Re: Kim

[Guest guest]

Kim,

I hope the following informations helps:

Gallbladder Dysfunction (Biliary Dyskinesia)

Gallstones are the most common cause of gallbladder

dysfunction and symptoms such as pain and infection

(cholecystitis). However, sometimes the gallbladder

can become inflamed and partially obstructed in the

absence of stones. The normal gallbladder contracts

through muscular activity in response to food, forcing

bile through its exit channel (the cystic duct) and

into the bile duct for passage into the intestine

(through the sphincter of Oddi or the papilla of

Vater). If these movements are not appropriately

coordinated, the pressure can rise and result in

gallbladder type pain.

In this condition, the gallbladder may appear normal

on the standard ultrasound scan; abnormalities are

only detected when the gallbladder is stimulated to

contract, with food or after an injection of a

stimulating hormone (cholecystokinin – CCK). Failure

of the gallbladder to contract properly, especially if

the patient's pain is reproduced, is good evidence of

gallbladder dysfunction. This can also be investigated

by a special type of isotope scan (HIDA scan) during

which the behavior of the bile can be watched and the

emptying of the gallbladder measured (the ejection

fraction). Patients with clearcut symptoms and

positive test results respond well to removal of the

gallbladder (laparoscopic cholecystectomy).

Papillary Stenosis: Sphincter of Oddi Dysfunction

The sphincter of Oddi is the muscular valve

surrounding the exit of the bile duct and pancreatic

duct into the duodenum, at the papilla of Vater. The

sphincter is normally closed, opening only in response

to a meal so that digestive juices can enter the

duodenum and mix with the food for digestion.

Sphincter of Oddi dysfunction and papillary stenosis

are conditions which occur when this sphincter

(opening) mechanism is disturbed. When the hole is too

tight, there is a backup of bile and pancreatic

juices. This can cause pain (biliary colic). More

prolonged obstruction may result in bile leaking back

into the blood stream, resulting in abnormalities of

the liver function tests, or even yellow jaundice

(discoloration of the eyes and skin). Also, blockage

to the pancreatic orifice can cause pancreatic pain or

attacks of pancreatitis.

Papillary Stenosis can be caused by passage of stones,

or scarring after treatments (i.e. endoscopic or

surgical sphincterotomy). Papillary stenosis usually

results in sufficient backup of bile flow that there

is stretching (dilatation) of the bile duct. This can

be recognized by scans and various x-rays, including

ERCP. Papillary stenosis requires endoscopic or

surgical treatment. The hole is enlarged by cutting,

to improve drainage. Occasionally it is necessary to

do a surgical bypass (choledochoduodenostomy, or

Roux-en-Y hepaticojejunostomy) to insure that drainage

is effective.

Spasm of the Sphincter

This is a more difficult problem. It may be one

manifestation of other muscular spasm problems in

different areas of the body (such as the esophagus or

intestine – irritable bowel syndrome). However, in

some patients, it is the prevailing complaint, and

requires focal attention. The pain symptoms are very

similar to those caused by bile duct or gallbladder

stones. Indeed, sphincter of Oddi dysfunction most

frequently occurs in patients who have previously

undergone removal of the gallbladder

(cholecystectomy). Some patients present with

unexplained attacks of acute pancreatitis when the

pancreatic sphincter is involved predominantly.

Diagnosis of sphincter of Oddi Dysfunction

Initially, tests are aimed to make sure that there are

no stones present. Standard ultrasound and CT scans

are not very accurate in detecting or excluding bile

duct stones; newer techniques such as MRCP and

endoscopic ultrasound are more sensitive, but not yet

widely available. Most patients are investigated with

ERCP. The doctor can examine the drainage hole of the

bile duct at the papilla of Vater, and inject dye into

the bile duct and pancreatic duct to look for stones

and other forms of obstruction. The possibility of

sphincter spasm (dysfunction) is considered only when

these other conditions have been excluded. Dysfunction

can be recognized by a special technique during ERCP,

called sphincter of Oddi manometry (SOM). This

involves passing a small catheter (tube) into the bile

duct and pancreatic duct, to measure the squeeze

pressure.

Treatment of Sphincter of Oddi Dysfunction

Antispasm medicines are available, but are not very

effective. A decision has to be made whether to cut

the sphincter (sphincterotomy), during ERCP, or at

surgery. When sphincter of Oddi manometry has

confirmed that the pressures are high, sphincterotomy

gives complete relief in 70-80% of patients;

unfortunately, sphincterotomy also carries a

significant risk of complications in this context,

particularly the provocation of pancreatitis, and the

possibility of perforation. Thus, this condition

should be approached and managed with considerable

care. Patients may warrant referral to specialist

centers.

Sphincterotomy procedures can sometimes scar after

months or years, causing papillary stenosis. Further

cutting (repeat sphincterotomy) is sometimes possible,

but there are limits; surgical bypass may be

necessary.

Attempts have been made to treat sphincter of Oddi

dysfunction without sphincterotomy – by placing a

temporary plastic splinting tube (stent), or by an

injection of botulinum toxin, which paralyzes the

sphincter. These treatments are experimental.

=====

Rupesh Parajuli

Nepal Chapter

Pancreatitis Association International (PAI)

Post Box No: 13946, Kathmandu, Nepal

Tel: 977-1-4479627, Fax: 977-1-4476878/4460560

Mobile: 977-9851078750

rupesh_parajuli@...

www.pancassociation.org

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