Sphincter of Oddi dysfunction in the post-cholecystectomy period

Abstract

The persistent post-cholecystectomy (CE) symptoms can be divided into four groups: 1) surgical errors; 2) recurrence of cholelithiasis; 3) functional disorders due to removal of the gallbladder (transient or persistent); 4) pathology not associated with CE. Biliary pain persists in 20–40% of patients after CE, in most cases caused by sphincter of Oddi dysfunction (SOD). SOD is subdivided into biliary, pancreatic, two-duct types, as well as pancreatobiliary reflux. The SOD is rooted in the increased pressure in the sphincter, which leads to the increased intraductal pressure and, as a result, to the occurrence of biliary or pancreatic pain. In addition, the direct contractile effects of cholecystokinin on smooth muscles of the biliary tract change due to mechanical disturbance of innervation. Hypertension of the pancreatic part of the sphincter of Oddi can cause not only the occurrence of functional pain of the pancreatic type, but also the development of recurrent pancreatitis. SOD is characterized by typical anamnestic data that are common to the functional pathology of the digestive system, such as duration of symptoms, absence of organic pathology, multiple complaints, a non-progressive course, the provoking role of psychoemotional factors. From a practical standpoint, the clinical criteria for SOD can be: 1) an attack of biliary or pancreatic pain; 2) a transient increase in the activity of hepatic or pancreatic enzymes; 3) transient expansion of the common bile or major pancreatic duct. If it is difficult to differentiate diagnosis, endoscopic ultrasonography is advisable. Antispasmodics and ursodeoxycholic acid form the basis of the treatment, especially when biliary sludge and microlithiasis are detected. There must be strong arguments for the surgical treatment.