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Fliss B, Krishnarajah K, Ebert L, Wunder C, Franckenberg S. The Correlation of Bile Duct Dilatation in Postmortem Computed Tomography of Lethal Intoxication Cases for Different Drug Types-A Retrospective Study. Med Sci (Basel) 2024; 12:65. [PMID: 39584915 PMCID: PMC11587109 DOI: 10.3390/medsci12040065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 10/27/2024] [Accepted: 11/06/2024] [Indexed: 11/26/2024] Open
Abstract
PURPOSE To assess (I) whether, in autopsy-proven lethal intoxications with opiates/opioids, a dilatation of the common bile duct (CBD) is still visible in postmortem computed tomography (PMCT) and (II) if a dilatation of the CBD might also be measurable for other substance groups (e.g., stimulants, hypnotics, antipsychotics, etc.). METHODS We retrospectively measured the CBD using PMCT in cases with lethal intoxication (n = 125) and as a control group in cases with a negative toxicological analysis (n = 88). Intoxicating substances were classified into the subgroups (opiates, opioids, stimulants, hypnotics, antipsychotics, gasses, and others). Significance between the study and control groups was tested with the Mann-Whitney U test, and correlations were examined by using crosstables. RESULTS There was a statistically significant difference between the CBD diameters in the intoxication group overall, when compared to the CBD diameter in the control group (p < 0.001). For both subgroups of "opiates" and "opioids", there was a strong statistically significant difference between the CBD diameter (being wider) in those groups compared to the control group (both p = 0.001). For the three subgroups "hypnotics", "stimulants", and "psychotropic drugs", there was no statistically significant difference between the CBD diameters in the intoxication subgroups when compared with the control group. The other subgroups were too small for statistical analysis. CONCLUSION A dilated common bile duct in postmortem computed tomography might be used as an indication for a lethal opioid or opiate intoxication only in regard to the specific case circumstances or together with other indicative findings in a postmortem investigation.
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Affiliation(s)
- Barbara Fliss
- Institute of Legal Medicine, Johannes-Gutenberg University Mainz, 55131 Mainz, Germany
| | | | - Lars Ebert
- Zurich Forensic Science Institute, 8010 Zurich, Switzerland;
| | - Cora Wunder
- Institute of Legal Medicine, Johannes-Gutenberg University Mainz, 55131 Mainz, Germany
| | - Sabine Franckenberg
- Institute of Forensic Medicine, University of Zurich, 8057 Zurich, Switzerland (S.F.)
- Diagnostic and Interventional Radiology, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland
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Li X, Liang Z. Causal effect of gut microbiota on pancreatic cancer: A Mendelian randomization and colocalization study. J Cell Mol Med 2024; 28:e18255. [PMID: 38526030 PMCID: PMC10962122 DOI: 10.1111/jcmm.18255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
The causal relationship between gut microbiota (GM) and pancreatic cancer (PC) remains unclear. This study aimed to investigate the potential genes underlying this mechanism. GM Genome-wide association study (GWAS) summary data were from the MiBioGen consortium. PC GWAS data were from the National Human Genome Research Institute-European Bioinformatics Institute (NHGRI-EBI) GWAS Catalogue. To detect the causal relationship between GM and PC, we implemented three complementary Mendelian randomization (MR) methods: Inverse Variance Weighting (IVW), MR-Egger and Weighted Median, followed by sensitivity analyses. Furthermore, we integrated GM GWAS data with blood cis-expression quantitative trait loci (eQTLs) and blood cis-DNA methylation QTL (mQTLs) using Summary data-based Mendelian Randomization (SMR) methods. This integration aimed to prioritize potential GM-affecting genes through SMR analysis of two molecular traits. PC cis-eQTLs and cis-mQTLs were summarized from The Cancer Genome Atlas (TCGA) data. Through colocalization analysis of GM cis-QTLs and PC cis-QTLs data, we identified common genes that influence both GM and PC. Our study found a causal association between GM and PC, including four protective and five risk-associated GM [Inverse Variance Weighted (IVW), p < 0.05]. No significant heterogeneity of instrumental variables (IVs) or horizontal pleiotropy was found. The gene SVBP was identified as a GM-affecting gene using SMR analysis of two molecular traits (FDR<0.05, P_HEIDI>0.05). Additionally, two genes, MCM6 and RPS26, were implicated in the interaction between GM and PC based on colocalization analysis (PPH4>0.5). In summary, this study provides evidence for future research aimed at developing suitable therapeutic interventions and disease prevention.
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Affiliation(s)
- Xin Li
- Department of Gastroenterology, The First Affiliated HospitalGuangxi Medical UniversityNanningChina
| | - Zhihai Liang
- Department of Gastroenterology, The First Affiliated HospitalGuangxi Medical UniversityNanningChina
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Hou JU, Park SW, Park SM, Park DH, Park CH, Min S. Efficacy of an artificial neural network algorithm based on thick-slab magnetic resonance cholangiopancreatography images for the automated diagnosis of common bile duct stones. J Gastroenterol Hepatol 2021; 36:3532-3540. [PMID: 34097761 DOI: 10.1111/jgh.15569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/17/2021] [Accepted: 06/05/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Magnetic resonance cholangiopancreatography (MRCP) can accurately diagnose common bile duct (CBD) stones but is laborious to interpret. We developed an artificial neural network (ANN) capable of automatically assisting physicians with the diagnosis of CBD stones. This study aimed to evaluate the ANN's diagnostic performance for detecting CBD stones in thick-slab MRCP images and identify clinical factors predictive of accurate diagnosis. METHODS The presence of CBD stones was confirmed via direct visualization through endoscopic retrograde cholangiopancreatography (ERCP). The absence of CBD stones was confirmed by either a negative endoscopic ultrasound accompanied by clinical improvements or negative findings on ERCP. Our base networks were constructed using state-of-the-art EfficientNet-B5 neural network models, which are widely used for image classification. RESULTS In total, 3156 images were collected from 789 patients. Of these, 2628 images from 657 patients were used for training. An additional 1924 images from 481 patients were prospectively collected for validation. Across the entire prospective validation cohort, the ANN achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 93.03%, 97.05%, 97.01%, 93.12%, and 95.01%, respectively. Similarly, a radiologist achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy 91.16%, 93.25%, 93.22%, 90.20%, and 91.68%, respectively. In multivariate analysis, only bile duct diameter > 10 mm (odds ratio = 2.45, 95% confidence interval [1.08-6.07], P = 0.040) was related to ANN diagnostic accuracy. CONCLUSION Our ANN algorithm automatically and quickly diagnoses CBD stones in thick-slab MRCP images, therein aiding physicians with optimizing clinical practice, such as whether to perform ERCP.
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Affiliation(s)
- Jong-Uk Hou
- School of Software, Hallym University, Chuncheon, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Seonjeong Min
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Brønden A, Knop FK. Gluco-Metabolic Effects of Pharmacotherapy-Induced Modulation of Bile Acid Physiology. J Clin Endocrinol Metab 2020; 105:5601203. [PMID: 31630179 DOI: 10.1210/clinem/dgz025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/04/2019] [Accepted: 10/04/2019] [Indexed: 02/08/2023]
Abstract
CONTEXT The discovery and characterization of the bile acid specific receptors farnesoid X receptor (FXR) and Takeda G protein-coupled receptor 5 (TGR5) have facilitated a wealth of research focusing on the link between bile acid physiology and glucose metabolism. Modulation of FXR and TGR5 activation have been demonstrated to affect the secretion of glucagon-like peptide 1, insulin, and glucagon as well as energy expenditure and gut microbiota composition, with potential beneficial effects on glucose metabolism. EVIDENCE ACQUISITION A search strategy based on literature searches in on PubMed with various combinations of the key words FXR, TGR5, agonist, apical sodium-dependent bile acid transporter (ASBT), bile acid sequestrant, metformin, and glucose metabolism has been applied to obtain material for the present review. Furthermore, manual searches including scanning of reference lists in relevant papers and conference proceedings have been performed. EVIDENCE SYNTHESIS This review provides an outline of the link between bile acid and glucose metabolism, with a special focus on the gluco-metabolic impact of treatment modalities with modulating effects on bile acid physiology; including FXR agonists, TGR5 agonists, ASBT inhibitors, bile acid sequestrants, and metformin. CONCLUSIONS Any potential beneficial gluco-metabolic effects of FXR agonists remain to be established, whereas the clinical relevance of TGR5-based treatment modalities seems limited because of substantial safety concerns of TGR5 agonists observed in animal models. The glucose-lowering effects of ASBT inhibitors, bile acid sequestrants, and metformin are at least partly mediated by modulation of bile acid circulation, which might allow an optimization of these bile acid-modulating treatment modalities. (J Clin Endocrinol Metab XX: 00-00, 2019).
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Affiliation(s)
- Andreas Brønden
- Center for Clinical M etabolic Research, Gentofte Hospital, University of Copenhagen, DK-2900 Hellerup, Denmark
| | - Filip K Knop
- Center for Clinical M etabolic Research, Gentofte Hospital, University of Copenhagen, DK-2900 Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
- Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen N, Denmark
- Steno Diabetes Copenhagen, DK-2820 Gentofte, Denmark
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Lee T, Anderson J, Thomas-Gibson S, Rees C. Use of intravenous hyoscine butylbromide (Buscopan) during gastrointestinal endoscopy. Frontline Gastroenterol 2018; 9:183-184. [PMID: 30046421 PMCID: PMC6056080 DOI: 10.1136/flgastro-2017-100877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Thomas Lee
- Gastroenterology, Northumbria Healthcare NHS Foundation Trust, UK,Northern Region Endoscopy Group (NREG), Newcastle, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK,Bowel Cancer Screening Programme Accreditation Panel, London, UK
| | - Siwan Thomas-Gibson
- Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK,Surgery, Imperial College, London, UK,Joint Advisory Group (on Gastrointestinal Endoscopy), London, UK
| | - Colin Rees
- Northern Region Endoscopy Group (NREG), Newcastle, UK,Department of Gastroenterology, South Tyneside General Hospital, South Shields, UK,British Society of Gastroenterology, London, UK,Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
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Dusunceli Atman E, Erden A, Ustuner E, Uzun C, Bektas M. MRI Findings of Intrinsic and Extrinsic Duodenal Abnormalities and Variations. Korean J Radiol 2015; 16:1240-52. [PMID: 26576112 PMCID: PMC4644744 DOI: 10.3348/kjr.2015.16.6.1240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/16/2015] [Indexed: 12/22/2022] Open
Abstract
This pictorial review aims to illustrate the magnetic resonance imaging (MRI) findings and presentation patterns of anatomical variations and various benign and malignant pathologies of the duodenum, including sphincter contraction, major papilla variation, prominent papilla, diverticulum, annular pancreas, duplication cysts, choledochocele, duodenal wall thickening secondary to acute pancreatitis, postbulbar stenosis, celiac disease, fistula, choledochoduodenostomy, external compression, polyps, Peutz-Jeghers syndrome, ampullary carcinoma and adenocarcinoma. MRI is a useful imaging tool for demonstrating duodenal pathology and its anatomic relationships with adjacent organs, which is critical for establishing correct diagnosis and planning appropriate treatment, especially for surgery.
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Affiliation(s)
- Ebru Dusunceli Atman
- Department of Radiology, Ankara University School of Medicine, Ankara 06100, Turkey
| | - Ayse Erden
- Department of Radiology, Ankara University School of Medicine, Ankara 06100, Turkey
| | - Evren Ustuner
- Department of Radiology, Ankara University School of Medicine, Ankara 06100, Turkey
| | - Caglar Uzun
- Department of Radiology, Ankara University School of Medicine, Ankara 06100, Turkey
| | - Mehmet Bektas
- Department of Gastroenterology, Ankara University School of Medicine, Ankara 06100, Turkey
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Zhou P, Li T, Su R, Gong Z. Effects of thienorphine on contraction of the guinea pig sphincter of Oddi, choledochus and gall bladder. Eur J Pharmacol 2014; 737:22-8. [PMID: 24830319 DOI: 10.1016/j.ejphar.2014.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 02/07/2023]
Abstract
Opioid analgesics are widely believed to cause spasm of the bile duct sphincter and so impede bile flow. Thienorphine is a partial opioid agonist that is a good candidate for the treatment of opioid dependence; however, to date, no studies have reported the effects of thienorphine on the function of the biliary tract. This study examined the in vivo effects of thienorphine on the guinea pig isolated sphincter of Oddi, choledochus and gall bladder and on bile flow. The area under the curve (AUC) of isolated sphincter of Oddi was not influenced by thienorphine or buprenorphine, whereas morphine increased the AUC of the isolated sphincter of Oddi in a concentration-dependent manner. Thienorphine and buprenorphine concentration-dependently decreased the AUC of isolated choledochus, while morphine increased the AUC of isolated choledochus. Thienorphine had no effect on the contractile amplitude or basal tension of isolated gall bladder muscle strips. In contrast, buprenorphine and morphine increased the contractile basal tension of isolated gall bladder muscle strips in a concentration-dependent manner. Thienorphine (0.01-1.0mg/kg) had no significant inhibitory effect on bile flow. However, morphine (1.0-10mg/kg) and buprenorphine (1.0mg/kg) significantly inhibited bile flow. The maximum inhibition of bile flow by buprenorphine was 63.9±12.9% and by morphine was 74.1±11.3%. In summary, thienorphine has little influence on the guinea pig isolated sphincter of Oddi, choledochus and gall bladder or on bile flow, which may result in a lack of adverse biliary colic effects.
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Affiliation(s)
- Peilan Zhou
- Beijing Institute of Pharmacology and Toxicology, 27th Taiping Road, Beijing 100850, China.
| | - Tingting Li
- Beijing Institute of Pharmacology and Toxicology, 27th Taiping Road, Beijing 100850, China.
| | - Ruibin Su
- Beijing Institute of Pharmacology and Toxicology, 27th Taiping Road, Beijing 100850, China.
| | - Zehui Gong
- Beijing Institute of Pharmacology and Toxicology, 27th Taiping Road, Beijing 100850, China.
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Agrawal MD, Mennitt KW, Zhang H, Samstein B, Kato T, Emond JC, Dutruel SP, Thimmappa ND, Prince MR. Morphine three-dimensional T1 gadoxetate MR cholangiography of potential living related liver donors. J Magn Reson Imaging 2014; 39:584-589. [PMID: 23723095 DOI: 10.1002/jmri.24188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 04/02/2013] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To assess low-dose morphine for distension and improved visualization of intrahepatic bile ducts on T1 MR cholangiography (MRC) in preoperative imaging of potential liver donors. MATERIALS AND METHODS Sixty-nine consecutive potential living related liver donors (mean age, 39 years; age range, 20 to 59 years) referred for pre-transplant MRI evaluation were evaluated without (n=30) or with (n=39) intravenous morphine injection (0.04 mg/kg). Morphine was injected pre-MRI while establishing intravenous access to allow ∼1 h for biliary distension before T1 MRC. Three radiologists reviewed intrahepatic biliary branch order visualization, common bile duct (CBD) diameter, and overall image quality. In 25 patients undergoing liver donation surgery, T1 MRC findings were correlated with intraoperative findings. This retrospective study was approved by the institutional review board. RESULTS Biliary visualization was improved post-morphine administration with biliary duct branch order visualization score of 3.2 and 3.3 at 45 and 60 min, respectively, compared with 2.7 without morphine (P<0.002); CBD diameter measured 5.3 and 5.5 versus 4.1 mm (P<0.005), and overall image quality score was 2.4 and 2.6 versus 1.8 (P<0.0006). Operative notes confirmed T1 MRC findings in 6/11 donors without morphine and 14/14 donors with morphine. CONCLUSION Intravenous low-dose morphine distends and improves visualization of bile ducts on T1 gadoxetate MRC.
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Affiliation(s)
- Mukta D Agrawal
- Department of Radiology, Weill Cornell Medical College & New York Presbyterian Hospital, New York, USA
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Cheon YK. How to interpret a functional or motility test - sphincter of oddi manometry. J Neurogastroenterol Motil 2012; 18:211-7. [PMID: 22523732 PMCID: PMC3325308 DOI: 10.5056/jnm.2012.18.2.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/24/2012] [Accepted: 03/04/2012] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Young Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Sommer CM, Schwarzwaelder CB, Ramsauer S, Stampfl U, Stiller W, Nickel F, Omri W, Kenngott HG, Gehrig T, Meinzer HP, Kauczor HU, Radeleff BA. Intravenous 64-multi-detector row CT-cholangiography of porcine livers: a feasibility study with definition of the temporal window for optimal bile duct delineation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:666-72. [PMID: 20703845 DOI: 10.1007/s00534-010-0263-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 01/06/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND/PURPOSE To assess the feasibility of intravenous 64-multi-detector row computed tomography (CT)-cholangiography of porcine livers with definition of the temporal window for optimal bile duct delineation. METHODS Six healthy Landrace pigs, each weighing 28.97 +/- 2.99 kg, underwent 64-multi-detector row CT-cholangiography. Each pig was infused with 50 ml of meglumine iotroxate continuously over a period of 20 min and, starting with the initiation of the infusion, 18 consecutive CT scans of the abdomen at 2-min intervals were acquired. All series were evaluated for bile duct visualization scores and maximum bile duct diameters as primary study goals and bile duct attenuation and liver enhancement as secondary study goals. RESULTS Of the 16 analyzed biliary tract segments, maximum bile duct visualization scores ranged between 4.00 +/- 0.00 and 2.83 +/- 1.47. Time to maximum bile duct visualization scores ranged between 10 and 34 min. Average bile duct visualization scores for the 10- to 34-min interval ranged between 3.99 +/- 0.05 and 2.78 +/- 0.10. Maximum bile duct diameters ranged between 6.47 +/- 1.05 and 2.65 +/- 2.23 mm. Time to maximum bile duct diameters ranged between 24 and 34 min. Average bile duct diameters for the 10- to 34-min interval ranged between 6.00 +/- 0.38 and 2.40 +/- 0.13 mm. CONCLUSIONS Intravenous 64-multi-detector row CT-cholangiography of non-diseased porcine liver is feasible, with the best bile duct delineation acquired between 10 and 34 min after initiation of the contrast agent infusion.
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Affiliation(s)
- Christof M Sommer
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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Kojima Y, Nakagawa H, Miyata A, Hirai T, Ohyama I, Okada A, Hiramatsu T, Ohhara Y, Kuwahara T. Long-term prognosis of bile duct stones: endoscopic papillary balloon dilatation versus endoscopic sphincterotomy. Dig Endosc 2010; 22:21-4. [PMID: 20078660 DOI: 10.1111/j.1443-1661.2009.00913.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM Endoscopic papillary balloon dilatation (EPBD), which allows preservation of papillary functions, is used as the first-line therapy in our hospital for common bile duct (CBD) stones to reduce biliary complications. In the present study, we investigated causal factors for CBD stones and compared long-term prognosis between EPBD and endoscopic sphincterotomy (EST). METHODS A total of 453 EPBD and 233 EST cases treated between April 1996 and May 2007 were examined. They were categorized into four groups: group 1, gallbladder (GB) with stones was resected after CBD stones were extracted (cholecystectomy for GB with stones); group 2, GB with stones was not resected after CBD stones were extracted (no cholecystectomy for GB with stones); group 3, only CBD stones were extracted while the GB without stones was not resected (GB without stones); and group 4, CBD stones with a history of cholecystectomy (absence of GB). Then, postoperative recurrence of CBD stones was compared. To examine changes in papillary functions by EPBD, Oddi's sphincter pressure was measured before and after EPBD. RESULTS Recurrence was observed in 31 EPBD and 40 EST cases. When recurrence rates by EPBD/EST were compared among the four treatment groups, they were lower with EPBD than with EST in all groups. Oddi's sphincter functions were preserved by 70% after EPBD. CONCLUSION Low-pressure EPBD in combination with isosorbide dinitrate enabled preservation of papillary functions by 70%, which would improve a long-term prognosis.
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Affiliation(s)
- Yuko Kojima
- Gastrointestinal Unit, Komaki City Hospital, Komaki, Japan.
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12
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Zernikow B, Michel E, Craig F, Anderson BJ. Pediatric palliative care: use of opioids for the management of pain. Paediatr Drugs 2009; 11:129-51. [PMID: 19301934 DOI: 10.2165/00148581-200911020-00004] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pediatric palliative care (PPC) is provided to children experiencing life-limiting diseases (LLD) or life-threatening diseases (LTD). Sixty to 90% of children with LLD/LTD undergoing PPC receive opioids at the end of life. Analgesia is often insufficient. Reasons include a lack of knowledge concerning opioid prescribing and adjustment of opioid dose to changing requirements. The choice of first-line opioid is based on scientific evidence, pain pathophysiology, and available administration modes. Doses are calculated on a bodyweight basis up to a maximum absolute starting dose. Morphine remains the gold standard starting opioid in PPC. Long-term opioid choice and dose administration is determined by the pathology, analgesic effectiveness, and adverse effect profile. Slow-release oral morphine remains the dominant formulation for long-term use in PPC with hydromorphone slow-release preparations being the first rotation opioid when morphine shows severe adverse effects. The recently introduced fentanyl transdermal therapeutic system with a drug-release rate of 12.5 microg/hour matches the lower dose requirements of pediatric cancer pain control. Its use may be associated with less constipation compared with morphine use. Though oral transmucosal fentanyl citrate has reduced bioavailability (25%), it inherits potential for breakthrough pain management. However, the gold standard breakthrough opioid remains immediate-release morphine. Buprenorphine is of special clinical interest as a result of its different administration routes, long duration of action, and metabolism largely independent of renal function. Antihyperalgesic effects, induced through antagonism at the kappa-receptor, may contribute to its effectiveness in neuropathic pain. Methadone also has a long elimination half-life (19 [SD 14] hours) and NMDA receptor activity although dose administration is complicated by highly variable morphine equianalgesic equivalence (1 : 2.5-20). Opioid rotation to methadone requires special protocols that take this into account. Strategies to minimize adverse effects of long-term opioid treatment include dose reduction, symptomatic therapy, opioid rotation, and administration route change. Patient- or nurse-controlled analgesia devices are useful when pain is rapidly changing, or in terminal care where analgesic requirements may escalate. In this article, we present detailed pediatric pharmacokinetic and pharmacodynamic data for opioids, their indications and contraindications, as well as dose-administration regimens that include practical strategies for opioid switching and dose reduction. Additionally, we discuss the problem of hyperalgesia and the use of adjuvant drugs to support opioid therapy.
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Affiliation(s)
- Boris Zernikow
- Children's Hospital, Witten/Herdecke University, Vodafone Foundation Institute for Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.
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Breiman RS, Coakley FV, Webb EM, Ellingson JJ, Roberts JP, Kohr J, Lutz J, Knoess N, Yeh BM. CT Cholangiography in Potential Liver Donors: Effect of Premedication with Intravenous Morphine on Biliary Caliber and Visualization. Radiology 2008; 247:733-7. [DOI: 10.1148/radiol.2473070964] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bagcivan I, Gursoy S, Yildirim MK, Kaya Temiz T, Yildirim S, Yilmaz A, Turan M. Investigation of relaxant effects of propofol on sheep sphincter of Oddi. Pancreatology 2007; 7:174-9. [PMID: 17592231 DOI: 10.1159/000104242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 12/07/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Intravenous anesthetics are often used for conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincter of Oddi (SO) manometry. This study was designed to investigate the effects of propofol on sheep SO. METHODS SO rings were mounted in a tissue bath and tested for changes in isometric tension in response to propofol (10(-8)-10(-4)M) in the presence or absence of L-NAME (3 x 10(-5)M), a non-specific inhibitor of nitric oxide (NO) synthase; indomethacin (10(-5)M), an inhibitor of cyclooxygenase; glibenclamide (10(-5)M), an inhibitor of ATP-sensitive potassium channels; tetraethylammonium (3 x 10(-4)M), inhibitors of calcium-activated potassium channels; 4-aminopyridine (10(-3)M), a voltage-dependent potassium channel blocker. Furthermore, we investigated the Ca(2+) antagonist feature of propofol in precontracted SO rings by CaCl(2). RESULTS Carbachol (10(-9)-10(-5)M) induced concentration-dependent contraction responses in the SO rings. Propofol (10(-8)-10(-4)M) produced concentration-dependent relaxation on isolated SO rings precontracted by carbachol (10(-6)M). Preincubation of SO rings by L-NAME (3 x 10(-5)M), indomethacin (10(-5)M), glibenclamide (10(-5)M), and 4-aminopyridine (10(-3)M) did not produce a significant alteration on propofol-induced relaxation responses (p > 0.05), while preincubation by tetraethylammonium (3 x 10(-4)M) significantly decreased the propofol-induced relaxation responses (p < 0.05). Propofol (10(-8)-10(-4)M) induced concentration-dependently relaxations in precontracted isolated SO rings by CaCl(2). CONCLUSION The results suggest that propofol induced concentration-dependent relaxations in precontracted isolated SO rings. These relaxations are independent from NO, cyclooxygenase metabolites, and opened ATP-sensitive and voltage-dependent potassium channels. Opened Ca(2+)-sensitive K(+) channels and inhibited L-type Ca(2+) channels existing in smooth muscle by propofol can contribute to these relaxations. Propofol can be beneficial as alternative drugs for obtaining selective relaxation during SO manometry after controlled clinical studies.
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Affiliation(s)
- Ihsan Bagcivan
- Department of Pharmacology, Cumhuriyet University School of Medicine, Sivas, Turkey.
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Nakagawa H, Ohara K. Safeguards against acute pancreatitis associated with endoscopic papillary balloon dilatation. ACTA ACUST UNITED AC 2006; 13:75-9. [PMID: 16547665 DOI: 10.1007/s00534-005-1061-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2005] [Accepted: 10/30/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Endoscopic papillary balloon dilatation (EPBD) is one of the methods used to remove bile duct stones. EPBD may preserve the function of the sphincter of Oddi in spite of the potential risk of acute pancreatitis caused by the procedure. There are only few reports of attempts to reduce the risk of acute pancreatitis in EPBD. METHODS We performed EPBD for bile duct stone removal in 201 patients. We used an 8-mm balloon followed by drip infusion of isosorbide dinitrate (ISDN) at a rate of 5 mg/h for low-pressure EPBD. The function of the minor duodenal papilla, the inflation pressure required for the disappearance of the notch sign in the bile duct, and the serum amylase level after EPBD were observed. RESULTS The median serum amylase level after the procedure was 367 IU/l. Acute pancreatitis occurred in two patients (1.0%). The two patients with acute pancreatitis had poor function of the minor duodenal papilla, a high inflation pressure (over 5 atm) required for disappearance of the notch, sign, and severe abdominal pain during balloon inflation; as well, the procedure took a long time. The rate of duct clearance was 99.5%. CONCLUSIONS EPBD with gradual inflation of the balloon at a low pressure, followed by ISDN drip infusion, could decrease the risk of acute pancreatitis associated with the procedure. Poor function of the minor duodenal papilla, high inflation pressure required for disappearance of the notch, sign, severe abdominal pain, and a lengthy procedure increase the risk of acute pancreatitis after EPBD.
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Affiliation(s)
- Hiroshi Nakagawa
- Gastrointestinal Unit, Komaki City Hospital, 1-20 Jyobushi Komaki, Aichi 485-8520, Japan
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16
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Schmidt S, Chevallier P, Novellas S, Gelsi E, Vanbiervliet G, Tran A, Schnyder P, Bruneton JN. Choledocholithiasis: repetitive thick-slab single-shot projection magnetic resonance cholangiopancreaticography versus endoscopic ultrasonography. Eur Radiol 2006; 17:241-50. [PMID: 16941091 DOI: 10.1007/s00330-006-0380-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2006] [Revised: 06/06/2006] [Accepted: 06/23/2006] [Indexed: 02/07/2023]
Abstract
This prospective study compares repetitive thick-slab single-shot projection magnetic resonance cholangiopancreatography (MRCP) with endoscopic ultrasonography (EUS) for the detection of choledocholithiasis. Fifty-seven consecutive patients (36 women, mean age 61) referred for suspected choledocholithiasis underwent MRCP, followed by EUS. Each procedure was performed by different operators blinded to the results of the other investigation. MR technique included a turbo spin-echo T2-weighted axial sequence with selective fat saturation (SPIR/TSE, TE=70 ms, TR=1,600 ms), followed by coronal dynamic MRCP. The same thick-slab slice was sequentially acquired 12 times as breath-hold single-shot projection imaging (SSh, TE=900 ms, TE=8,000 ms) centred on the common bile duct (CBD). Two experienced radiologists independently and blindly evaluated MR images for the detection of CBD stones. Their inter-observer agreement kappa was determined. Secondly, the two observers read MR images in consensus again. CBD stones were demonstrated in 18 out of 57 patients (31.6 %) and confirmed by endoscopic retrograde cholangiography (ERCP, n=17) or intraoperative cholangiography (n=1). Clinical follow-up served as the "gold standard" in patients with negative results without following invasive procedure (n=28). Sensitivity, specificity, accuracy, positive and negative predictive value for MRCP resulting from consensus reading were 94.9%, 94.4%, 94.7%, 97.4% and 89.5%, respectively. Corresponding values of EUS were 97.4%, 94.4%, 96.5%, 97.4% and 94.4%. Inter-observer agreement kappa was 0.81. Repetitive thick-slab single-shot projection MRCP is an accurate non-invasive imaging modality for suspected choledocholithiasis and should be increasingly used to select those patients who require a subsequent therapeutic procedure, namely ERCP.
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Affiliation(s)
- S Schmidt
- Department of Diagnostic and Interventional Radiology, CHUV, Rue du Bugnon, 1011, Lausanne, Switzerland.
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Zernikow B, Schiessl C, Wamsler C, Janssen G, Griessinger N, Fengler R, Nauck F. [Practical pain control in pediatric oncology. Recommendations of the German Society of Pediatric Oncology and Hematology, the German Association for the Study of Pain, the German Society of Palliative Care, and the Vodafone Institute of Children's Pain Therapy and Palliative Care]. Schmerz 2006; 20:24-39. [PMID: 16421708 DOI: 10.1007/s00482-005-0459-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.
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Affiliation(s)
- B Zernikow
- Vodafone-Stiftungsinstitut für Kinderschmerztherapie und Pädiatrische Palliativmedizin, Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke.
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Bagcivan I, Kaya T, Yildirim MK, Turan M. Investigation of the relaxant effects of pinacidil and cromakalim on the sheep sphincter of Oddi. Pancreatology 2006; 6:286-90. [PMID: 16636601 DOI: 10.1159/000092690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2005] [Accepted: 11/28/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS ATP-sensitive K+ (KATP) channels play an important role in the regulation of smooth muscle membrane potential. This study was designed to investigate the effects of pinacidil and cromakalim, KATP-sensitive channel activators, on sheep sphincters of Oddi (SO). METHODS SO rings were mounted in a tissue bath and tested for changes in isometric tension in response to pinacidil (10(-9)-10(-4)M) and cromakalim (10(-9)-10(-4)M) in the presence or absence of glibenclamide (10(-6)M), a blocker of KATP channels. Furthermore, concentration-dependent contraction responses of carbachol were obtained. RESULTS Carbachol (10(-9)-10(-5)M) induced concentration-dependent contraction responses in the SO rings. Pinacidil (10(-9)-10(-4)M) and cromakalim (10(-9)-10(-4)M) induced concentration-dependent relaxation in isolated SO rings precontracted with carbachol (10(-6)M). At their maximum effects, both pinacidil and cromakalim produced nearly full relaxation. In the presence of glibenclamide, concentration-relaxation curves for pinacidil and cromakalim underwent rightward parallel shifts. There were no significant differences between pEC50 and E(max) values of pinacidil and cromakalim in the absence of glibenclamide (10(-6)M) (p > 0.05), but pEC(50) values of pinacidil and cromakalim in the presence of glibenclamide (10(-6)M) were significantly reduced (p < 0.05). CONCLUSION These results suggest that the relaxation caused in sheep SO by pinacidil and cromakalim is mediated through the same glibenclamide-sensitive KATP channel. Pinacidil and cromakalim have an equipotent relaxing effect in isolated sheep SO and they can be beneficial as alternative drugs for obtaining selective relaxation during SO manometry after controlled clinical studies.
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Affiliation(s)
- Ihsan Bagcivan
- Department of Pharmacology, Cumhuriyet University School of Medicine, Sivas, Turkey.
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Talwar A, Dare C, Pain J. Does topical GTN on the sphincter of Oddi facilitate ERCP? A double-blind randomized control trial. Surg Endosc 2005; 19:902-4. [PMID: 15868252 DOI: 10.1007/s00464-004-9166-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Accepted: 11/03/2004] [Indexed: 01/22/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangio pancreatography (ERCP) is a technically challenging procedure. Glyceryl trinitrate (GTN) has been shown to reduce tone in the sphincter of Oddi (SO), cannulation of which is a rate-limiting factor. A double-blind randomized control trial was performed to assess whether topical GTN on the SO would facilitate cholangiography and/or bile duct cannulation. METHODS 104 patients requiring ERCP for biliary symptoms were randomized into two groups, 52 controls pretreated with 5 ml 0.9% normal saline (NS) and 52 pretreated with 5 ml GTN (concentration 1 mg/ml). RESULTS There was no significant between the control group and the GTN group in primary cannulation rate (p = 0.76), time taken to cholangiography (p = 0.58), or time to cannulation (p = 0.43). CONCLUSION Topically administered GTN to the SO does not aid in obtaining a cholangiogram or cannulation during an ERCP.
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Affiliation(s)
- A Talwar
- Department of General Surgery, Poole General Hospital, Longfleet Road, Dorset, BH15 2JB, United Kingdom.
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Wu SD, Zhang ZH, Li DY, Jin JZ, Kong J, Tian Z, Wang W, Wang MF. Nitroester drug’s effects and their antagonistic effects against morphine on human sphincter of Oddi motility. World J Gastroenterol 2005; 11:2319-23. [PMID: 15818745 PMCID: PMC4305818 DOI: 10.3748/wjg.v11.i15.2319] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effects of nitroester drugs on human sphincter of Oddi (SO) motility and their antagonistic effects against morphine which shows excitatory effect on Oddi’s sphincter motility.
METHODS: The effects of these drugs on SO were evaluated by means of choledochofiberoscopy manometry. A total of 67 patients having T-tubes after cholecystectomy and choledochotomy were involved in the study, they were randomly divided into glyceryl trinitrate (GTN) group, isosorbide dinitrate (ISDN) group, pentaerythritol tetranitrate (PTN) group, morphine associated with GTN group, morphine associated with ISDN group and morphine associated with PTN group. Basal pressure of Oddi’s sphincter (BPOS), amplitude of phasic contractions (SOCA), frequency of phasic contractions (SOF), duration of phasic contractions (SOD), duodenal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed. Morphine was given intramuscularly while nitroester drugs were applied sublingually.
RESULTS: BPOS and SOCA decreased significantly after administration of ISDN and GTN, BPOS reduced from 10.95±7.49 mmHg to 5.92±4.04 mmHg (P<0.05) evidently after application of PTN. BPOS increased from 7.37±5.58 mmHg to 16.60±13.87 mmHg, SOCA increased from 54.09±38.37 mmHg to 100.70±43.51 mmHg, SOF increased from 7.15±3.20 mmHg to 10.38±2.93 mmHg and CBDP increased 3.75±1.95 mmHg to 10.49±8.21 mmHg (P<0.01) evidently after injection of morphine. After associated application of ISDN and GTN, the four indications above decreased obviously. As for application associated with PTN, SOCA and SOF decreased separately from 100.64±44.99 mmHg to 66.17±35.88 mmHg and from 10.70±2.76 mmHg to 9.04±1.71 mmHg (P<0.05) markedly.
CONCLUSION: The regular dose of GTN, ISDN and PTN showed inhibitory effect on SO motility, morphine showed excitatory effect on SO while GTN, ISDN and PTN could antagonize the effect of morphine. Among the three nitroester drugs, the effect of ISDN on SO was most significant.
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Affiliation(s)
- Shuo-Dong Wu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital, China Medical University, Shenyang 110004, Liaoning Province, China.
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21
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Nakagawa H. COMPARING BALLOON DIAMETER ON PERFORMING ENDOSCOPIC PAPILLARY BALLOON DILATATION WITH ISOSORBIDE DINITRATE DRIP INFUSION FOR REMOVAL OF BILE DUCT STONES. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00405.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Silva AC, Friese JL, Hara AK, Liu PT. MR cholangiopancreatography: improved ductal distention with intravenous morphine administration. Radiographics 2004; 24:677-87. [PMID: 15143221 DOI: 10.1148/rg.243035087] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Magnetic resonance (MR) cholangiopancreatography has proved a robust and noninvasive imaging modality for evaluating the biliary and pancreatic ducts without the use of ionizing radiation. Although MR cholangiopancreatography reliably depicts the main extrahepatic and intrahepatic bile ducts, it does not depict the segmental intrahepatic ducts unless they are dilated. The segmental ducts are difficult to visualize with MR cholangiopancreatography because of their small caliber and the limited spatial resolution and signal-to-noise ratio achievable with standard MR pulse sequences. However, visualization of the normal (ie, nondistended) biliary system is necessary for the evaluation of donor candidates for living related liver transplantation. Because of the prevalence of variant biliary anatomy, MR cholangiopancreatography is often used for preoperative evaluation of prospective liver donors. Intravenous morphine administered prior to MR cholangiopancreatography can improve image quality by causing the sphincter of Oddi to contract, which increases pressure in and distention of the biliary and pancreatic ducts. Morphine administration may also be particularly helpful for the evaluation of patients with primary sclerosing cholangitis, malignant neoplasms such as cholangiocarcinoma, or cystic and non-organ-deforming benign pancreatic neoplasms.
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Affiliation(s)
- Alvin C Silva
- Department of Diagnostic Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.
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Piccinni G, Angrisano A, Testini M, Bonomo GM. Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation. J Clin Gastroenterol 2004; 38:350-9. [PMID: 15087695 DOI: 10.1097/00004836-200404000-00010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Giuseppe Piccinni
- Department of Applications in Surgery of Innovative Technologies, University of Bari, School of Medicine, Bari, Italy.
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24
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Prajapati DN, Hogan WJ. Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment. Gastroenterol Clin North Am 2003; 32:601-18. [PMID: 12858608 DOI: 10.1016/s0889-8553(03)00025-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.
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Affiliation(s)
- Devang N Prajapati
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Błaut U, Marecik J, Hartwich A, Herman RM, Laskiewicz J, Thor PJ. The effect of transcutaneous nerve stimulation on intraductal biliary pressure in post-cholecystectomy patients with T-drainage. Eur J Gastroenterol Hepatol 2003; 15:21-6. [PMID: 12544690 DOI: 10.1097/00042737-200301000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) on intraductal biliary pressure (IDP) in basal conditions and after intravenous morphine and oral meal stimulation. DESIGN AND METHODS Fifteen patients (5 male, 10 female) aged 31-83 years (mean 61.5 +/- 13.7 years) with prior cholecystectomy and residual in situ T-tube were examined. Final radiographs excluded any organic abnormalities. The study consisted of three sessions. On the first day (session 1), after the initial manometric intraductal pressure was measured for 15 min, TENS (using a PRO-TENS pocket stimulator) was applied for 15 min. Measurement was continued for 15 min after termination of TENS. The measurement was performed using a water-perfused manometry system (Synectics Medical, Stockholm, Sweden) by a triple-channel manometric catheter inserted into the common bile duct through a T-drain. On the following day (session 2), the protocol was similar except that, after basal IDP measurement, morphine hydrochloride 0.08 mg/kg was injected intravenously 10 min before TENS. On the third day (session 3), after basal measurements were taken, patients were given a standard test meal and the IDP was recorded continuously for 45 min. To estimate the effects of the stimuli applied, absolute intraductal pressure changes were analysed. RESULTS In session 1, TENS reduced basal IDP in all patients by a mean of 3.95 +/- 1.6 mmHg. In 13 patients, 15 min after cessation of TENS a further decrease in IDP was observed. In two patients, termination of TENS was followed by a rebound increase in IDP; however, it did not reach the initial value (mean total decrease 5.05 +/- 2.25 mmHg). In session 2, administration of morphine produced an evident increase in IDP in all subjects by 6.9 +/- 2.7 mmHg. TENS decreased IDP in 13 patients. In two patients, TENS initially failed to lower elevated pressure, but it appeared several minutes after the end of stimulation. In 13 patients, the final IDP values were lower than the baseline pressures. In session 3, after administration of a test meal, IDP decreased within 30-40 min by a mean of 4.89 +/- 1.29 mmHg. CONCLUSIONS TENS decreased basal as well as elevated IDP in the majority of the T-drain patients studied. The effect of TENS persisted after its termination. Elevated IDP is believed to be responsible for pain in patients with sphincter of Oddi dysfunction (SOD). Therefore, we think that TENS can be used effectively and safely as an optional therapeutic method in the treatment of biliary dyskinesia.
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Affiliation(s)
- Urszula Błaut
- Department of Pathophysiology, Jagiellonian University, Cracow, Poland
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Abstract
If the mechanism of pain in patients with sphincter of Oddi (SO) dysfunction is functional obstruction of the biliary tract, and at least in some patients it results from sphincter smooth muscle hypertrophy, then smooth muscle relaxants should have a theoretic role in the management of these patients. Calcium channel antagonists and other smooth muscle relaxants have been shown in "acute" manometric studies to alter SO motility. However, the effect of these agents on vascular smooth muscle remains a concern and often limits their use. At present the role of medical therapy is somewhat unclear because few well-conducted studies have used manometric criteria for the diagnosis of SO dysfunction and the selection of patients for therapy. The main drawback is that no drugs appear to be specific for the SO, long acting, and free of side effects.
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Affiliation(s)
- Alexander Craig
- Gastrointestinal Surgical Unit, Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, 5042, Australia.
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Howerton DH. Sphincter of Oddi manometry: is timing everything? Am J Gastroenterol 2001; 96:1933-4. [PMID: 11419856 DOI: 10.1111/j.1572-0241.2001.03900.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- D H Howerton
- Eastern Virginia School of Medicine, Norfolk, USA
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Wrobleski DM, Barth MM, Oyen LJ. Necrotizing pancreatitis: pathophysiology, diagnosis, and acute care management. AACN CLINICAL ISSUES 1999; 10:464-77. [PMID: 10865531 DOI: 10.1097/00044067-199911000-00006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Severe acute necrotizing pancreatitis is a disease that is caused by premature activation of pancreatic enzymes. Cytokine release contributes to systemic manifestations such as systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), adult respiratory distress syndrome (ARDS), and sepsis. Diagnosis is based on a history of abdominal pain, laboratory values such as serum amylase and lipase levels, and CT scan. Medical management focuses on fluid and electrolyte balance, antibiotic therapy, pain control, and decreasing systemic complications. Surgery is indicated when infectious pancreatic necrosis has been identified. This article addresses incidence and etiology; pathophysiology; clinical manifestations; diagnostics; and medical and surgical patient care management.
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Affiliation(s)
- D M Wrobleski
- Critical Care Section, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
The sphincter of Oddi (SO) functions to regulate the flow of bile and pancreatic juices as well as to prevent the reflux of duodenal contents into the pancreatobiliary system. When dysfunction of the sphincter occurs, symptoms develop relating to either the biliary or pancreatic portions of the sphincter. The mechanism of this dysfunction remains speculative. SO manometry remains the "gold standard" to correctly diagnose the disorder and stratify therapy. Division of the sphincter is effective for SO stenosis, but there is no proven therapy for SO dyskinesia.
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Affiliation(s)
- J Toouli
- Gastrontestinal Surgical Unit, Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, 5042, Australia
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Barthet M, Bouvier M, Pecout C, Berdah S, Viviand X, Mambrini P, Abou E, Salducci J, Grimaud JC. Effects of trimebutine on sphincter of Oddi motility in patients with post-cholecystectomy pain. Aliment Pharmacol Ther 1998; 12:647-52. [PMID: 9701528 DOI: 10.1046/j.1365-2036.1998.00346.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Trimebutine is an opiate modulator of the gastrointestinal motility that interacts with enkephalinergic receptors. AIM To evaluate the effects of trimebutine (50 mg intravenous injection) on the motility of the sphincter of Oddi (SO) as assessed by endoscopic manometry. METHODS Endoscopic manometry was performed on 15 cholecystectomized patients who presented with symptoms suggestive of SO dysfunction. Prior to the endoscopic manometry, endoscopic ultrasonography was performed in order to rule out the possible presence of a bile duct stone. RESULTS Injecting trimebutine resulted in a significant increase in the SO antegrade phasic contraction rate (P = 0.02). Trimebutine decreased the basal pressure of the SO (32.5 vs. 27.5 mmHg), but the difference is not statistically significant (P = 0.11). The effects of trimebutine differed depending on the basal SO motility anomalies involved, but the period of latency was similar (mean 89 s: range 30-240 s). The basal anomalies were an increased basal SO pressure of > 40 mmHg in three patients, a tachyoddia (frequency of phasic contractions (PC) > 10/min) in six patients, prolonged PC (> 10 s) in two patients and an absence of phasic contraction in one patient. The basal pressure of the SO decreased in the three patients presenting with SO hyperpressure, but returned to a normal value in one case. The frequency of the PC decreased to normal in three out of the six patients with tachyoddia. The duration of the PC returned to normal in the two patients with prolonged PC whereas their frequencies increased. Prolonged PC developed in the patient without any detectable phasic contraction. CONCLUSIONS Trimebutine modulates SO motility in various ways depending on the basal SO motility anomaly observed after cholecystectomy. This regulatory effect suggests the existence of encephalinergic control of SO motility.
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Affiliation(s)
- M Barthet
- Department of Gastroenterology, Hopital Nord, Marseille, France
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Abstract
OBJECTIVE Sphincter of Oddi dysfunction (SOD) is a biliary disorder with a recognized pathophysiology and demonstrated surgical treatment. We sought to examine whether women with SOD were overrepresented on measures of somatization, sexual and physical abuse, socially compliant attitudes, and familial psychiatric illness. METHOD We matched 33 women with SOD to 33 normal controls by age, sex, and race, and, with a case-controlled cross-sectional questionnaire, compared the groups on the study variables. Statistics included a chi 2 for categorical variables, t tests for scores of somatization and attitudes of social desirability, and Pearson correlation coefficients for post hoc associations of variables. Bonferroni corrections were used with chi 2 values to reduce capitalization by chance. RESULTS SOD patients exhibited excessive nongastroenterological somatic complaints compared with controls (p < .0001). There was a statistical increase in reports of childhood sexual, but not physical, abuse in the SOD women (p < .02) compared with controls. The severity of the abuse correlated strongly with the severity of somatic complaints. There were no differences in social desirability attitudes or family psychiatric histories of the two groups. CONCLUSIONS We conclude that SOD is associated with a high degree of somatization in adulthood, and a mean rate more than four times that of controls in self-reports of sexual abuse in childhood. The severity of childhood sexual abuse is correlated with the severity of somatization in later life. A psychological model for this disorder is suggested by the data. Increased psychiatric attention is indicated in the treatment of women with this disorder.
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Affiliation(s)
- H D Abraham
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island, USA.
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Minami A, Nakatsu T, Uchida N, Hirabayashi S, Fukuma H, Morshed SA, Nishioka M. Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function. Dig Dis Sci 1995; 40:2550-4. [PMID: 8536511 DOI: 10.1007/bf02220440] [Citation(s) in RCA: 143] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (< 12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min, P < NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P = NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.
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Affiliation(s)
- A Minami
- Third Department of Internal Medicine, Kagawa Medical School, Japan
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Abstract
The effect of propofol was studied in 11 patients who had common bile duct sphincter of Oddi manometry for suspected dysfunction. Patients were initially sedated with midazolam and then further or resedated with propofol for the second set of pressure measurements. Recordings were made about 10 min after giving each drug. No patient had elevated basal pressure initially. Average basal pressure was unchanged (16.7 +/- 16.4 mm Hg), phasic contraction frequency was unchanged (3.4 +/- 3.8/min), and phasic contraction amplitude fell but did not achieve statistical significance (91.8 +/- 77.3 mm Hg, P = 0.1). There was no difference in lowest blood pressure, pulse, or oxygen saturation recorded during midazolam or propofol sedation. Subjectively, the patients were more sedated during propofol administration. It is concluded that propofol is a safe and effective agent for conscious sedation. It does not alter the sphincter of Oddi pressure profile in patients with normal basal sphincter pressures and thus could be used as an alternative and perhaps better form of sedation for ERCP with sphincter of Oddi manometry.
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Affiliation(s)
- J S Goff
- Gastroenterology Department, University of Colorado Health Sciences Center, Fort Collins, USA
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Kalloo AN, Pasricha PJ. Effect of gastric distension and duodenal fat infusion on biliary sphincter of Oddi motility in healthy volunteers. Dig Dis Sci 1995; 40:745-8. [PMID: 7720464 DOI: 10.1007/bf02064972] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Although sphincter of Oddi (SO) dysfunction has been implicated in the pathogenesis of postcholecystectomy syndrome and pancreatitis, little is known about normal physiologic stimuli, such as intraduodenal fat on human SO motility. Furthermore, gastric distension that frequently accompanies endoscopic manometry has been shown in animal studies to affect SO motility. We evaluated the effects of intraduodenal fat and gastric distension on SO basal pressure. Asymptomatic volunteers had SO manometry performed while sequentially performing gastric distension and intraduodenal fat perfusion. Five subjects (ages 29.8 +/- 4.8 years, range 22-35 years) had a mean basal sphincter of Oddi pressure of 23.4 +/- 5 mm Hg (range 17-31 mm Hg). Injection of air into the stomach caused no appreciable change in either intragastric pressure or SO pressure. Intraduodenal fat infusion resulted in a decrease in mean SO basal pressure from 23.4 +/- 5.0 to 4.4 +/- 4.4 mm Hg (P = 0.004). These results demonstrate that gastric distension does not affect SO basal pressure and that intraduodenal fat infusion reduces SO basal pressure.
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Affiliation(s)
- A N Kalloo
- Section of Therapeutic Endoscopy, Johns Hopkins Hospital, Baltimore, Maryland 21287-4461, USA
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Stankov G, Schmieder G, Zerle G, Schinzel S, Brune K. Double-blind study with dipyrone versus tramadol and butylscopolamine in acute renal colic pain. World J Urol 1994; 12:155-61. [PMID: 7951343 DOI: 10.1007/bf00192278] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
To investigate the combined analgesic and spasmolytic effect of dipyrone, 104 patients suffering from "severe" or "excruciating" colic pain due to a confirmed calculus in the upper urinary tract were randomized to receive i.v. either 2.5 g dipyrone (36 patients), 100 mg tramadol (35 patients), or 20 mg butylscopolamine (33 patients) in a multicentre, observer-blind, parallel-group study conducted in 8 German centres. The three treatment groups were homogeneous when analyzed by age, sex, height, and baseline pain intensity. Dipyrone was significantly more effective than tramadol in reducing pain for the primary endpoint, pain intensity differences (PID) at 20, 30, and 50 min after drug administration, and was significantly more effective than butylscopolamine at 30 and 50 min for the secondary efficacy endpoint, pain intensity differences on a categorical scale. Dipyrone had the highest SPID0-2 h of the three drugs (P < 0.05). Only 5 patients receiving dipyrone needed "rescue" medication as compared with 13 patients given tramadol and 11 patients receiving butylscopolamine. Adverse events were observed in 4 patients receiving butylscopolamine and in 1 patient each given dipyrone and tramadol. "Distinct" pain relief as assessed on a visual analogue scale (VAS) is a reliable method of determining the onset of analgesic action in the colic pain model.
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Affiliation(s)
- G Stankov
- DIAS Institute (Institute for Drug Investigation, Auditing and Statistics), Kirchheim/München, Germany
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Allescher HD, Safrany L, Neuhaus H, Feussner H, Classen M. Aerobilia and hypomotility of the sphincter of Oddi in a patient with chronic intestinal pseudo-obstruction. Gastroenterology 1992; 102:1782-7. [PMID: 1568590 DOI: 10.1016/0016-5085(92)91744-o] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 50-year-old woman with a typical history of chronic idiopathic intestinal pseudo-obstruction was admitted to hospital because of an acute episode of abdominal cramps, nausea, and vomiting. The diagnosis of chronic idiopathic intestinal pseudo-obstruction had been established in this patient who had malnutrition and extreme weight loss as a result of severe malabsorption syndrome. The abdominal roentgenogram showed a typical hypotonic intestine with an enlarged stomach and distended intestinal loops with the radiological signs of an ileus. In addition to former episodes, there was also a transient aerobilia. The patient had not undergone biliary surgery or endoscopic sphincterotomy. To investigate the cause of the findings, endoscopic retrograde cholangiopancreatography and endoscopic manometry of the sphincter of Oddi were performed. The endoscopy showed the stomach and duodenum with a wide and dilated lumen and no spontaneous motility. Endoscopic manometry of the biliary tract and the sphincter of Oddi showed several abnormalities compared with a group of normal volunteers or patients who were examined via biliary manometry for other reasons. There was a low basal pressure (3.5 mm Hg) in the sphincter of Oddi together with low-amplitude phasic contractions (25-30 mm Hg), but the contraction frequency was in the normal range. Further investigations of the motility of the gastrointestinal tract in this patient showed diffuse esophageal spasms and a markedly delayed gastric emptying. The findings of biliary manometry in this patient suggest involvement of the sphincter of Oddi and the biliary system in chronic idiopathic pseudo-obstruction.
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Affiliation(s)
- H D Allescher
- II Medizinische Klinik und Poliklinik, Technischen Universität München, Germany
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Ibuki Y, Kudo M, Todo A. Endoscopic retrograde extraction of common bile duct stones with drip infusion of isosorbide dinitrate. Gastrointest Endosc 1992; 38:178-80. [PMID: 1568616 DOI: 10.1016/s0016-5107(92)70387-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Y Ibuki
- Department of Internal Medicine, Kobe City General Hospital, Japan
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Abstract
The nature, frequency, severity, and possible causes of complications after 207 sphincter of Oddi manometry measurements were studied in 146 patients. Acute pancreatitis was diagnosed in 6% (12 of 207) of the investigations and in 8% (12 of 146) of the patients examined. The pancreatitis was mild in all patients. After cannulation of the pancreatic duct, acute pancreatitis occurred in 10 of 95 (11%) patients compared with one of 93 (1%) when the manometry catheter entered the bile duct only (p less than 0.02). Seven (58%) of the patients who developed acute pancreatitis, however, were found to be suffering from chronic pancreatitis. Some 26% of all sphincter of Oddi manometry measurements on patients with this diagnosis were complicated by an acute attack of pancreatitis compared with 3% (p less than 0.001) in patients without signs of chronic pancreatitis. In all patients the pancreatitis developed within three hours of manometry. We conclude that pancreatitis may occasionally follow sphincter of Oddi manometry measurement, even in patients without pancreaticobiliary disease, and that underlying chronic pancreatitis constitutes a definite risk. Sphincter of Oddi manometry measurement in control subjects should therefore be performed only in centres where the safety of the procedure has been established, and the presence of chronic pancreatitis should be excluded beforehand. Cannulation of the pancreatic duct should be avoided. Manometry can be safely performed, however, as an outpatient procedure.
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Affiliation(s)
- P Rolny
- Department of Medicine, (Division of Gastroenterology), Orebro Medical Center Hospital, Sweden
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Affiliation(s)
- P A Grace
- Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London
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Rolny P, Arlebäck A, Funch-Jensen P, Kruse A, Järnerot G. Clinical significance of manometric assessment of both pancreatic duct and bile duct sphincter in the same patient. Scand J Gastroenterol 1989; 24:751-4. [PMID: 2814340 DOI: 10.3109/00365528909093117] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this study both pancreatic and bile duct sphincter pressures were measured on the same occasion by means of endoscopic manometry in 42 patients with long-standing upper abdominal pain. Nine (53%) of the 17 patients with abnormal sphincter function had a marked difference between the pancreatic duct sphincter pressure (PSOP) and the bile duct sphincter pressure (BSOP): 6 patients with a clinical diagnosis of biliary dyskinesia showed elevated BSOPs, whereas the PSOPs were normal. The reverse, an abnormal PSOP but normal or only a slightly elevated BSOP, was registered in the three patients with chronic pancreatitis. These findings indicate that a motor abnormality may be restricted to only one of the sphincters. Thus, when the sphincter of Oddi is investigated only from the pancreatic duct, manometry may either fail to show an abnormal BSOP in some patients with biliary dyskinesia, or it may falsely suggest this diagnosis in patients with unrecognized pancreatitis.
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Affiliation(s)
- P Rolny
- Dept. of Medicine, Orebro Medical Center Hospital, Sweden
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