Chapter 23 - Biliary motility and sphincter of Oddi disorders

Abstract

Motility disorders of biliary system include gall bladder dyskinesia and sphincter of Oddi dysfunction (SOD). Impaired contractility with or without inflammation of gall bladder is presumed to result in symptoms associated with gall bladder dyskinesia. However, gall bladder contractility is not always impaired in these patients and therefore, the term functional gall bladder disorder may be preferred to gall bladder dyskinesia. The diagnosis of gall bladder dyskinesia relies on clinical history suggestive of biliary pain, exclusion of gall stones and objective evidence of impaired gall bladder contractility measured by cholecystoscintigraphy. The mainstay of management in patients with functional gall bladder disorder is cholecystectomy. In SOD, the pathophysiology is more complex and incompletely understood. Interruption of cholecysto-sphincteric reflex and visceral hyperalgesia after cholecystectomy have been proposed as plausible mechanisms of pain in patients with SOD. The classical phenotyping of SOD into three phenotypes (type I, II and III) has been challenged by recent evidence which disapproves the existence of type III SOD. The diagnosis of SOD relies on clinical suspicion, exclusion of functional and organic mimickers, and SO manometry. The mainstay of management is endoscopic sphincterotomy in appropriately selected patients with suspected SOD. Both SO manometry and endoscopic sphincterotomy are considered as high risk procedures for pancreatitis. Therefore, careful selection of patients is paramount. Endotherapy does not benefit patients with type III SOD regardless of the results of SO manometry.