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home - Biliary - Miscellaneous - Sphincter of Oddi Disease Written by Dr Sebastian Zeki

Sphincter of Oddi Disease

Features of functional gallbladder and SOD disorders-Episodes last >30m or longer.-Recurrent symptoms occurring at different intervals (not daily).-The pain builds up to a steady level.-Severe pain.-Exclusion of other structural disease that would explain the symptoms. Functional gallbladder disorder Supportive tests:Dilation of the CBD:Biliary provocation tests Increase >2mm post CCK/ fat meal is pathologic.Hepatobiliary scintigraphy- can show delayed biliary drainage if gallbladder absent.Thus scintigraphy only supportive. Type 1 criteria(a)Pancreatic enzymes > 1.5 times the ULN assoc. with pain(b) Dilated pancreatic duct (> 6 mm in the head and > 5 mm in the body by ERCP)(c) Delayed drainage of contrast after ERCP (>9 mins). Type 2 patients have one or two of the type 1 criteria Type 3 no type 1 criteria Pancreatic SOD No relief with bowel movements/ postural change/ antacids Severe Criteria for Diagnosis of Biliary SOD:Must include both of the following:-Criteria for functional gallbladder and sphincter of Oddi disorder-Normal amylase/lipase-Supportive criteria include inc. ALT, Alk Phos or conjugated bilirubin temporally related to at least 2 pain episodes. Criteria for Functional Pancreatic SOD: Must include both of the following:-Criteria for functional gallbladder and sphincter of Oddi disorder-Elevated amylase/lipase SO StenosisDue to any inflammatory/ scarring pathologyPatients have inc. basal SO pressure (>40 mmHg)- does not relax with smooth muscle relaxants.SOD Dyskinesia:1. Can have elevated basal SO pressure-decreases in response to smooth muscle relaxants2. Increases in response to CCK (paradoxical)3. Rapid SO contraction frequency (>7/min) and an excess in retrograde phasic contractions (>50 %) Type 3Biliary-type pain only40 % of these have SOD on manometryType 2Biliary-type pain+ one type 1 55 % of these have SOD on manometryType 1Biliary-type painAbnormal ALT, bilirubin or Alk Phos >2 times normal on >2 or more occasions CBD>8 mm diameter on ultrasound. 80% of these have SOD on manometry. Type 3 Medication trials first to rule out other functional problems (eg Ca channel blockers/ nitrates to relax SO/ URSO) Type 2 Need SOD manometry (basal pressure >40mmHg) or hepatobiliary scintigraphy if intact gallbladder prior to sphincterotomy Type 1: Responds to sphincterotomy, which can be performed without prior biliary manometry. Criteria for functional gallbladder disorder:Criteria for functional gallbladder and sphincter of Oddi disorders Gallbladder is presentNormal liver enzymes, conjugated bilirubin, and amylase/lipase Sphincter of Oddi Disease Classification and Aetiology Pancreatic SOD can respond to sphincterotomyHowever pancreatitis can also occur after sphincterotomy esp pancreatic and esp in patients with pancreatic sphincter hypertension.May reduce the incidence by pancreatic stent placement Epigastric or RUQ pain and ALL the following: Supportive criteria include:-Pain associated with nausea and vomiting;-Pain radiates to the back and/or right infrasubscapular region-Pain awakens from sleep in the middle of the nightApproproate CBD and PD basal and phasic wave contracton at ERCP manometry Pancreatic provocation tests>1.5 mm (assessed by transabdominal ultrasound, CT or MRI) lasting for > 30m after secretin iv is pathologic.MRCP Secretin Test:Diagnostic accuracy 75% for type 2 and 46% for type 3. Biliary SOD SOD Aetiology Written by Dr Sebastian Zeki