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sphincter of Oddi dysfunction

Epidemiology: - more prevalent among middle-aged women Pathology: 1) papillary stenosis - fixed anatomic narrowing of the sphincter of Oddi, typically due to fibrosis 2) sphincter of Oddi dyskinesia - manometric abnormalities of the sphincter of Oddi 3) impedance of pancreatic juice & bile flow Clinical manifestations: - right upper quadrant abdominal pain - pain is characteristically sharp, postprandial (1-2 hours), & located in the right upper quadrant or epigastrium - pain may be associated with nausea &/or vomiting - pain may last for several hours & can occur at night - pain may radiate to the back or shoulder blades - fever, chills, & jaundice are uncommon - may also present with acute recurrent pancreatitis Laboratory: - liver function tests may be abnormal* a) serum alkaline phosphatase may be increased b) serum bilirubin may be increased c) serum ALT may be increased * liver function tests generally normalize between episodes of pain [5] Special laboratory: - ERCP with sphincter of Oddi mannometry (gold standard) - upper GI endoscopy with endoscopic ultrasound may be normal [5] Radiology: - abdominal ultrasound (after fatty meal stimulation) - biliary scintigraphy - magnetic resonance cholangiopancreatography* may be normal [5] - dilated common bile duct in the absence of gallstones [5] * perform magnetic resonance cholangiopancreatography anyway prior to ERCP despite no stones seen on ultrasound if high risk of cholelithiasis &/or choledocholelithiasis (sickle cell disease) [5] Complications: - cholecystectomy common due to missed diagnosis Management: 1) goal of treatment is to reduce sphincter of Oddi pressure, thereby improving drainage of biliary & pancreatic secretions into the duodenum 2) medical, endoscopic, or surgical therapy 3) medical therapy: a) calcium channel blockers & long-acting nitrates may reduce basal pressure & improve symptoms b) response rate of only about 75% c) not expected to be effective enough 4) endoscopic sphincterotomy is the standard of therapy a) low morbidity and mortality rates b) response rates > 90% c) good results in long-term follow-up d) high complication rate of pancreatitis after endoscopic sphincterotomy

Related

sphincter of Oddi; sphincter of the hepatopancreatic/bilaropancreatic ampulla; Glisson sphincter

General

biliary disease

References

  1. Sphincter of Oddi Dysfunction: Johns Hopkins University http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&disease=12&organ=3&lang_id=1
  2. Wikipedia: Sphincter of Oddi dysfunction http://en.wikipedia.org/wiki/Sphincter_of_Oddi_dysfunction
  3. Petersen BT An evidence-based review of sphincter of Oddi dysfunction: part I, presentations with 'objective' biliary findings (types I and II). Gastrointest Endosc. 2004 Apr;59(4):525-34 PMID: 15044889
  4. Sherman S and Lehman GA Sphincter of Oddi Dysfunction: Diagnosis and Treatment JOP. J. Pancreas (Online) 2001; 2(6):382-400 http://www.joplink.net/prev/200111/200111_04.pdf
  5. NEJM Knowledge+ Gastroenterology