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Lege Artis Medicinae

JANUARY 20, 2005

[POST-CHOLECYSTECTOMY SYNDROME AND SPHINCTER OF ODDI DYSFUNCTION]

MADÁCSY László

[After cholecystectomy, recurrent biliary-like pain, alone or in association with a transient increase in liver enzymes may be the clinical manifestation of the sphincter of Oddi dysfunction (SOD). Most of the clinical information concerning SOD refers to postcholecystectomy patients who have been classified according to clinical presentation, laboratory results and endoscopic retrograde cholangio-pancreatography (ERCP) findings as: biliary type I, biliary type II, and biliary type III. The prevalence of SOD has been reported to vary from 9 to 11% in unselected patients having postcholecystectomy syndrome up to 68% in a selected group of patients without organic disorder and complaining of postcholecystectomy pain. Diagnostic work-up of postcholecystectomy patients for suspected SOD includes liver biochemistry and pancreatic enzyme levels plus negative findings of structural abnormalities. Usually this would include transabdominal ultrasound, gastroscopy and ERCP. Depending on the available resources, endoscopic ultrasound and magnetic resonance cholangiography may precede endoscopic retrograde cholangiopancreatography in specific clinical conditions. In SOD patients, the endoscopic sphincter of Oddi manometry is the gold-standard diagnostic method to evaluate the abnormal motor function of the sphincter of Oddi. Quantitative evaluation of bile transit with cholescintigraphy is valuable in the decision whether to perform sphincter of Oddi manometry or to treat. The standard treatment for SOD is sphincterotomy. In biliary type I patients, the indication for endoscopic sphincterotomy is straightforward without the need of additional investigations. Slow bile transit on cholescintigraphy in biliary type II patients is an indication to perform endoscopic sphincterotomy without sphincter of Oddi manometry. Positive Nardi or Debray evocative test in biliary type III patients is an indication to perform sphincter of Oddi manometry. Medical therapy with nitrosovasodilatators, Ca-channel blockers, theophyllin compounds, β2 receptor agonists and anticholinerg drugs can be useful in biliary type II and type III patients preceding endoscopic sphincterotomy. If medical therapy fails, one might proceed to perform ERCP and endoscopic sphincterotomy but only in patients with abnormal SO manometry results.]