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Clinical manifestations and diagnosis of sphincter of Oddi dysfunction

INTRODUCTION

The sphincter of Oddi 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 clinical manifestations and diagnosis of sphincter of Oddi dysfunction will be reviewed here. The treatment of this disorder is discussed separately. (See "Treatment of sphincter of Oddi dysfunction".)

ANATOMY

The sphincter of Oddi (SO) is composed of small circular and longitudinal muscular segments that are approximately 6 to 10 mm in total length and are contained mostly within the wall of the duodenum (figure 1) [1]. The muscle fibers surround the intraduodenal segment of the common bile duct and the ampulla of Vater (picture 1). A circular aggregate of muscle fibers known as the sphincter choledochus (or sphincter of Boyden) maintains resistance to bile flow, and thereby permits filling of the gallbladder during fasting and prevents retrograde reflux of duodenal contents into the biliary tree. A separate structure, called the sphincter pancreaticus, encircles the distal pancreatic duct. The muscle fibers of the sphincter pancreaticus are interlocked with those of the sphincter choledochus in a figure eight pattern. Although the pancreatic and biliary sphincter portions of the SO can be distinguished anatomically, their manometric features are similar and a direct anatomic and manometric correlation has not been established.

The muscle fibers of the SO function independently from those of the duodenal musculature. The motility of the SO is complex and not completely understood, but is known to vary in the fasting and fed states.

  • During fasting, SO motility is integrated with the migrating motor complex (MMC), permitting coordinated release of bile into the duodenum. Myoelectrical potentials within the SO increase during phase one of the MMC, reach a maximum during phase three, and then decrease rapidly.
  • During the fed state, myoelectrical potentials within the SO vary depending upon the type and quantity of nutrients ingested and may be influenced by endogenous hormones such as cholecystokinin [2,3].
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