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Ryu J, Paik KH, Kwon CI, Koh DH, Song TJ, Jeong S, Park WS. The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11195692. [PMID: 36233560 PMCID: PMC9573508 DOI: 10.3390/jcm11195692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.
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Affiliation(s)
- Jieun Ryu
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Kyu-Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13497, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
| | - Dong Hee Koh
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
| | - Tae Jun Song
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seok Jeong
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Correspondence: ; Tel.: +82-42-220-9339
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Boivineau G, Gonzalez JM, Gasmi M, Vitton V, Barthet M. Sphincter of Oddi dysfunction. J Visc Surg 2022; 159:S16-S21. [DOI: 10.1016/j.jviscsurg.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Černá P, Kilpatrick S, Gunn-Moore DA. Feline comorbidities: What do we really know about feline triaditis? J Feline Med Surg 2020; 22:1047-1067. [PMID: 33100169 PMCID: PMC10814216 DOI: 10.1177/1098612x20965831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PRACTICAL RELEVANCE Feline triaditis describes concurrent pancreatitis, cholangitis and inflammatory bowel disease (IBD). The reported prevalence is 17-39% in ill referral patients. While the aetiology is poorly understood, it is known to include infectious, autoimmune and physical components. What is not known is whether different organs are affected by different diseases, or the same process; indeed, triaditis may be part of a multiorgan inflammatory disease. Feline gastrointestinal tract anatomy plays its role too. Specifically, the short small intestine, high bacterial load and anatomic feature whereby the pancreatic duct joins the common bile duct before entering the duodenal papilla all increase the risk of bacterial reflux and parenchymal inflammation. Inflammation may also be a sequela of bowel bacterial translocation and systemic bacteraemia. DIAGNOSTIC CHALLENGES Cholangitis, pancreatitis and IBD manifest with overlapping, vague and non-specific clinical signs. Cholangitis may be accompanied by increased serum liver enzymes, total bilirubin and bile acid concentrations, and variable ultrasonographic changes. A presumptive diagnosis of pancreatitis is based on increased serum pancreatic lipase immunoreactivity or feline pancreas-specific lipase, and/or abnormal pancreatic changes on ultrasonography, though these tests have low sensitivity. Diagnosis of IBD is challenging without histopathology; ultrasound findings vary from normal to mucosal thickening or loss of layering. Triaditis may cause decreased serum folate or cobalamin (B12) concentrations due to intestinal disease and/or pancreatitis. Triaditis can only be confirmed with histopathology; hence, it remains a presumptive diagnosis in most cases. EVIDENCE BASE The literature on feline triaditis, pancreatitis, cholangitis and IBD is reviewed, focusing on histopathology, clinical significance and diagnostic challenges. Current management recommendations are provided. Further studies are needed to understand the complex pathophysiology, and in turn improve diagnosis and treatment.
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Affiliation(s)
- Petra Černá
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, and Small Animal Clinic, The University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | | | - Danielle A Gunn-Moore
- The Royal (Dick) School of Veterinary Studies, and The Roslin Institute, University of Edinburgh, UK
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Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi. Gastrointest Endosc Clin N Am 2013; 23:405-34. [PMID: 23540967 DOI: 10.1016/j.giec.2012.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.
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Vitton V, Ezzedine S, Gonzalez JM, Gasmi M, Grimaud JC, Barthet M. Medical treatment for sphincter of oddi dysfunction: Can it replace endoscopic sphincterotomy? World J Gastroenterol 2012; 18:1610-5. [PMID: 22529689 PMCID: PMC3325526 DOI: 10.3748/wjg.v18.i14.1610] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 06/16/2011] [Accepted: 02/27/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To report the results of a medical management of sphincter of oddi dysfunction (SOD) after an intermediate follow-up period.
METHODS: A total of 59 patients with SOD (2 men and 57 women, mean age 51 years old) were included in this prospective study. After medical treatment for one year, the patients were clinically re-evaluated after an average period of 30 mo.
RESULTS: The distribution of the patients according to the Milwaukee’s classification was the following: 11 patients were type 1, 34 were type 2 and 14 were type 3. Fourteen patients underwent an endoscopic sphincterotomy (ES) after one year of medical treatment. The median intermediate follow-up period was 29.8 ± 3 mo (3-72 mo). The initial effectiveness of the medical treatment was complete, partial and poor among 50.8%, 13.5% and 35%, respectively, of the patients. At the end of the follow-up period, 37 patients (62.7%) showed more than 50% improvement. The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively (64.2% vs 62.2%, respectively).
CONCLUSION: Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because, after an intermediate follow-up period, the two treatments show the same success rates.
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Lambie H, Cook A, Scarsbrook A, Lodge J, Robinson P, Chowdhury F. Tc99m- hepatobiliary iminodiacetic acid (HIDA) scintigraphy in clinical practice. Clin Radiol 2011; 66:1094-105. [DOI: 10.1016/j.crad.2011.07.045] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 06/23/2011] [Accepted: 07/05/2011] [Indexed: 01/18/2023]
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Delhaye M, Matos C, Arvanitakis M, Devière J. Pancreatic ductal system obstruction and acute recurrent pancreatitis. World J Gastroenterol 2008; 14:1027-33. [PMID: 18286683 PMCID: PMC2689404 DOI: 10.3748/wjg.14.1027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.
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Abstract
AIM Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management. METHODS A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful. RESULTS Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile-duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured. CONCLUSION In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.
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Sonoda Y, Kawamoto M, Woods CN, Schloithe AC, Carati CJ, Toouli J, Saccone GTP. Sphincter of Oddi function in the Australian brush-tailed possum is inhibited by intragastric ethanol. Neurogastroenterol Motil 2007; 19:401-10. [PMID: 17509022 DOI: 10.1111/j.1365-2982.2007.00907.x] [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: 02/08/2023]
Abstract
The role of sphincter of Oddi (SO) function in alcoholic acute pancreatitis (AP) is unclear. We aimed to compare the effect of i.v. and intragastric (IG) ethanol on SO function (i.e. trans-sphincteric flow; TSF) and investigate possible neural mechanisms. The involvement of gastric mucosal damage was also investigated by pretreatment with pantoprazole. In anaesthetized Australian possums, blood pressure (BP), TSF and blood ethanol concentrations were measured after i.v. or IG ethanol. Possums were subjected to acute vagotomy, atropine, L-nitro arginine methyl ester (L-NAME) or pantoprazole pretreatment prior to IG ethanol. BP was not significantly altered by ethanol. Ethanol decreased TSF in a dose and route-dependent manner. The lowest dose of IG ethanol reduced TSF but this response was not duplicated by i.v. ethanol producing the same blood ethanol concentrations. Acute vagotomy, atropine or L-NAME pretreatment blocked the ethanol-induced decrease in TSF and simultaneously suppressed the blood ethanol concentration. Pantoprazole pretreatment reduced the TSF response and blood ethanol concentrations implicating mechanisms induced by gastric mucosal damage. We conclude that ethanol (and/or its metabolites) reduces TSF via humoral and neural mechanisms involving vagal pathways, muscarinic receptors and nitric oxide. Reduced TSF could contribute to the onset of AP.
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Affiliation(s)
- Y Sonoda
- Pancreatobiliary Research Group, Department of General and Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, Australia
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Woods CM, Toouli J, Saccone GTP. Exogenous purines induce differential responses in the proximal and distal regions of the possum sphincter of Oddi. ACTA ACUST UNITED AC 2007; 27:27-38. [PMID: 17199873 DOI: 10.1111/j.1474-8673.2006.00387.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
1. The aim of this study was to compare the effect of exogenous ATP and adenosine on spontaneous motility of the proximal and distal regions of the possum sphincter of Oddi (SO). 2. ATP or adenosine (1 microm-1 mm) was applied to distal-SO or proximal-SO muscle rings in organ baths in the absence or presence of tetrodotoxin (TTX) or P1/P2 antagonists. 3. Both ATP and adenosine altered spontaneous activity, predominantly in proximal-SO rings. 4. Exogenous ATP induced a bi-phasic response consisting of a brief TTX-sensitive excitatory component, and a longer-lasting TTX-insensitive inhibitory component. 5. The excitatory ATP response likely involves P2X receptors, whereas the late inhibitory response likely involves P2Y receptors. 6. Exogenous adenosine decreased spontaneous SO activity, via a TTX-insensitive mechanism. 7. Exogenous purines modulate SO motility, acting primarily in the proximal region of the SO, via neural and non-neural mechanisms and multiple purine receptor subtypes.
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Affiliation(s)
- C M Woods
- Pancreatobiliary Research Group, Department of General and Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, SA 5042, Australia
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Siegel JH, Cohen SA. Pull or push pancreatic sphincterotomy for sphincter of Oddi dysfunction? A conundrum for experts only. Gastrointest Endosc 2006; 64:723-5. [PMID: 17055864 DOI: 10.1016/j.gie.2006.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Accepted: 04/27/2006] [Indexed: 02/08/2023]
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Woods CM, Toouli J, Saccone GTP. Exogenous adenosine triphosphate and adenosine stimulate proximal sphincter of oddi motility via neural mechanisms in the anesthetized Australian possum. Dig Dis Sci 2006; 51:1347-56. [PMID: 16832616 DOI: 10.1007/s10620-006-9128-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 01/22/2006] [Indexed: 12/15/2022]
Abstract
We aimed to determine if exogenous adenosine triphosphate or adenosine modulated sphincter of Oddi motility and involved neural mechanisms. Sphincter of Oddi motility was recorded in anesthetized possums by manometry. Adenosine triphosphate or adenosine (1 microM-10 mM) was applied topically to the sphincter before and after pretreatment with tetrodotoxin, hexamethonium, atropine, or Nomega-nitro-L-arginine methyl ester. Sphincter contraction amplitude and frequency were quantified. Adenosine triphosphate induced a concentration-dependent increase in proximal sphincter contraction amplitude and frequency (P < 0.05). This response was reduced by tetrodotoxin and atropine but enhanced by hexamethonium and Nomega-nitro-L-arginine methyl ester. Adenosine concentration dependently increased proximal sphincter contraction amplitude (P < 0.05) only. This response was reduced by tetrodotoxin, atropine, and Nomega-nitro-L-arginine methyl ester, whereas hexamethonium had no effect. We conclude that exogenous adenosine triphosphate and adenosine stimulate proximal sphincter of Oddi motility via neural mechanisms, involving cholinergic motor neurons. Adenosine triphosphate may further modulate sphincter motility via nicotinic and nitrergic pathways.
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Affiliation(s)
- C M Woods
- Pancreatobiliary Research Group, Department of General and Digestive Surgery, Flinders Medical Centre, Bedford Park, SA 5042, Australia
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Abstract
The underlying mechanisms involved in the pathogenesis of acute pancreatitis are ill understood. The mortality rate of this disease has not significantly improved over the past few decades. Current treatment options are limited, and predominantly aimed at supportive therapy. A key feature of severe acute pancreatitis is the presence of extensive tissue necrosis with both local and systemic manifestations of inflammatory response syndromes. A better understanding of the underlying pathophysiology of severe acute pancreatitis may lead to more targeted therapeutic options, potentially leading to improved survival. Animal models of acute pancreatitis are therefore an essential investigative tool for these aims to be achieved. This review discusses the suitability of recent non-invasive models of acute pancreatitis such as hormone-induced, alcohol-induced, immune-mediated, diet-induced, gene knockout and L-arginine; and invasive models including closed duodenal loop, antegrade pancreatic duct perfusion, biliopancreatic duct injection, combination of secretory hyperstimulation with minimal intraductal bile acid exposure, vascular-induced, ischaemia/reperfusion and duct ligation.
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Affiliation(s)
- Kim Hue Su
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
| | - Christine Cuthbertson
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
| | - Christopher Christophi
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
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Barthet M, Vitton V. [Sphincter of Oddi dysfunction]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2005; 29:832-8. [PMID: 16294153 DOI: 10.1016/s0399-8320(05)86355-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Marc Barthet
- Hôpital Nord, Chemin des Bourrelys, 13915 Marseille Cedex 20
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Chen JWC, Shi CX, Teng MJ, Schloithe AC, Toouli J, Saccone GTP. Scorpion venom stimulates biliary/duodenal motility and pancreatic exocrine secretion. Neurogastroenterol Motil 2004; 16:447-54. [PMID: 15306000 DOI: 10.1111/j.1365-2982.2004.00566.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Scorpion envenomation causes severe upper abdominal pain associated with nausea and vomiting. Although scorpion venom (SV) stimulates pancreatic and gastric secretion in animal models, its effects on duodenal and biliary motility have not been reported. The aim of this study was to determine the effects of SV on sphincter of Oddi (SO), duodenal and gall bladder motility and pancreatic amylase output. Anaesthetized Australian possums (n = 21) were infused with SV via intravenous or closed intra-arterial routes. Blood pressure, SO, duodenal and gall bladder motility were continuously monitored for 4 h. Trans-sphincteric flow (TSF), an indicator of bile duct resistance, was measured concurrently. The amylase output in pancreatic juice was also measured. SV infusion resulted in profound transient increase in blood pressure, SO motility and a significant decrease in TSF. No significant differences were noted in SO basal pressure changes. A transient increase in gall bladder tone, duodenal contraction amplitude and frequency, and amylase output were noted. Following the peak in blood pressure, amylase output, SO, gall bladder and duodenal motility were depressed. SV induces a rapid but transient increase in biliary and duodenal motility that is associated with stimulation of pancreatic amylase output. These changes may contribute to gastrointestinal symptoms associated with early phases of envenomation.
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Affiliation(s)
- J W C Chen
- Department of General and Digestive Surgery, Pancreatobiliary Research Group, Flinders Medical Centre, Flinders University, Bedford Park, SA 5042, Australia.
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Sandstrom P, Woods CM, Brooke-Smith M, Saccone GTP, Toouli J, Svanvik J. Highly selective iNOS inhibition and sphincter of Oddi motility in the Australian possum. ACTA ACUST UNITED AC 2004; 181:321-31. [PMID: 15196093 DOI: 10.1111/j.1365-201x.2004.01296.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM Inducible nitric oxide synthase (iNOS) plays a major role in acute pancreatitis. Selective inhibitors of iNOS are being developed as therapeutic agents. Sphincter of Oddi (SO) dysfunction may cause pancreatitis and nitric oxide is necessary for SO relaxation. A new highly selective iNOS inhibitor, AR-C102222AA (AR-C), is evaluated together with the established iNOS inhibitor, L-N(6)-(1-iminoethyl)lysine (L-NIL), and the selective neuronal nitric oxide synthase (nNOS) blocker S-methyl-l-thiocitrulline (SMTC). METHODS In anaesthetized Australian Brush-tailed possums, the effect of topical, i.v. or i.a. administration of these drugs was evaluated on spontaneous SO motility, blood pressure (BP) and pancreatic vascular perfusion. SO motility was recorded by manometry and pancreatic vascular perfusion by laser Doppler fluxmetry. Also, the effect of SMTC and AR-C on electrical field stimulation (EFS)-induced non-cholinergic non-adrenergic (NANC) SO relaxation in vitro was evaluated. RESULTS Infusion of AR-C (0.1-30 micromol kg(-1)) increased SO contraction frequency (P = 0.026) only at the two highest doses. L-NIL infusion (0.15 to 14.7 micromol kg(-1)) also increased SO contraction frequency at 8.8 micromol kg(-1) (P < 0.05) and reduced SO contraction amplitude at the two highest doses (P < 0.05). SMTC injections (0.5 nmol-2.4 micromol) produced a dose-dependent increase in SO contraction frequency (P = 0.009), but no effect was seen on the other parameters. In vitro SMTC (40-400 microm) inhibited EFS-induced NANC relaxation in a dose-dependent manner (P < 0.0005). In contrast AR-C (10-500 microm) had no effect on EFS-induced NANC relaxation (P > 0.05). CONCLUSIONS At low doses, AR-C does not effect SO motility or EFS-induced NO mediated relaxation. However, high doses of AR-C and L-NIL in vivo influenced SO motility by inhibiting nNOS activity and these effects need be considered in relation to therapeutic doses of this agent.
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Affiliation(s)
- P Sandstrom
- Department of Biomedicine and Surgery, University Hospital of Linkoping, Sweden
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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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Sandstrom P, Gasslander T, Sundqvist T, Franke J, Svanvik J. Depletion of serum L-arginine in patients with acute pancreatitis. Pancreas 2003; 27:261-6. [PMID: 14508133 DOI: 10.1097/00006676-200310000-00012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Acute pancreatitis may be initiated by interference with the pancreatic outflow to the duodenum. This flow is normally regulated by reflex relaxation of the sphincter of Oddi in which nitric oxide is an important mediator. AIM To test the hypothesis that acute pancreatitis involves a depletion in serum L-arginine resulting in impaired production of nitric oxide. METHODS We measured serum L-arginine and L-citrulline and urinary nitrite/nitrate concentrations 1 to 3 days after the onset of symptoms in 11 patients with gallstone pancreatitis, 10 patients with alcoholic pancreatitis, and 6 patients with idiopathic pancreatitis. We compared their results with those from control groups of 13 healthy blood donors, 9 patients fasting before hernia operations, 8 patients with acute cholecystitis, and 9 alcoholic subjects but no pancreatitis. Serum arginine and citrulline concentrations were measured with high performance liquid chromatography, and urinary nitrite/nitrate spectrophotometrically. RESULTS Patients with acute pancreatitis, of whatever cause, had lower serum L-arginine and L-citrulline concentrations than controls. Patients with gallstone and idiopathic pancreatitis also have reduced urinary concentrations of nitrite and nitrate but this was not seen in patients with alcoholic pancreatitis. CONCLUSIONS L-arginine and L-citrulline concentrations are depleted in the serum of patients with acute pancreatitis. Reduced urinary nitrite and nitrate in gallstone pancreatitis indicate that there is a defect formation of nitric oxide. This may cause a functional obstruction of the outflow of pancreatic juice to the duodenum and so may be involved in the pathophysiology of acute pancreatitis.
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Affiliation(s)
- Per Sandstrom
- Department of Biomedicine and Surgery, Faculty of Health Sciences, University Hospital, Linköping, Sweden
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Kusnierz-Cabala B, Kedra B, Sierzega M. Current concepts on diagnosis and treatment of acute pancreatitis. Adv Clin Chem 2003; 37:47-81. [PMID: 12619705 DOI: 10.1016/s0065-2423(03)37006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- B Kusnierz-Cabala
- Department of Clinical Biochemistry, Collegium, Medicum Jagiellonian University, Krakow, Poland
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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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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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Affiliation(s)
- Choichi Sugawa
- Departments of *Surgery and Pathology, Wayne State University, Detroit, Michigan, USA and 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Daisuke Higuchi
- Departments of *Surgery and Pathology, Wayne State University, Detroit, Michigan, USA and 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Teisa An
- Departments of *Surgery and Pathology, Wayne State University, Detroit, Michigan, USA and 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Charles E Lucas
- Departments of *Surgery and Pathology, Wayne State University, Detroit, Michigan, USA and 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Satoshi Tokioka
- Departments of *Surgery and Pathology, Wayne State University, Detroit, Michigan, USA and 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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Lai KH, Lo GH, Cheng JS, Fu MT, Wang EM, Chan HH, Wang YY, Hsu PI, Lin CK. Effect of somatostatin on the sphincter of Oddi in patients with acute non-biliary pancreatitis. Gut 2001; 49:843-846. [PMID: 11709520 PMCID: PMC1728542 DOI: 10.1136/gut.49.6.843] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Somatostatin has been used to prevent pancreatitis after endoscopic retrograde cholangiopancreatography but its effect on acute non-biliary pancreatitis is still unclear. AIM The purpose of this study was to evaluate the function of the sphincter of Oddi (SO) and the effect of somatostatin on patients with non-biliary pancreatitis. METHODS Twenty patients (18 males, two females) with acute pancreatitis (alcoholic 18, idiopathic two) received SO manometry within one week after admission. After baseline measurement, a bolus dose of somatostatin (Stilamin, Serono) 250 microg was infused slowly, and SO manometry was repeated after five minutes. Continuous infusion of somatostatin 250 microg/h was given for 12 hours after SO manometry. Serum amylase, lipase, glucose, and C reactive protein (CRP) levels were examined before and after somatostatin infusion. RESULTS SO manometry was unsuccessful in six patients due to contracted sphincter. In the remaining 14 patients, high SO basal pressure (SOBP >40 mm Hg) was found in seven patients. After somatostatin infusion, mean SOBP decreased from 48.8 (29) to 31.9 (22) mm Hg (p<0.01). One patient had a paradoxical reaction to somatostatin (SOBP increased from 30 to 50 mm Hg) while the other 13 patients had a fall in SOBP after somatostatin. One patient developed abdominal pain with a serum amylase level of 2516 IU/l after SO manometry. No other side effects or changes in amylase, lipase, glucose, or CRP levels were observed in the other 19 patients after SO manometry and somatostatin infusion. DISCUSSION Sphincter of Oddi dysfunction is common in patients with acute non-biliary pancreatitis and in most cases somatostatin can relax the sphincter.
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Affiliation(s)
- K H Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, School of Medicine, National Yang Ming University, Taiwan, ROC.
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Shrestha S, Pasricha PJ. Chronic Visceral Right Upper Quadrant Pain Without Gallstones. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:123-131. [PMID: 11469970 DOI: 10.1007/s11938-001-0024-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with chronic visceral right upper quadrant pain without gallstones can be broadly categorized into two groups: patients with gallbladder dyskinesia, and patients with sphincter of Oddi dysfunction (SOD). Treating patients with these disorders is often challenging to clinicians due to the difficulty at arriving at a definite diagnosis, and the lack of efficacy of various treatment modalities. The only real treatment option for patients with gallbladder dyskinesia is cholecystectomy; however, the results are difficult to predict in an individual patient. Patients with SOD can be approached according to a classification that at least partially reflects the underlying pathophysiology. Patients with type I SOD have underlying papillary stenosis, and benefit from empiric sphincterotomy. Patients with type II SOD may have muscle spasm as predominant pathophysiology; this group of patients benefit from sphincterotomy only if increased sphincter pressure is demonstrated by sphincter of Oddi manometry. Patients with type III SOD may have visceral hyperalgesia; a trial of antidepressants or a therapeutic trial with botulinum toxin injection into the ampulla should be considered prior to more invasive endoscopic therapy.
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Affiliation(s)
- Sanjeeb Shrestha
- Division of Gastroenterology, University of Texas Medical Branch, 301 University Boulevard, 4.106 MuCullough Building, Galveston, TX 77555-0764, USA.
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Affiliation(s)
- D L Franga
- Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
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Wehrmann T, Schmitt TH, Arndt A, Lembcke B, Caspary WF, Seifert H. Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction. Aliment Pharmacol Ther 2000; 14:1469-77. [PMID: 11069318 DOI: 10.1046/j.1365-2036.2000.00814.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the technical feasibility, safety, and short-term efficacy of botulinum toxin injection for pancreatic sphincter of Oddi dysfunction and to analyse whether the symptomatic response to botulinum toxin might be a predictor of outcome for endoscopic sphincterotomy. METHODS Fifteen consecutive patients (nine female, aged 38 +/- 12 years) with frequent attacks (median four) of acute pancreatitis within 6 months, and manometrically proven pancreatic sphincter of Oddi dysfunction underwent endoscopic injection of 100 units of botulinum toxin into the major papilla. All patients underwent prospective follow-up thereafter and in cases of recurrent pancreatitis manometry this was repeated and pancreatic sphincterotomy was performed. RESULTS No side-effects occurred after botulinum toxin injection in any patient. Within 3 months after botulinum toxin treatment, 12 out of 15 patients remained asymptomatic (80% primary response). Only one out of three patients without symptomatic benefit showed continued elevated pancreatic sphincter pressure at manometry and only this patient benefited from pancreatic sphincterotomy later on. Eleven of the 12 patients initially responding to botulinum toxin injection developed a symptomatic relapse 6 +/- 2 months after botulinum toxin treatment. These patients then achieved long-term clinical remission from pancreatic or combined (biliary and pancreatic, n=5) sphincterotomy (median follow-up, 15 months). CONCLUSION Endoscopic botulinum toxin injection into the papilla of Vater is a safe procedure for treatment of pancreatic sphincter of Oddi dysfunction that may provide short-term relief in about 80% of the patients. Those patients who respond to botulinum toxin may subsequently gain definitive cure from sphincterotomy.
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Affiliation(s)
- T Wehrmann
- Department of Internal Medicine II, J.W. Goethe-University Hospital, Frankfurt am Main, Germany.
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Chen JW, Thomas A, Woods CM, Schloithe AC, Toouli J, Saccone GT. Sphincter of Oddi dysfunction produces acute pancreatitis in the possum. Gut 2000; 47:539-45. [PMID: 10986215 PMCID: PMC1728061 DOI: 10.1136/gut.47.4.539] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Sphincter of Oddi dysfunction has been implicated as a cause of various forms of acute pancreatitis. However, there is no direct evidence to show that sphincter of Oddi dysfunction can cause obstruction of trans-sphincteric flow resulting in acute pancreatitis. AIMS To determine if induced sphincter of Oddi spasm can produce trans-sphincteric obstruction and, in combination with stimulated pancreatic secretion, induce acute pancreatitis. METHODS In anaesthetised possums, the pancreatic duct was ligated and pancreatic exocrine secretion stimulated by cholecystokinin octapeptide/secretin to induce acute pancreatitis. In separate animals, carbachol was applied topically to the sphincter of Oddi to cause transient sphincter obstruction. Sphincter of Oddi motility, trans-sphincteric flow, pancreatic duct pressure, pancreatic exocrine secretion, plasma amylase levels, and pancreatic tissue damage (histology score) were studied and compared with variables in ligation models. RESULTS Acute pancreatitis developed following stimulation of pancreatic exocrine secretion with peptides after pancreatic duct ligation (p<0.05). Neither pancreatic duct ligation nor stimulation of pancreatic exocrine secretion with cholecystokinin octapeptide/secretin alone resulted in acute pancreatitis. Topical carbachol stimulated sphincter of Oddi motility abolished trans-sphincteric flow, and increased pancreatic exocrine secretion (p<0.05) and pancreatic duct pressure to levels comparable with pancreatic duct ligation (p<0.001). Carbachol application (with or without combined peptide stimulation) elevated plasma amylase levels (p<0.01) and produced pancreatic tissue damage (p<0.05). Decompression of pancreatic duct ameliorated these effects (p<0.05). CONCLUSION Induced sphincter of Oddi dysfunction when coupled with stimulated pancreatic secretion causes acute pancreatitis. This may be an important pathophysiological mechanism causing various forms of acute pancreatitis.
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Affiliation(s)
- J W Chen
- Department of General and Digestive Surgery, Flinders Medical Centre, Flinders University of South Australia, Australia
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Jakobs R, Riemann JF. The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer. Gastroenterol Clin North Am 1999; 28:783-800, xii. [PMID: 10503150 DOI: 10.1016/s0889-8553(05)70087-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.
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Affiliation(s)
- R Jakobs
- Department of Gastroenterology, Klinikum der Stadt Ludwigshafen gGmbH, Academic Teaching Hospital, University of Mainz, Germany
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