Sphincter Of Oddi Research Articles

Therapy for patients with bile duct III of sphincter of Oddi dysfunction after cholecystectomy

Objective To study the therapeutic effect of pinaverium bromid and oryz-aspergillus enzyme and pancreatin tablet on patients with bile duct Ⅲ of sphincter of Oddi dysfunction (SOD) after cholecystectomy. Methods 72 patients who had a diagnosis consistent with bile duct Ⅲ of SOD seen from February 2010 to February 2013 in our hospital were randomly divided into the control group and the treatment group. Patients in the control group were given pinaverium bromid for 3 months while patients in the treatment group were, in addition to pinaverium bromid, given oryz-aspergillus enzyme and pancreatin tablet. Relief of abdominal pain, abdominal distention and recurrence of the above symptoms after drug withdrawal were studied. Results The scores on abdominal pain in the treatment group before and after treatment were 7.5±1.1 and 3.0±1.6(P 0.05), respectively. Alleviation of abdominal distention in the treatment group was superior to the control group (P<0.05). The scores of abdominal pain and distention in half year after 3 months' therapy in the treatment group were 3.1±1.7 and 1.7±1.1, respectively, which obviously were lower than the control group (5.4±1.4 and 5.0±0.6, P<0.05). Conclusions Pinaverium bromid and oryz-aspergillus enzyme and pancreatin tablet could effectively alleviate abdominal pain and distention in patients with bile duct Ⅲ of SOD after cholecystectomy and the recurrence rates of symptoms were significantly lower. Key words: Cholecystectomy; Sphincter of oddi dysfunction, bile duct Ⅲ; Clinical effect

Effects of sphincter of Oddi motility on the formation of cholesterol gallstones.

To investigate the mechanisms and effects of sphincter of Oddi (SO) motility on cholesterol gallbladder stone formation in guinea pigs. Thirty-four adult male Hartley guinea pigs were divided randomly into two groups, the control group (n = 10) and the cholesterol gallstone group (n = 24), which was sequentially divided into four subgroups with six guinea pigs each according to time of sacrifice. The guinea pigs in the cholesterol gallstone group were fed a cholesterol lithogenic diet and sacrificed after 3, 6, 9, and 12 wk. SO manometry and recording of myoelectric activity were obtained by a multifunctional physiograph at each stage. Cholecystokinin-A receptor (CCKAR) expression levels in SO smooth muscle were detected by quantitative real-time PCR (qRT-PCR) and serum vasoactive intestinal peptide (VIP), gastrin, and cholecystokinin octapeptide (CCK-8) were detected by enzyme-linked immunosorbent assay at each stage in the process of cholesterol gallstone formation. The gallstone formation rate was 0%, 0%, 16.7%, and 83.3% in the 3, 6, 9, and 12 wk groups, respectively. The frequency of myoelectric activity in the 9 wk group, the amplitude of myoelectric activity in the 9 and 12 wk groups, and the amplitude and the frequency of SO in the 9 wk group were all significantly decreased compared to the control group. The SO basal pressure and common bile duct pressure increased markedly in the 12 wk group, and the CCKAR expression levels increased in the 6 and 12 wk groups compared to the control group. Serum VIP was elevated significantly in the 9 and 12 wk groups and gastrin decreased significantly in the 3 and 9 wk groups. There was no difference in serum CCK-8 between the groups. A cholesterol gallstone-causing diet can induce SO dysfunction. The increasing tension of the SO along with its decreasing activity may play an important role in cholesterol gallstone formation. Expression changes of CCKAR in SO smooth muscle and serum VIP and CCK-8 may be important causes of SO dysfunction.

MORPHO-FUNCTIONAL STATE OF THE GALLBLADDER IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The paper deals with the results of the research which show the presence of typical signs of chronic acalculous cholecystitis in patients suffering from chronic obstructive pulmonary disease as well. The findings, which have been obtained, allow us to state that more severe COPD causes higher degree of gallbladder hypokinetic dysfunction, biliary type hypertonic dysfunction of Oddi's sphincter, the activity in inflammatory process in the gallbladder, besides, the risk of gallstone formation, with predominant bile pigments and calcium in them, is bigger.

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

Effect of nalfurafine hydrochloride on the basal pressure of the sphincter of Oddi in anesthetized rabbits

Background: Opioid analgesics, which are classified as μ-opioid receptor agonists, are known to induce spasms or contraction of the sphincter of Oddi (SO), thereby inducing or exacerbating biliary diseases such as biliary obstruction, gallbladder dysfunction, cholelithiasis, pancreatitis, biliary dyskinesia, cholangitis, and cholecystitis. However, effects of κ-opioid receptor agonists on SO contraction have not been clarified. In the present study, we investigated the effect of nalfurafine hydrochloride (nalfurafine), ( E )- N -[17-(cyclopropylmethyl)-4,5α-epoxy-3,14-dihydroxymorphinan-6β-yl]-3-(furan-3-yl)- N -methylprop-2-enamide monohydrochloride, a selective κ-opioid receptor agonist, on spontaneous contraction of rabbit SO. Methods: SO contraction was measured using manometry in anesthetized rabbits. Rabbits were anesthetized with intravenous administration of 25 mg/kg sodium pentobarbital. An open tip catheter was inserted into the common bile duct toward the SO ampullae. Saline was perfused through the lumen of the open tip catheter at a constant rate of 6 ml/hr using a syringe pump. Nalfurafine, morphine, and pentazocine were intravenously (i.v.) administered and perfusion pressure was recorded. Results: Morphine (0.3 mg/kg, i.v.) and pentazocine (3 mg/kg, i.v.) were found to increase SO perfusion pressure, suggesting that these opioid analgesics may cause SO contraction. In contrast, nalfurafine (0.2 μg/kg, i.v.) decreased the perfusion pressure, indicating that this κ-opioid receptor agonist suppresses SO contraction. Conclusions: These findings suggest that nalfurafine is unlikely to induce or exacerbate biliary diseases and may be safely used in patients with these disorders.

Endoscopic treatment of difficult extrahepatic bile duct stones, EPBD or EST: An anatomic view.

Large bile duct stone (> 10 mm) or multiple stones (≥ 3) are challenging for endoscopists. Endoscopic sphincterotomy (EST) is a routine therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedure usually used. It is safe and effective, but severe perforation or massive bleeding are the main causes of mortality. Because of the permanent destroy of Oddi sphincter, the use of EST is still controversial. Endoscopic papillary balloon dilation (EPBD) gives another way to open the sphincter. Less incidence of bleeding, perforation and partly preserving the Oddi sphincter's function are the main advantages. But high incidence of post-ERCP pancreatitis becomes a predominant problem. According to the anatomical feature of Oddi sphincter, limited EST + EPBD seems a more reasonable procedure. Compared to the former two procedures, it makes the stone extraction process much easier with lower incidences of short-term and long-term complications.

Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma for hepatolithiasis.

To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS) and risk factors for recurrence in hepatolithiasis. From March 1993 to December 2012, 202 consecutive patients with hepatolithiasis underwent OSPCHS at our department. The Oddi sphincter preserved procedure consisted of common hepatic duct exploration, stone extraction, hilar bile duct plasty, establishment of subcutaneous stoma to the bile duct. Patients with recurrent stones can undergo stone extraction and/or biliary drainage via the subcutaneous stoma which can be incised under local anesthesia. The long-term results were reviewed. Cox regression model was employed to analyze the risk factors for stone recurrence. Ninety-seven (48.0%) OSPCHS patients underwent hepatic resection concomitantly. The rate of surgical complications was 10.4%. There was no perioperative death. The immediate stone clearance rate was 72.8%. Postoperative cholangioscopic lithotomy raised the clearance rate to 97.0%. With a median follow-up period of 78.5 mo (range: 2-233 mo), 24.8% of patients had recurrent stones, 2.5% had late development of cholangiocarcinoma, and the mortality rate was 5.4%. Removal of recurrent stones and/or drainage of inflammatory bile via subcutaneous stoma were conducted in 44 (21.8%) patients. The clearance rate of recurrent stones was 84.0% after subsequent choledochoscopic lithotripsy via subcutaneous stoma. Cox regression analysis showed that residual stone was an independent prognostic factor for stone recurrence. In selected patients with hepatolithiasis, OSPCHS achieves excellent long-term outcomes, and residual stone is an independent prognostic factor for stone recurrence.

Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children.

The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children. All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up. 551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5%) presented with CBD stones with a mean age at symptom onset of 10.4 years (min-max: 4 months-18 years). A majority of the patients presented with hemolytic disease (61%). In 55% of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72% of success rate. In 9 cases (25%) of failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min-max: 1 month-5 years). All patients were stone free at last clinical and radiological evaluation. A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72% of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children.

Effects of cholecystectomy on the changes of motility of Beagle dogs' sphincter of Oddi.

To observe the effect of cholecystectomy on the changes of motion pattern of Beagle dogs' sphincter of Oddi (SO), and investigate the modulatory role of nitric oxide (NO) and cholecystokinin (CCK) in the regulation of SO. Pressure of common bile duct, SO motility, response to bolus injections of cholecystokinin (CCK, 20 ng/kg and 100 ng/kg), basal pressure (BP) and phasic contraction amplitude (PCA) were measured respectively by manometry in six Beagle dogs before and after cholecystectomy. After cholecystectomy, the pressure and diameter of common bile ducts (CBD) was significantly increased (p<0.01); BP and phasic contraction frequency (PCF) were also increased, however, no significant differences were found between the two groups; the SO motilities was not significantly changed. The relaxation responded to physiological dose of CCK (20ng/kg) was decreased, while bolus-dose of CCK (100ng/kg) induced rapid contractions and decreased PCA after cholecystectomy. The regulation pattern of SO pressure modulated by NO and its inhibitor had changed after cholecystectomy. After cholecystectomy in Beagle dogs, no obviously change of motion pattern of SO was observed through self-compensation, but these compensations may lead to some changes of regulation pattern of CCK and NO on SO.

Repairing bile duct defects while preserving the sphincter of oddi

In recent years,the incidence of iatrogenic bile duct injury has increased.The traditional treatment methods often cause severe complications,such as biliary-enteric anastomosis,which removes the sphincter of Oddi's function.With the development and potential translational use of engineered tissue,surgeons have focused on keeping normal physiological function after operations.In this manuscript,we review the strategy to repair bile duct defects without sacrificing the sphincter of Oddi' s function.This article may be referenced for clinical research. Key words: Biliary tract surgical procedures; Intraoperative complications ; Tissue engineering; Biocompatible materials

Effect of endoscopic sphincterotomy on function of sphincter of Oddi and long-term complications

Objective To investigate the effect of EST on function of sphincter of Oddi and on the long-term complications. Methods A total of 68 patients with common bile duct stones were recruited from January 2009 to January 2013 in The First People＇s Hospital of Hangzhou. All patients were under follow-up to observe the incidence of late complications after EST. Oddi sphincter manometry and bile bacterial culture were performed before EST and one year later. Results With the 13-36 months follow-up,the incidence of late complications was 16.9% （11/65）. The peak pressure and frequency of contraction of Oddi sphincter after EST were significantly lower than those before EST, but there were no significant differences between patients with complication and without （ P 〉 0. 05 ）. After EST, positive rate of biliary bacteria in patients with complications was much higher than that in patients without complications [70% （7/10）vs. 31.7% （13/41）, P = 0. 026], although there were no significant differences between them before EST [54. 5% （6/11 ） vs. 46. 3% （25/54） , P = 0. 618 ）. Logistic regression analysis showed that cholecystolithiasis, bile duct diameter （ 〉 1.5 cm）, number of stone （ 〉 3 ）, maximun diameter of stone （ 〉 20 mm）, large EST were independent risk factors for late complications of EST. Conclusion Importance should be attached to the late complications of EST with Oddi sphincter function declination, and biliary enteric reflux being the basic factor in late compilations after EST, which are also influenced by many risk factors. Key words: Sphincterotomy, endoscopic ; Sphincter of Oddi ; Manometry; Late complications

Influence of paeoniflorin on intracellular calcium ion concentration in the sphincter of Oddi of hypercholesterolemic rabbits.

This study aimed to investigate the influence of hypercholesterolemia (HC) on intracellular calcium ion concentration in the sphincter of Oddi (SO) of rabbits and the influence of paeoniflorin on intracellular calcium ion concentration in the hypercholesterolemic rabbit SO. Sixteen purebred New Zealand rabbits were randomly divided into two groups: the control group and the HC model group (8 rabbits in each group). The control group was fed standard diet. The HC group was fed standard diet plus cholesterol for a total of 8 weeks to induce and establish the rabbit HC model. The SO segment of HC rabbits was taken and enzyme treated to obtain SO cells. After primary culture, immunohistochemical analysis was performed. Fluo-3/AM was used to load SO cells, and then intracellular calcium ion concentration was determined by confocal microscopy. Intracellular calcium ion in the SO of the HC group was higher than that of the normal group; intracellular calcium ion in the HC rabbit SO of the paeoniflorin group was lower than that of the control group, where the paeoniflorin effect was greater with higher concentrations. High cholesterol caused an increase in intracellular calcium ion concentration in the rabbit SO, and paeoniflorin can reduce intracellular calcium ion concentration in the HC rabbit SO in a concentration-dependent manner.

Roles of sphincter of Oddi motility and serum vasoactive intestinal peptide, gastrin and cholecystokinin octapeptide.

To investigate roles of sphincter of Oddi (SO) motility played in pigment gallbladder stone formation in model of guinea pigs. Thirty-four adult male Hartley guinea pigs were divided randomly into two groups: the control group and pigment stone group. The pigment stone group was divided into 4 subgroups with 6 guinea pigs each according to time of sacrifice, and were fed a pigment lithogenic diet and sacrificed after 3, 6, 9 and 12 wk. SO manometry and recording of myoelectric activity of the guinea pigs were obtained by multifunctional physiograph at each stage. Serum vasoactive intestinal peptide (VIP), gastrin and cholecystokinin octapeptide (CCK-8) were detected at each stage in the process of pigment gallbladder stone formation by enzyme-linked immunosorbent assay. The incidence of pigment gallstone formation was 0%, 0%, 16.7% and 66.7% in the 3-, 6-, 9- and 12-wk group, respectively. The frequency of myoelectric activity decreased in the 3-wk group. The amplitude of myoelectric activity had a tendency to decrease but not significantly. The frequency of the SO decreased significantly in the 9-wk group. The SO basal pressure and common bile duct pressure increased in the 12-wk group (25.19 ± 7.77 mmHg vs 40.56 ± 11.81 mmHg, 22.35 ± 7.60 mmHg vs 38.51 ± 11.57 mmHg, P < 0.05). Serum VIP was significantly elevated in the 6- and 12-wk groups and serum CCK-8 was decreased significantly in the 12-wk group. Pigment gallstone-causing diet may induce SO dysfunction. The tension of the SO increased. The disturbance in SO motility may play a role in pigment gallstone formation, and changes in serum VIP and CCK-8 may be important causes of SO dysfunction.

The distribution and chemical coding of neurons supplying the sphincter of Oddi in mammals

The major duodenal papilla (papilla of Vater) is an important structure associated with the biliary tract and, in some species, the pancreas. It usually represents a slight elevation on the intestinal mucosa where the dilated junction (ampulla of Vater) of the commmon bile duct and pancreatic duct enters the duodenum. The ampulla is surrounded by a specifically arranged muscle structure called the sphincter of Oddi (SO) which controls the flow of bile and pancreatic fluid. The function of the sphincter is regulated by a complex system that involves many hormonal and neural factors. The literature in the field contains detailed data on the morphology of the SO in a number of mammalian species. However, the comprehensive information about the anatomy and neurochemistry of the innervation of this structure is very limited. The present review article summarizes the current knowledge on the innervation of the SO in mammals. Special emphasis has been put on the localization and chemical coding of neurons contributing to this nerve supply.

Specific biochemical amniotic fluid pattern of fetal isolated esophageal atresia

Perinatal care of esophageal atresia (EA) may be improved by prenatal diagnosis. Ultrasound findings (polyhydramnios and/or nonvisualization of fetal stomach) lead to a detection rate of ~50%. An amniotic fluid (AF) biochemical pattern characterized by high total protein, γ-glutamyl transpeptidase (GGTP), and normal l-leucine-aminopeptidase (AMP) leads to a 100% detection rate. The aim of this study was to explain this specific pattern. On the basis of enzyme activities assay, the following four objectives were sought: (i) comparing AF markers between EA and other digestive tract atresias, (ii) determining local GGTP synthesis in the esophagus (immunohistobiochemistry), (iii) determining the presence of a specific AF-AMP activity inhibitor, and (iv) comparing AF-AMP and AF-GGTP half-lives. The AF-EA pattern was similar to that observed in upper duodenal atresia (above the Oddi sphincter). No local synthesis of GGTP was observed in the esophagus. No AF-AMP activity inhibitor was found. AF-GGTP had a longer half-life than AF-AMP. Due to the swallowing anomaly observed in EA, GGTP and AMP values physiologically observed at 18 wk will decrease on the basis of the half-lives of markers, with a flat slope for GGTP and a sharp slope for AMP, therefore explaining the differences observed in the AF-EA pattern.

A rabbit model for simultaneous recording the electromyography of the gallbladder and sphincter of Oddi and the pressure of gallbladder and common bile duct

Objective To investigate an animal model for recording the electromyography (EMG) of the gallbladder/sphincter of Oddi and the pressure of gallbladder and common bile duct.Methods The animal model was established in 6 rabbits.A 7F central venous catheter was adopted to penetrate into the gallbladder through the liver.A pair bipolar platinum electrode was stitched onto the gallbladder at the serosal side.Another 7F central venous catheter with a pair bipolar platinum electrode was used to insert into the common bile duct near the sphincter of Oddi (SO).The signal of myoelectrical activity of SO and the gallbladder was recorded through a multi-channel physiological instrument.Meanwhile the changes in the pressure of the gallbladder and common bile duct were observed.Results The spike potential of SO in rabbits was above 0.05 mV,and the most value was 0.26 mV.The frequency of the spike potential was 2 times/min.The slow wave potential of SO was below 0.05 mV,and the frequency was 8-11 times/min.The pressure of gallbladder was 15 cm H2O (6.83-15.00 cm H2O).The pressure of common bile duct was 22 cm H2O (11-22 cm H2O).The EMG of gallbladder was unclear.Conclusion Rabbits can be used to establish the animal model recording the EMG of gall bladder and SO,and the pressure of common bile duct and gallbladder simultaneously,which provides a method for studying the myoelectric activity of SO and gallbladder motility. Key words: Gallbladder; Sphincter of Oddi; Myoelectric activity; Rabbit

Biliary type Sphincter of Oddi dysfunction: Symptomatic outcomes and complications after ERCP AND endoscopic sphincterotomy

Introduction: The diagnosis and therapy of functional biliary disorders remains a challenge. Sphincter of Oddi (SO) dysfunction (SOD) can be defined such as a motility disorder of the SO. Endoscopic sphincterotomy (EST) is a standard treatment of choice in those patients with organic SO stenosis or abnormal SO manometry. The aims of our current study were to analyze the outcome and complications of EST in our SOD patients.

287 Prospective Randomized Trial Comparing Covered Metal Stent Placed Above and Across the Sphincter of Oddi in Malignant Biliary Obstruction

In patients with malignant biliary obstruction, covered self-expandable metal stent (C-SEMS) placement above the sphincter of Oddi (SO) would prevent ascending bacterial colonization, thereby resulting in the prolonged duration of stent patency and lower incidence of cholangitis.

Function of Oddi＇s sphincter with normal pancreatobiliary confluence and pancreatobiliary reflux

Objective To explore the impact of basal sphincter of Oddi （SO） pressure on pancre- atobiliary reflux （PBR）. Methods A total of 120 consecutive patients who received therapeutic ERCP for biliary tract diseases with or without the history of EST were enrolled, and were assigned to normal basal SO pressure group （n = 23 ）, elevated basal pressure group （ n = 55 ） and EST group （ n = 24）. Basal SO pressure, bile amylase （BA）and bacteria culture findings were compared between the three groups. Results There were no differences in positive rate of bacteria culture, SO pressure increase and BA between the normal basal SO pressure group and elevated basal pressure group. In the latter group, negative correlation was observed between SO pressure and BA. The BA value [ median（ quartile range） ] in patients with common bile duet I〉 15 mm [4270 （12 337）U/L] was significantly higher than that in patients with common bile duct 〈 15 mm [ 279. 5 （1370）U/L]. Furthermore, significant difference in both the proportion of elevated BA patients （83.3% vs. 59.0% ） （P 〈0.05） and the positive rate of bacteria culture （75.0% vs. 33.3% ） was seen between the intact papilla patients in the former two groups and those in EST group （P 〈 0. 05 ）. Conclusion There was no direct correlation between the elevated basal SO pressure and PBR, but marked increase in diameter of common bile duct can lead to a rise in BA. Moreover, although EST can bring about PBR and bile bacterial infection, it may facilitate the outflow of the refluent pancreatic juice by relieving eholestasis. Key words: Sphincter of Oddi manometry; Normal pancreatobiliary junction; Biliary amylase; Pancreatobiliary reflux

Physiology and Pathophysiology of the Biliary Tract: The Gallbladder and Sphincter of Oddi—A Review

The biliary tract collects, stores, concentrates, and delivers bile secreted by the liver. Its motility is controlled by neurohormonal mechanisms with the vagus and splanchnic nerves and the hormone cholecystokinin playing key roles. These neurohormonal mechanisms integrate the motility of the gallbladder and sphincter of Oddi (SO) with the gastrointestinal tract in the fasting and digestive phases. During fasting most of the hepatic bile is diverted toward the gallbladder by the resistance of the SO. The gallbladder allows the gradual entry of bile relaxing by passive and active mechanisms. During the digestive phase the gallbladder contracts, and the SO relaxes allowing bile to be released into the duodenum for the digestion and absorption of fats. Pathological processes manifested by recurrent episodes of upper abdominal pain affect both the gallbladder and SO. The gallbladder motility and cytoprotective functions are impaired by lithogenic hepatic bile with excess cholesterol allowing the hydrophobic bile salts to induce chronic cholecystitis. Laparoscopic cholecystectomy is the standard treatment. Three types of SO dyskinesia also cause biliary pain. Their pathophysiology is not completely known. The pain of types I and II usually respond to sphincterotomy, but the pain due to type III usually does not.