Role of Endoscopic Ultrasonography and a Trial of Tricyclic Antidepressants in Patients with Suspected Sphincter of ODDI Dysfunction III

Abstract

Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry (SOM) and sphincterotomy in patients with suspected Sphincter of Oddi dysfunction (SOD) III often leads to an unpredictable treatment response and might be associated with a high incidence of post procedure pancreatitis. The purpose of this research is to describe upper abdominal endoscopic ultrasonography (EUS) findings in a group of patients with suspected SOD III and evaluate the role of trial of tricyclic antidepressants (TCA) in helping symptoms thereby reducing the need for ERCP with SOM and sphincterotomy in this scenario. Methods: Over a 12 month period, 17 patients (all female) with suspected SOD III (Recurrent episodes of right upper quadrant and epigastric pain with normal liver enzymes and pancreatic enzymes and no evidence of common bile duct or pancreatic duct dilation on imaging studies) were referred to our center for consideration of ERCP with SOM and possible sphincterotomy. Prior to performing ERCP with SOM, patients were asked to undergo an upper abdominal endoscopic ultrasonography (EUS). If the EUS findings were insufficient to explain the cause of pain, patients were placed on a TCA. Patients underwent ERCP with SOM if pain did not improve with at least a 2 month trial of TCA. Results: Mean age of patients was 49 years (Range 22–73 yrs). EUS findings were normal in 16 (94%) patients, 1 patient had choledocholithiasis who later underwent ERCP with stone extraction. 12/16 patients were on amitriptyline (dose 10–25 mg/day), and the other 4 were on nortriptyline (dose 10–20 mg/day). 3/16 patients (19%) subsequently underwent ERCP with SOD manometry as their symptoms did not improve with TCA. All these patients were treated with endoscopic sphincterotomy as their SOD pressures were high (>40 mmHg). Conclusion: Conclusions: 1) Upper abdominal EUS is non-diagnostic for abdominal pain in the majority of patients with suspected SOD III 2) A therapeutic trial of TCA seems to be a reasonable option to pursue prior to proceeding with endoscopic sphincterotomy in this cohort of patients.