Patients with Atypical Sphincter of Oddi Dysfunction Symptoms Can Benefit from Endoscopic Biliary Manometry

Abstract

Introduction: Sphincter of Oddi dysfunction (SOD) is a clinical syndrome of biliary or pancreatic obstruction related to mechanical or functional abnormalities of the sphincter of Oddi. Diagnosis of SOD is usually established by endoscopic biliary manometry (EBM) performed at the time of ERCP and measures the biliary and pancreatic sphincter pressures. Depending on the results it can determine which treatments such as endoscopic sphincterotomy or Botulinum toxin injection should be given. However, the Rome III guidelines, developed for the investigation of patients with SOD, propose that unless patients meet all the criteria then they should not undergo invasive investigations such as EBM. These patients may present with a variety of symptoms which may be biliary, pancreatic, mixed or atypical in nature and this may make diagnosis difficult without doing EBM. Aims and Methods: The Royal London Hospital is a tertiary referral centre for this condition and this study was a retrospective audit of patients referred here for the investigation of SOD and who underwent EBM. It involved patients who had EBM from 1st January 2004 to 31st July 2008 and looked at the long term outcomes and complication rates. Results: 131 patients (104 females) underwent EBM during this period. 60 patients had biliary symptoms, 21 had pancreatic, 23 had mixed biliary and pancreatic and 27 had atypical abdominal symptoms. Overall 63% of patients had some improvement and long term no-one had worsening of symptoms post EBM. The Rome III guidelines do not include atypical patients for the investigation of SOD. However in our study, 11 patients in the atypical group had elevated biliary or pancreatic duct pressure (>40 mm Hg) of which 6 underwent sphincterotomy and 9 patients had ampullary Botulinum toxin injection. 11 of the atypical patients showed some improvement following EBM. In the atypical group 2 patients developed post-ERCP pancreatitis and 1 patient suffered a fatal guide wire perforation. In total 19 patients developed post-ERCP pancreatitis (12 following sphincterotomy and 5 post-Botulinum toxin injection) and 5 patients developed perforation. Conclusions: Rome III guidelines for the diagnosis of SOD are unnecessarily restrictive and therefore may lead to the under-diagnosis and treatment of this condition. Many patients, who may not fit these criteria, including those with atypical symptoms, may potentially benefit from undergoing EBM and endoscopic treatments.