ubicación del Esfínter de Oddi (ampolla de Váter) y su importancia en la presentación clínica en pacientes con colecistitis litiásica biliar benigna / Abnormalities in the region of the Oddi’s Sphincter (Vater’s blister) and their important in patients with benign biliary lithiasic cholecystitis

Tipo de estudio: prospectivo, descriptivo, realizado durante el período noviembre 2005 a junio 2006 en el hospital “Luis Vernaza”, sala “Santa Cecilia”. Objetivo: conocer la incidencia de las variaciones anatómicas anormales mediante el uso de la técnica de la colangiografía intraoperatoria realizada durante la colecistectomía; determinar la importancia clínica de la ubicación del esfínter de Oddi en el duodeno. Resultados: de un universo de pacientes, de sexo femenino, se obtuvo el siguiente porcentaje de variaciones anatómicas: 47 pacientes cuyo esfínter de Oddi fue ubicado en posición normal, es decir en la segunda porción 8 pacientes en la primera porción del duodeno y 5 en la tercera porción. Conclusión: pacientes que presentaron variedades anatómicas anormales del esfínter de Oddi presentaron cuadro clínico más severo.

Prospective and descriptive carried out from November 2005 to June 2006 at the “Luis Vernaza” Hospital, “Santa Cecilia” Room. Objective: to be aware of the prevalence of abnormal anatomic variations through the technique of intraoperative bile duct X-ray carried out during the cholecystectomy; and determine the clinical importance of the location of the Odd’s Sphincter in the duodenum. Results: in a sample of 60 female patients the following percentages of anatomic variations were found: 47 patients whose Oddi’s Sphincter was located in a normal second portion. 8 patients in the first portion of the duodenum and 5 of them in the third portion. Conclusion: patients with abnormal anatomic variations of Oddi’s Sphincter presented a more severe pathological clinical case.

Recurrent Acute Pancreatitis Associated with Sphincter of Oddi Dysfunction in a Child / 대한소아소화기영양학회지

Recent studies suggest that sphincter of Oddi dysfunction (SOD) is one of the possible causes of unexplained recurrent acute pancreatitis in children. A 14-year-old boy who had suffered from idiopathic recurrent acute pancreatitis was diagnosed with SOD. Abdominal ultrasonography, computerized tomography, and magnetic resonance cholangiopancreatography revealed no evidence of stone, tumor, or pancreatic ductal anomaly. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi manometry (SOM) revealed elevated basal pressure and tachyoddia consistent with SOD. Hence, an endoscopic pancreatic sphincterotomy was performed. We report a case of recurrent acute pancreatitis associated with SOD in a child. ERCP and SOM may be considered in patients with multiple unexplained attacks of pancreatic pain and negative abdominal imaging.