Treatment of sphincter of Oddi dysfunction
- Lyndon V Hernandez, MD, MPH
Lyndon V Hernandez, MD, MPH
- Clinical Associate Professor
- Medical College of Wisconsin
- Marc F Catalano, MD, FACP, FACG
Marc F Catalano, MD, FACP, FACG
- Associate Professor of Medicine
- Medical College of Wisconsin
The sphincter of Oddi (SO) is a muscular structure that encompasses the confluence of the distal common bile duct and the pancreatic duct as they penetrate the wall of the duodenum (figure 1). The term "sphincter of Oddi dysfunction" has been used to describe a clinical syndrome of biliary or pancreatic obstruction related to mechanical or functional abnormalities of the sphincter of Oddi. The terms papillary stenosis, sclerosing papillitis, biliary spasm, biliary dyskinesia, and postcholecystectomy syndrome have been used synonymously.
The treatment of sphincter of Oddi dysfunction (SOD) will be reviewed here. The clinical manifestations and diagnosis of this disorder are discussed separately. (See "Clinical manifestations and diagnosis of sphincter of Oddi dysfunction".)
Few studies have addressed the long-term natural history of sphincter of Oddi dysfunction (SOD). The available data suggest that the clinical course is variable depending in part upon the initial biliary classification. (See "Clinical manifestations and diagnosis of sphincter of Oddi dysfunction", section on 'Classification systems'.)
In a one-year follow-up study, seven type II patients (biliary pain and either abnormal liver tests or a dilated common bile duct) with abnormal sphincter of Oddi (SO) pressure treated by a sham procedure continued to have symptoms, which resolved only after subsequent sphincterotomy. All patients continued to do well four years later. Five other type II patients with abnormal SO pressure refused sphincterotomy. At four-year follow-up, three were unimproved, while two had "fair" improvement.
The clinical course is unpredictable after a sham or endoscopic sphincterotomy in patients with type III biliary pain (biliary pain but normal liver tests and common bile duct). In one report, 11 such patients were followed for two years after sphincterotomy. Four improved symptomatically while seven had no change. Eleven other patients had a sham procedure, of whom five improved, while six had no change in symptoms during two years of follow-up .
- Toouli J, Roberts-Thomson IC, Kellow J, et al. Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction. Gut 2000; 46:98.
- Döbrönte Z, Simon L, Patai A. [Management of Oddi sphincter dyskinesis. Results of drug therapy and sphincterotomy]. Orv Hetil 1995; 136:2165.
- Guelrud M, Mendoza S, Rossiter G, et al. Effect of nifedipine on sphincter of Oddi motor activity: studies in healthy volunteers and patients with biliary dyskinesia. Gastroenterology 1988; 95:1050.
- Khuroo MS, Zargar SA, Yattoo GN. Efficacy of nifedipine therapy in patients with sphincter of Oddi dysfunction: a prospective, double-blind, randomized, placebo-controlled, cross over trial. Br J Clin Pharmacol 1992; 33:477.
- Craig AG, Tottrup A, Toouli J, Saccone GT. Relative effects of dihydropyridine L-type calcium channel antagonism on biliary, duodenal, and vascular tissues: an in vivo and in vitro analysis in Australian brush-tailed possum. Dig Dis Sci 2002; 47:2029.
- Craig AG, Toouli J. Slow release nifedipine for patients with sphincter of Oddi dyskinesia: results of a pilot study. Intern Med J 2002; 32:119.
- Brandstätter G, Schinzel S, Wurzer H. Influence of spasmolytic analgesics on motility of sphincter of Oddi. Dig Dis Sci 1996; 41:1814.
- Bar-Meir S, Halpern Z, Bardan E. Nitrate therapy in a patient with papillary dysfunction. Am J Gastroenterol 1983; 78:94.
- Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008; 68:69.
- Ahmed F, Sherman S. Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008; 68:75.
- Riemann JF, Lux G, Förster P, Altendorf A. Long-term results after endoscopic papillotomy. Endoscopy 1983; 15 Suppl 1:165.
- Meshkinpour H, Mollot M. Sphincter of Oddi dysfunction and unexplained abdominal pain: clinical and manometric study. Dig Dis Sci 1992; 37:257.
- Thatcher BS, Sivak MV Jr, Tedesco FJ, et al. Endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi. Gastrointest Endosc 1987; 33:91.
- Neoptolemos JP, Bailey IS, Carr-Locke DL. Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy. Br J Surg 1988; 75:454.
- Seifert E. Long-term follow-up after endoscopic sphincterotomy (EST). Endoscopy 1988; 20 Suppl 1:232.
- Geenen JE, Hogan WJ, Dodds WJ, et al. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter-of-Oddi dysfunction. N Engl J Med 1989; 320:82.
- Bozkurt T, Orth KH, Butsch B, Lux G. Long-term clinical outcome of post-cholecystectomy patients with biliary-type pain: results of manometry, non-invasive techniques and endoscopic sphincterotomy. Eur J Gastroenterol Hepatol 1996; 8:245.
- Wehrmann T, Wiemer K, Lembcke B, et al. Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5-year prospective trial. Eur J Gastroenterol Hepatol 1996; 8:251.
- Roberts-Thomson IC, Toouli J. Is endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy effective? Gastrointest Endosc 1985; 31:370.
- Botoman VA, Kozarek RA, Novell LA, et al. Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction. Gastrointest Endosc 1994; 40:165.
- Lawrence C, Howell, Conklin D, et al. ERCP sphincterotomy without initial manometry for type II sphincter of Oddi dysfunction patients: a safe and effective strategy. Gastrointest Endosc 2004; 59:P99.
- Lin OS, Soetikno RM, Young HS. The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of Oddi dysfunction. Am J Gastroenterol 1998; 93:1833.
- Petersen BT. An evidence-based review of sphincter of Oddi dysfunction: part I, presentations with "objective" biliary findings (types I and II). Gastrointest Endosc 2004; 59:525.
- Petersen BT. Sphincter of Oddi dysfunction, part 2: Evidence-based review of the presentations, with "objective" pancreatic findings (types I and II) and of presumptive type III. Gastrointest Endosc 2004; 59:670.
- Cotton PB, Durkalski V, Romagnuolo J, et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA 2014; 311:2101.
- Elton E, Howell DA, Parsons WG, et al. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Gastrointest Endosc 1998; 47:240.
- Tarnasky P, Cunningham J, Cotton P, et al. Pancreatic sphincter hypertension increases the risk of post-ERCP pancreatitis. Endoscopy 1997; 29:252.
- Wehrmann T, Seifert H, Seipp M, et al. Endoscopic injection of botulinum toxin for biliary sphincter of Oddi dysfunction. Endoscopy 1998; 30:702.
- Funch-Jensen P, Kruse A. Manometric activity of the pancreatic duct sphincter in patients with total bile duct sphincterotomy for sphincter of Oddi dyskinesia. Scand J Gastroenterol 1987; 22:1067.
- Ugljesić M, Bulajić M, Milosavljević T, Stimec B. Endoscopic manometry of the sphincter of Oddi in sphincterotomized patients. Hepatogastroenterology 1995; 42:348.
- Toouli J, Di Francesco V, Saccone G, et al. Division of the sphincter of Oddi for treatment of dysfunction associated with recurrent pancreatitis. Br J Surg 1996; 83:1205.
- Moody FG, Becker JM, Potts JR. Transduodenal sphincteroplasty and transampullary septectomy for postcholecystectomy pain. Ann Surg 1983; 197:627.
- Nardi GL, Michelassi F, Zannini P. Transduodenal sphincteroplasty. 5-25 year follow-up of 89 patients. Ann Surg 1983; 198:453.
- Anderson TM, Pitt HA, Longmire WP Jr. Experience with sphincteroplasty and sphincterotomy in pancreatobiliary surgery. Ann Surg 1985; 201:399.
- Stephens RV, Burdick GE. Microscopic transduodenal sphincteroplasty and transampullary septoplasty for papillary stenosis. Am J Surg 1986; 152:621.
- Hästbacka J, Järvinen H, Kivilaakso E, Turunen MT. Results of sphincteroplasty in patients with spastic sphincter of Oddi. Predictive value of operative biliary manometry and provocation tests. Scand J Gastroenterol 1986; 21:516.
- Nussbaum MS, Warner BW, Sax HC, Fischer JE. Transduodenal sphincteroplasty and transampullary septotomy for primary sphincter of Oddi dysfunction. Am J Surg 1989; 157:38.
- Lee SK, Kim MH, Kim HJ, et al. Electroacupuncture may relax the sphincter of Oddi in humans. Gastrointest Endosc 2001; 53:211.
- NATURAL HISTORY
- TREATMENT GOALS
- PHARMACOLOGIC TREATMENT
- Calcium channel blockers
- Ursodeoxycholic acid
- ENDOSCOPIC THERAPY
- Endoscopic sphincterotomy
- - Biliary pain
- - Recurrent pancreatitis
- Botulinum toxin injection
- OTHER APPROACHES
- SUMMARY AND RECOMMENDATIONS