Biliary Manometry Research Articles

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures.

Background and objectivePercutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.Patients and methodsA total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.ResultsAmong the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.ConclusionBiliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) is a benign non-tumoral disorder of the major papilla. It occurs mainly after cholecystectomy but can also occur before surgery. Biliary pain and biliary colic are the most frequent symptoms although recurrent pancreatic pain or pancreatitis can also be presenting symptoms. In about half of the cases, there is a fibrotic stricture of the sphincter of Oddi, probably secondary to the passage of biliary stones, while in the remaining half, the syndrome is due to ampullary motility disorders. The diagnosis of SOD first requires exclusion of choledocholithiasis or ampullary tumor, by means of ERCP, endoscopic ultrasound or magnetic resonance imaging. Findings on biliary manometry will establish the diagnosis, but this technique is performed less and less often because its high risk of inducing pancreatitis discourages its use as a diagnostic procedure. Biliary scintigraphy offers a risk-free alternative albeit with lower sensitivity. Medical treatment relies on the administration of trimebutine and nitroglycerine when pain occurs. Their efficacy is moderate. Sometimes patients are referred for endoscopic sphincterotomy. Endoscopic treatment should be performed only for patients with biliary pain associated with hepatic function disorders and/or bile duct dilatation. Practicians and patients should be aware that endoscopic sphincterotomy in this clinical setting is associated with a high risk of pancreatitis and its efficacy is limited in patients with pain but without laboratory anomalies or dilatation of the biliary duct (type III Milwaukee classification). Patients with Milwaukee classification type III disorders have mostly functional complaints or psychosocial disabilities and require only medical management.

Sa1438 - Outcome of Endoscopic Sphincterotomy in Biliary Manometry Confirmed Sphincter of Oddi Dysfuncton type 2 Patients: A Medium-Term Follow-Up

Sa1438 - Outcome of Endoscopic Sphincterotomy in Biliary Manometry Confirmed Sphincter of Oddi Dysfuncton type 2 Patients: A Medium-Term Follow-Up

Clinical and experimental substantiation of the method the biliary debit manometry

Introduction. In spite of the permanent improvement of the diagnostic methods of causes of biliary obstruction it has not 100 % sensitivity and specificity and received data can be erroneous and difficult for clinical interpretation. Substantiation. To assess at the modern scientific and technical level the functional state of patency of terminal section of choledoch using modified method of debit manometry that consists in registration of the volume of liquid injected into bile-excreting and the pressure in it. Materials and methods of research. At elaboration of methods at the first stage it was carried out numerical modeling on the base of physical model of bile-excreting system with assessment of the levels of pressure in bile-excreting ducts at liquid injection, assessment of form of the curve of pressure changes and factors that influence on form and parameters of curve. At the second stage it was carried out an experimental assessment of correspondence of these models to the real data received in department of morbid anatomy. And at the last clinical stage it was carried out diagnostics of disorders of patency of bile-excreting system with following assessment of diagnostic and practical value of this method. Results. The data received in experiment and modeling allowed to interpret the results of debit manometry received at examination of patients on the next algorithm: at the first stage it was assessed the type of curve: bell-shaped – disorder of outflow is absent but at the fast evacuation the disorders of consistency of sphincteral apparatus cannot be excluded, tooth-shaped – indicates the disorder of outflow of bile what can be caused by both organic and functional reasons, horizontal type – indicates the strict obstruction usually of organic character. At the second one it were assessed the quantitative indicators, the high level of pressure at the bolus introduction testified to the bile-excreting ways (BEW) obstruction, the low one – to an inconsistency of sphincteral apparatus. Conclusions. The numerical experimental data allowed establish regularities of bile-excreting system functioning from the positions of hydrodynamics. Verification of these data in conditions of controlled experiment on the real bile-excreting ducts allowed confirm these conclusions and specify the features of hemodynamics in conditions of dissected sphincteral apparatus

Biliary manometry in patients with common bile duct stones and juxtapapilary duodenal diverticulum

Objective To explore the impact of juxtapapilary duodenal diverticulum on the formation of choledocholithiasis and biliary manometry after surgery. Methods The clinical data of 97 patients with common bile duct stones who successfully underwent ERCP and biliary manometry treatment from May 2011 to March 2014 were retrospectively analyzed. Ninty-seven common bile duct stone patients were divided to two groups, that is, 52 cases of juxta-papilary duodenal diverticulum (experimental group) and 45 cases without juxta-papilary duodenal diverticulum (control group). The biliary manometric results before and after EST of both groups were compared. Results The basal pressure of sphincter Oddi of the experimental group before EST[(84.8±26.1)mmHg]was higher than that of the control group before EST[(75.5±14.6)mmHg](P 0.05). The biliary manometry was performed in 81 patients after one month and it was found that the basal pressure of sphincter Oddi of experimental group was still higher than that of the control group[(34.8±17.1) mmHg VS (29.6±15.3)mmHg, P<0.05]. The biliary pressure of common bile of the experimental group was higher than that of the control group[(19.9±11.2)mmHg VS (17.1±13.1)mmHg, P<0.05]. Conclusion The existence of juxtapapilary duodenal diverticulum increases the pressure of common bile duct and Oddi sphincter and leads to CBD stones. Key words: Biliary manometry; Juxta-papilary duodenal diverticulum; Cholangiopancreatography, endoscopic retrograde; Choledocholithiasis; Sphincter of Oddi pressure; Common bile duct pressure

Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction: Inefficacious Therapy for a Fictitious Disease

Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction: Inefficacious Therapy for a Fictitious Disease

PTH-004 Subjective Description Of Pain Does Not Predict Biliary Manometry Or Response To Endotherapy In Sphincter Of Oddi Dysfunction: Are The Rome Criteria Fit For Purpose?

IntroductionIn the absence of biochemical or radiological evidence of biliary obstruction, Sphincter of Oddi dysfunction (SOD) is a difficult condition to diagnose and to treat. The Rome III diagnostic criteria...

PTH-012 Response To Peri-ampullary Botox Injection And Subsequent Long Term Response To Endoscopic Sphincterotomy In Type 2/3 Sphincter Of Oddi Dysfunction

IntroductionPain relief following the peri-ampullary injection of Botulinum toxin A may offer a safe alternative to biliary manometry that accurately identifies patients with Type 2/3 Sphincter of Oddi Dysfunction (SOD)...

Biliary manometery profile in biliary ascariasis

Background and Aims: Abnormalities in biliary manometry have been documented in biliary duct disorders. The present study was conducted to study sphincter of Oddi and bile duct manometery in patients with single documented episode of biliary ascariasis and compared with healthy subjects.

Differential effects of norUDCA and UDCA in obstructive cholestasis in mice

Background & AimsThe quest for effective drugs to treat cholangiopathies led to the development of norUDCA previously shown to have potent choleretic effects and to heal cholangiopathy in Abcb4 knockout (Abcb4−/−) mice. Its mother compound UDCA had detrimental effects in common bile duct ligated (CBDL) mice, presumably related to its choleretic effects. norUDCA choleretic effects may therefore raise safety concerns when used in cholangiopathies with biliary obstruction. We therefore aimed at comparing the effects of UDCA and norUDCA in clear-cut obstructive cholestasis.Methods0.5% UDCA- or norUDCA-fed wild type and Abcb4−/− mice were subjected to CBDL or selective bile duct ligation (SBDL) and compared to controls with regard to liver injury. Bile flow, bile composition, and biliary manometry were compared in UDCA-fed, norUDCA-fed and control mice. Toxicity of UDCA and norUDCA was compared in vitro.ResultsCompared to UDCA, liver injury in CBDL mice was significantly lower in almost all norUDCA groups. In SBDL mice, only UDCA induced bile infarcts in the ligated lobes, whereas norUDCA even ameliorated liver injury. In vitro, UDCA induced cellular ATP depletion and was significantly more toxic than norUDCA in HepG2 cells, mouse bile duct epithelial cells, and primary human hepatocytes.ConclusionsCompared to norUDCA, UDCA is significantly more toxic in CBDL mice. norUDCA, in contrast to UDCA, significantly ameliorates liver injury in SBDL mice. Our findings uncover profound differences in metabolism and therapeutic mechanisms of both bile acids with important clinical consequences.

PTU-078 Delays in the diagnosis and management of patients with suspected sphincter of oddi dysunction

IntroductionSphincter of oddi dysfunction (SOD) is difficult to diagnose and treat. Biliary manometry is considered to be the gold standard for diagnosing SOD but is not widely available. A significant...

Mo1324 ERCP in Patients With Prior Whipple's Resection: An Increasing Problem in Long-Term Follow-up

remained significant predictors of clinical response (OR 5.4, 95% CI 1.2-24 p 0.028; OR 7.7, 95% CI 1.8-31.3 p 0.005, respectively). Conclusions: The SOD scintigraphic score is not an adequate screening test for biliary SOD because of its poor sensitivity for abnormal biliary manometry. However, an abnormal SOD score 6 is a good predictor of clinical response to endoscopic therapy for patients with SOD type III. Predictors of response to therapy include elevated basal pressure and SOD type.

Biliary manometry in patients with cholelithiasis

Objective To explore the relationship between cholelithiasis and the function of sphincter of Oddi （SO）. Methods To identify the existence of calculi, choledochoscopy was performed in patients 6 weeks after exploration of the common bile duct （CBD） and T tube drainage, in which 71 were patients with stones in gall bladder, CBD or intra-hepatic bile duct, and 9 with trauma of pancreas or liver. Biliary manometry was performed after choledochoscopy, and an additional manometry was applied after calculus removal if calculi were detected. The indices measured included SO basal pressure （ SOBP）, amplitude of SO contractions （ SOCA）, frequency of SO contractions （SOF） and CBD pressure （CBDP）. The patients with cholelithiasis were classified into cholecystolithiasis group, choledocholithiasis group, and hepatolithiasis group according to the position of calculi. Patients with trauma were assigned as the control group. Results All variables in 50 patients with choledocholithiasis were similar before and after the procedure. The variables in patients with cholecystolithiasis and choledocholithiasis had no difference from those of the control （ P 〉 0.05）. The SOBP and SOCA of patients in hepatolithiasis group were lower than those of the control group （ P 〈 0. 05）, while no difference in SOF was detected （ P 〉 0. 05 ）. Conclusion The function of SO in patients with hepatolithiasis is abnormal （decrease in SOBP and SOCA）. Biliary manometry cannot be the reliable evidence for the existence of calculi in bile duct. Key words: Biliary calculi; Sphincter of Oddi; Manometry

Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD) is a poorly-understood disorder, typically presenting as postcholecystectomy, "biliary-type," right-sided abdominal and/or chest wall pain. Most patients referred to specialist clinics for work-up of presumed SOD do not, in fact, have anything wrong with their bile ducts or biliary sphincter mechanisms. A careful history and focused physical examination will often identify the true source of the pain syndrome, ranging from chest wall costochondritis and nerve injury at surgical trochar sites, to gastroparesis and visceral hypersensitivity ("irritable bowel"). The Rome III classification of functional gallbladder and biliary disorders defines SOD as episodic (not daily) pain lasting more than 30 min, which is disruptive of normal activities and not associated with bowel upset. It is not relieved by gastric acid suppression or antispasmodics. Other causes of abdominal pain must be excluded. Standard work-up includes endoscopic retrograde cholangiopancreatography (ERCP) with biliary manometry, which risks post-ERCP pancreatitis, especially in young women with normal bile ducts and liver serology. Noninvasive tests for SOD, such as timed ("gated") cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid (HIDA) scans and secretin-stimulated magnetic resonance cholangiopancreatography, are imperfect and still evolving. Although many doubt the very existence of SOD, a multidisciplinary approach to the management of pre- and postcholecystectomy abdominal pain syndromes is long overdue.

Motor function changes of sphincter of Oddi in rabbits with hypercholesteremia.

Objective To investigate the effects of hypercholesteremia on the motor function of sphincter of Oddi (SO). Methods Thirty-two rabbits were divided into control group and experimental groups. In the control group, the rabbits were fed with normal diet. In the experimental groups, the rabbits were fed with normal diet + cholesterol for 4, 6 and 10 weeks. Myoelectric activity and pressures of SO were detected. All data were analyzed by t test. Results The serum total cholesterol and low density lipoprotein cholesterol were at a high level in rabbits which were fed with normal diet + cholesterol for 10 weeks (t=9.63, 11.38, P <0.05); basal pressure, pike pressure and amplitude of SO were significantly elevated (t=5.23, 6.34, 3.24, P < 0.05) ; the spike potential of SO changed to myoelectronic activity, with prolonged time period of myoelectronic activity, while the discharge rate was decreased (t=13.68, 10.18, P < 0.05). Conclusion Hypercholesteremia may change the motor function of SO and enhance its peristalsis to speed up the excretion of bile. Key words: Hypercholesteremia; Sphincter of Oddi; Biliary manometry; Myoelectric activity

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

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.

Ruggero Oddi: 120 years after the description of the eponymous sphincter: A story to be remembered

This article presents a short account of theories, methods, and experimental data formulated and carried out 120 years ago, by Ruggero Oddi, then a 4th-year student in medicine, about the identification of the common bile duct sphincter. A historical picture emerges which leads us to think that Oddi not only discovered the bile duct sphincter, but also described bile duct dilation after cholecystectomy and performed biliary manometry for the first time. The role of serendipity and the almost unknown contribution of Arturo Marcacci, Oddi's "maestro" are also mentioned.

Role of Biliary Stress Manometry after Biliary Stricture Dilation in Living Donor Liver Transplant Recipients

To report on the use of biliary manometry for determining treatment completion in living donor liver transplant recipients. Twenty of 85 patients (24%) who underwent living donor liver transplantation developed postoperative anastomotic biliary strictures. Fifteen patients underwent transhepatic biliary drainage and percutaneous dilation. In 10 patients, biliary stress manometry was used to assess treatment adequacy after a mean of 2.5 dilation sessions occurring during a mean period of 62 days (range, 5-55 days). An intrabiliary pressure of less than 20-cm H2O after an escalating intrabiliary infusion to 1,200 mL per hour for 3 minutes was defined as the success threshold (in lieu of a capped external catheter "clinical trial"). There were no complications during the infusion study. In all 10 patients in whom manometry was successful, biliary catheters were removed. One patient (who underwent manometry and catheter removal after only one dilation session) required repeat intubation 7 weeks later. The remaining nine patients (90%) remained free of evidence of biliary obstruction at a mean of 8.4 months. With Kaplan-Meier survival analysis, the probability of biliary patency at 3, 6, and 12 months was 90%. This biliary stress manometry protocol offers a promising alternative to the catheter "clinical trial" for determining endpoints for multisession anastomotic biliary stricture dilation in living donor transplant recipients.

Solid state biliary manometry catheter: Impact on diagnosis and post-study pancreatitis

Perfusion manometry of the sphincter of Oddi has been the standard for the investigation of patients with presumed sphincter of Oddi dysfunction (SOD). Microtransducer manometry (MTM) of the sphincter of Oddi represents an alternative to perfusion manometry. The technical success and reproducibility of MTM are as good as for perfusion manometry. Current data suggest that the upper limit for normal of basal sphincter of Oddi pressures measured with MTM lies at approximately 35 mm Hg. Pancreatitis risk after MTM in patients with SOD compares favorably with that after perfusion manometry. Low cost and ease of handling make MTM of the sphincter of Oddi an attractive alternative.

ERCP/Manometry Findings in 1,343 Idiopathic Pancreatitis Patients

Background: ERCP with sphincter of Oddi manometry can detect abnormalities in patients otherwise classified as idiopathic pancreatitis. Methods: All patients undergoing ERCP at Indiana University Medical Center have data prospectively entered into a database. 1,547 patients from 1994-2006 were classified initially as idiopathic pancreatitis. After review of medical history, non-invasive imaging, prior endoscopies, and blood studies, 204 patients were eliminated for known causes of pancreatitis. This study reviews the findings of ERCP with or without manometry of the remaining 1,343 patients in correlation with the pre-ERCP clinical diagnosis. Results: Clinical categories were based upon the pre-ERCP diagnosis: a single episode of acute pancreatitis in 281 (20.9%), acute recurrent pancreatitis (IARP) in 758 (56.4%), chronic pancreatitis (CP) in 304 (22.6%). Post-procedure diagnoses were: (See table). Biliary manometry findings were the following: elevated biliary sphincter pressures were found in 63 (41.7%) of the 151 attempted manometries in patients with 1 documented episode of pancreatitis, in 153 (32.9%) patients with acute recurrent pancreatitis of the 465 performed manometries, and in 30 (23.6%) of 127 manometries of CP. Elevated major pancreatic sphincter pressures were found in 93/154 (60.4%) with acute pancreatitis x1, in 266/488 (54.5%) with acute recurrent pancreatitis, and in 69/158 (43.7%) with chronic pancreatitis. Summary: In our large case series of idiopathic pancreatitis patients, ERCP and manometry frequently detects abnormalities that may be a cause of pancreatitis or lead to persistence of symptoms. Manometry abnormalities are the most common treatable cause of idiopathic pancreatitis. Long term outcomes of therapy studies are in progress. Conclusion: ERCP with sphincter of Oddi manometry is indicated for most patients with idiopathic pancreatitis. Tabled 1 ERCP findings Number of patients % of total Sphincter of Oddi dysfunction 539 40.1 Pancreas divisum 240 17.9 Periampullary diverticulum 82 6.1 Choledocholithiasis 61 4.6 Intraductal mucinous tumors 55 4.1 Cholelithiasis (alone) 26 1.9 Anomalous pancreatobiliary junction 7 0.5 Choledochocele 5 0.4 Papilla of Vater adenoma/cancer 4 0.3 Annular pancreas 4 0.3 Open table in a new tab