Su1548 THE IMPACT OF INCREASED BILE DUCT PRESSURE RELATED TO PAPILLARY STENOSIS AND THE ROLE OF VISCERAL HYPERSENSITIVITY IN PATIENTS WITH REFRACTORY RIGHT UPPER QUADRANT (RUQ) PAIN POST CHOLECYSTECTOMY

Abstract

Functional abdominal pain is commonly related to visceral hypersensitivity (VH) and recent studies have shown success in management of such patients with Amitriptyline. A subgroup of patients with chronic RUQ pain post cholecystectomy routinely fail medical management and are referred for evaluation of Sphincter of Oddi (SOD) dysfunction/papillary stenosis. The association of RUQ pain, dilated common bile duct (CBD) and elevated liver function tests (LFT’s) is strongly suggestive of papillary stenosis as it has been shown to benefit the most from biliary sphincterotomy. The aim of this study was to determine the risks/benefits of endoscopic sphincterotomy in this subgroup of patients with refractory RUQ pain and to delineate the role of Amitriptyline in the presence of VH. Retrospective review, from 2015 to 2018, of treatment outcomes of patients with post cholecystectomy RUQ abdominal pain refractory to medical treatment. All patients had treatment with biliary sphincterotomy by single expert endoscopist. Patients with pancreaticobiliary malignancies or prior history of pancreatitis were excluded from the study. Data including patient demographics, clinical symptoms (pre and post ERCP), elevated LFT’s, CBD size, use of narcotics, prior history of IBS, post procedure complications (pancreatitis, bleeding) and prophylactic pancreatic duct stent placement was collected. Patients with no or partial improvement were treated with low dose (10-25 mg) Amitriptyline daily for presumed VH. 75 patients were included in the study. Mean age was 52 years with 68 (93%) females. 30 (40%) of patients had a dilated CBD. 14 (19%) had elevated LFT’s. 57 (76%) had constant RUQ pain. A total of 67 (89%) patients reported improvement in symptoms post sphincterotomy (49 (65%) patients achieved partial resolution and 18 (24%) complete resolution). A total of 13 (17%) patients did not achieve symptoms resolution and were treated with Amitriptyline. 12 out of 13 patients (92%) experienced a favorable symptom response to Amitriptyline. 6 (8%) patients had minor complications (pain and mild pancreatitis) and 1 patient (1%) had a major complication (necrotizing pancreatitis). A prophylactic pancreatic duct stent was placed in 38 (50.7%) of patients. 44 (58.6%) patients were discharge home post procedure. Biliary sphincterotomy provided by expert endoscopist is a very effective and safe intervention for patients with refractory RUQ abdominal pain post cholecystectomy. Constant RUQ pain and failure to respond to medical management should raise the suspicion for papillary stenosis. Based on the response to sphincterotomy, we extrapolate that elevated CBD pressure is the cause of discomfort in these patients with visceral hypersensitivity. Therefore, low dose Amitriptyline should be used for patients with partial response to biliary sphincterotomy.Graph 1: One-sample z-test of symptom improvement in included patientsView Large Image Figure ViewerDownload Hi-res image Download (PPT)