Pancreatic Sphincter Of Oddi Dysfunction Research Articles

An exceptional case of persistently elevated serum amylase and lipase levels due to type 2 pancreatic sphincter of ODDI dysfunction

An exceptional case of persistently elevated serum amylase and lipase levels due to type 2 pancreatic sphincter of ODDI dysfunction

Risk factors for ERCP-related complications and what is the specific role of ASGE grading system.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the main therapeutic and sometimes diagnostic methods in biliary and pancreatic diseases. A grading system for the difficulty of ERCP (grade one to four, the higher grade represents the more complexity of the procedure) has been developed by the American Society for Gastrointestinal Endoscopy (ASGE). This study aimed to assess the prevalence of ERCP-related complications, their common risk factors, and specifically the role of difficulty of the procedure based on ASGE grading. This cross-sectional study was performed on 620 ERCP-operated patients over 4 years in two tertiary referral centers affiliated with Isfahan University of Medical Sciences. Data about the difficulty of procedures based on the ASGE grading scale, complications including pancreatitis, bleeding, infection, perforation, arrhythmia, respiratory suppression, aspiration, and major common risk factors were collected. The overall prevalence of complications was 11.6% including pancreatitis 8.2%, perforation 0.8%, gastrointestinal bleeding 1.3%, cholangitis 2.4%, and cardiopulmonary problems 0.5% (arrhythmia 0.3% and respiratory depression 0.2%). Patients with pancreatic contrast injection (66.7% vs. 11.3% P = 0.04) and sphincter of Oddi dysfunction (SOD) (44.4% vs. 11.1%; P = 0.01) showed a statistically significant higher overall complication rate. The association of these risk factors remained significant in multivariable logistic regression analysis. Patients with pancreatic contrast injection also showed a statistically significant higher prevalence of post-ERCP pancreatitis (66.7% vs. 11.3% P = 0.04). Furthermore, a significantly higher prevalence of arrhythmia (3.6% vs. 0; P = 0.008) was observed among patients with difficult cannulation. Based on the ASGE difficulty grading score, most of the patients were classified as grade 2 (74.2%) and 3 and 4 (23.4%). No statistically significant difference was noted between the difficulty-based groups in terms of complications. The current study showed that the most critical risk factors of ERCP-induced complications were pancreatic contrast injection and SOD. ASGE grading scale for ERCP complexity did not predict the occurrence of complications in our study population.

Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography.

Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.

Functional Pancreatic Sphincter Dysfunction in Children: Recommendations for Diagnosis and Management.

Functional pancreatic sphincter dysfunction (FPSD), previously characterized as pancreatic sphincter of Oddi dysfunction, is a rarely described cause of pancreatitis. Most studies are reported in adults with alcohol or smoking as confounders, which are uncommon risk factors in children. There are no tests to reliably diagnose FPSD in pediatrics and it is unclear to what degree this disorder contributes to childhood pancreatitis. We conducted a literature review of the diagnostic and treatment approaches for FPSD, including unique challenges applicable to pediatrics. We identified best practices in the management of children with suspected FPSD and formed a consensus expert opinion. In children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP), we recommend that other risk factors, specifically obstructive factors, be ruled out before considering FPSD as the underlying etiology. In children with ARP/CP, FPSD may be the etiology behind a persistently dilated pancreatic duct in the absence of an alternative obstructive process. Endoscopic retrograde cholangiopancreatography with sphincterotomy should be considered in a select group of children with ARP/CP when FPSD is highly suspected and other etiologies have been effectively ruled out. The family and patient should be thoroughly counseled regarding the risks and advantages of endoscopic intervention. Endoscopic retrograde cholangiopancreatography for suspected FPSD should be considered with caution in children with ARP/CP when pancreatic ductal dilatation is absent. Our consensus expert guidelines provide a uniform approach to the diagnosis and treatment of pediatric FPSD. Further research is necessary to determine the full contribution of FPSD to pediatric pancreatitis.

Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis.

Background and study aims Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.

706 Change in Incidence RATES of Idiopathic Recurrent Acute Pancreatitis Following ERCP With Sphincter of Oddi Manometry: Post-Hoc Analysis With Long Term Follow-Up of a Randomized, Clinical Trial

Pancreatic sphincter of Oddi dysfunction (SOD) is frequently identified in individuals with idiopathic, recurrent acute pancreatitis (iRAP). However, the efficacy of biliary (BES) and dual endoscopic sphincterotomy (DES) in: 1) eliminating future episodes of acute pancreatitis (AP),2) reducing AP frequency, and 3) decreasing progression to chronic pancreatitis (CP), is uncertain. Aims: Measure the impact of BES and DES on the rate of recurrence of iRAP (episode frequency) and progression to CP in SOD patients, via post hoc analysis of a previously conducted randomized clinical trial.

705 Prophylasix of Post-ERCP Pancreatitis With Nafamostat Mesilate: Comparison of 24-Hour and 8-Hour Infusion of Nafamostat Mesilate: a Prospective Randomized Comparison Trial

705 Prophylasix of Post-ERCP Pancreatitis With Nafamostat Mesilate: Comparison of 24-Hour and 8-Hour Infusion of Nafamostat Mesilate: a Prospective Randomized Comparison Trial

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-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)...

A non-precut method for pancreatic duct cannulation using triple lumen needle knife

Selective cannulation is essential and is considered the most difficult part of an ERCP procedure. Selective cannulation may became difficult when the papilla is swollen, tiny, hooknose-shaped or in an abnormal position. Precut technique is sometimes required to achieve cannulation in difficult patients. However, it may be dangerous when the papilla is small. We report a case with successful cannulation by using a triple lumen needle knife (NF) without precutting. A 42-year-old woman with recurrent upper abdominal pain was admitted to our hospital. Her serum amylase level was 411 (normal 10-60) IU/L. MRCP revealed a mildly dilated pancreatic duct of 7mm (Fig. 1a). The pancreas otherwise was normal. Patient was suspected to have type I pancreatic sphincter of Oddi dysfunction (SOD). During ERCP, a tiny rigid major papilla was found (Fig. 1b). Attempted cannulation of the pancreatic duct with a guidewire-preloaded (Jagwire, Boston, Marborough, MA) sphincterotome (Clevercut, Olympus, Japan) and sequentially a 5 Fr cannula (PR-126Q-1, Olympus, Japan) were tried. Then guidewire was extended outside for direct cannulation with the help of the sphincterotome. However, all of the regular methods failed because the papilla was firm and the opening was small. After 40 min of attempting, we switched to a triple lumen needle knife

Covering the Cover

Covering the Cover

Su1395 Pancreatic Sphincter Hypertension Treated by Endoscopic Sphincterotomy (ES) of the Pancreatic Segment of the Sphincter of Oddi (SO): Role of Repeat Sphincter Oddi (SO) Manometry (SOM) Following Short-Term Pancreatic Duct Stenting

SO dysfunction (SOD) is a syndrome previously described in postcholecystectomy pts presenting w/ abd pain only (type III) w/ or w/o high LFTs & dilated CBD (Type I, Type II).Controversies still exist in biliary SOD, pancreatic SOD presents a greater diagnostic & therapeutic challenge. ancreatic sphincter hypertension of the major papilla, a variant of SOD, is a potential cause of acute recurrent (ARP), chronic pancreatitis (CP) & pancreatic-type pain.Little long-term data exists describing pancreatic SOD including presentation, ES technique & long-term outcome.Response rates of ES vary (64-91%). Experience suggests failure to respond to pancreatic ES include: 1.Inadequate pancreatic ES. 2.Recurrent pancreatic stenosis. 3.Presence of CP. AIM:Determine long-term outcome of pancreatic ES in pts w/ pancreatic SO hypertension.Determine rate of residual sphincter hypertension in pts following pancreatic ES.

Long-Term Outcome of Pancreatic Sphincterotomy in Patients with Idiopathic Acute Recurrent Pancreatitis (IARP) and Pancreatic Sphincter of Oddi Dysfunction (SOD)

Pancreatic duct SOD is a controversial presumed cause of IARP. ERCP, pancreatic sphincter of Oddi manometry (SOM), and single or dual endoscopic sphincterotomy for SOD is recommended for patients with IARP although little patient outcome data is available. Methods: A review of patients with IARP who underwent ERCP with manometry between 1998 and 2006 was conducted. They were divided into two groups: those with documented hypertension who underwent pancreatic sphincterotomy (SOD-pES, n=36) and those with normal manometry who had no endoscopic therapy (Nl SOM, n=32). Both groups received surveys regarding their episodes of pancreatitis and quality of life both prior to, and after ERCP. Mean follow-up was 5.83 years with 15% lost to follow-up. Results: Respondents (54%) were demographically similar to non-respondents. A statistically significant reduction in severity of symptoms (P< 0.01) and ER visits (P<0.05) was reported by both groups. The SOD-pES group reported a higher mean reduction in symptom severity. When compared to the Nl SOM group, a larger percentage of the SOD-pES group reported resolution or significant improvement in symptoms (75% vs 47%) and a lesser rate of relapse (6% vs 14%). This difference was maintained with a statistically significant reduction in narcotic use (P<0.05), frequency of physician- (P<0.05) and self-diagnosed (P<0.001) episodes of pancreatitis. A larger percentage of the SOD-pES group reported improvement in overall condition (63% vs 30%), with a statistically significant improvement in the mean score (P<0.05). In contrast, a large majority of Nl SOM group reported no change or worsening of symptoms (70% vs 27.5%). Conclusion: Compared to IARP patients with normal SOM and no endoscopic therapy, IARP patients with manometry-proven pancreatic SOD derived a sustained clinical benefit from pancreatic sphincterotomy.

Biliary dyskinesia in the pediatric patient

The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.

Moderate and Severe Post ERCP Pancreatitis; Despite Prophylactic Pancreatic Stent Placement

Introduction: Placement of prophylactic pancreatic stents (PP stents) is a proven method to reduce the rate and severity of post ERCP pancreatitis (PEP) in high risk settings. This study was done to determine the rate of early passage of PP stents in moderate and severe PEP. We hypothesized that stent passage by the 3rd day after placement might be premature and contribute to more frequent or severe PEP. Methods: We analyzed 27,176 ERCP procedures over 13 year period (January 1994 to September 2007) which were prospectively entered into our ERCP database. PP stents were placed in 7,661 patients. Of those, 580 patients (7.5%) developed PEP; mild 460 (6.0%), moderate 87 (1.1%) and severe 33 (0.4%). Patients who were hospitalized at our institution for moderate (59) or severe PEP (27) had abdominal X-rays reviewed for stent persistence or passage from the pancreas. Risk factors for PEP were reviewed. Results: Risk factors for developing moderate PEP were not significantly different from those with severe PEP: female (79.7% versus 92.9%), sphincter of Oddi manometry (94.9% versus 88.9%), pancreatic sphincter of Oddi dysfunction (SOD) (59.3% versus 59.3%), biliary SOD (30.5% versus 29.6%), balloon dilation (8.5% versus 14.8%), dual sphincterotomy (67.8% versus 55.6%), pancreatography including tail filling (81.0 %versus 88.9%), no chronic pancreatitis (72.4% versus 88.9%) and normal cholangiogram (78.2% versus 80.8%). Patients with moderate and severe PEP had 6.6 and 6.9 risks factors, respectively (p = NS). Stent diameter in moderate PEP were; 3 Fr, 42.4%; 4 Fr, 35.6%; > 4 Fr, 22.0%. In severe PEP, stent diameter were; 3 Fr, 51.9%; 4 Fr, 25.9%; > 4 Fr, 22.2%. Protective stents passed from the pancreatic duct by the 3rd day in 7 patients with moderate PEP (11.9%) and 5 patients with severe PEP (18.5%) (p = 0.505). Hospitalization days in patients with moderate PEP whose stent passed by and after the 3rd day were 7.43 (1.46) and 8.37 (1.16) days, respectively (p = NS). Hospitalization days in patients with severe PEP whose stent passed by and after the 3rd day were 21.60 (6.11) and 22.23 (3.13) days, respectively (p = NS). A confounding variable was the co-existence of perforation in 1 moderate and 3 severe PEP. Summary: The frequency of moderate and severe PEP in high risk patients with PP stent placement is relatively low but PEP still occurs. Our study showed that more than 80% of patients who developed moderate and severe PEP still had the PP stent in place more than 3 days. Conclusion: Early stent fall out does not appear to be a significant contributing factor for moderate and severe PEP. The optimal duration of PP stent placement is unknown.

Risk factors in endoscopic manometry for suspected dysfunction of Oddi's sphincter

An increased incidence of pancreatitis having been reported after endoscopic manometry (EM) of the sphincter of Oddi, its incidence and severity as well as potential risk factors were investigated prospectively. Between June 1988 and June 1996, standardised manometry was performed in 207 patients with suspected biliary and 23 with suspected pancreatic sphincter of Oddi dysfunction (SOD). All patients had been observed in hospital for at least 24 hours before the test. The diagnostic criteria of post-manometric pancreatitis (PMP) were epigastric pain and a rise in the concentration of serum amylase to at least three times normal. Potential risk factors for PMP were elucidated by uni- and multivariate analysis. Pancreatitis occurred in 19 patients (9%) with suspected biliary and in 6 (26%) with suspected pancreatic SOD (P < 0.01), 17 of mild and 8 of moderate degree. There were no deaths and no lasting sequelae. Previous pancreatitis after endoscopic retrograde cholangiopancreatography and the presence of SOD were identified as patient-associated risk factors (P < 0.01 for each). Method-associated risk factors were duration of manometry of more than 5 min (P < 0.05) and manometry in the pancreatic duct system (P < 0.05). The risk of pancreatitis was reduced by simultaneous endoscopic sphincterotomy for SOD (P < 0.01). Specific and often avoidable risk factors for postmanometric pancreatitis were identified: technical procedure, pancreatitis, SOD. With short duration of manometry, avoiding of manometry in the pancreatic duct system and with patient's informed consent for simultaneous endoscopic sphincterotomy risk of pancreatitis may be lowered.

Biliary and gallbladder dyskinesia

Gallbladder and biliary dyskinesia are conditions that are becoming increasingly recognized due to improved technology. They are motility disorders that affect the gallbladder and sphincter of Oddi (SO), respectively. Gallbladder dyskinesia presents with typical biliary pain in the absence of gallstones. Work-up includes laboratory tests and imaging to rule out gallstones. Further investigation leads to a functional radionuclide study to investigate gallbladder ejection fraction. An ejection fraction of less than 40% is considered abnormal, and patients should be referred for cholecystectomy. Symptom relief after the procedure has been seen in 94% to 98% of patients. The term sphincter of Oddi dysfunction (SOD) describes a collection of pain syndromes that are attributed to a motility disorder of the SO. SOD can be further subdivided into biliary and pancreatic SOD. Patients typically have had a prior cholecystectomy and present with episodic biliary pain. The initial work-up includes laboratory tests and imaging to rule out other structural causes of abdominal pain, such as retained gallstones. Imaging and laboratory studies further subdivide patients into types of SOD. SO manometry (SOM) is the gold standard for assessing biliary dyskinesia and can help stratify patients into one of two groups: SO stenosis versus SO dyskinesia. Those with stenosis (type I SOD) are the most likely to respond to treatment with endoscopic biliary sphincterotomy (EBS). As the vast majority of type I patients (>/= 90%) benefit from EBS, SOM is not necessary. Pancreatic SOD patients can be similarly divided into one of three groups. These patients present with recurrent bouts of abdominal pain and/or pancreatitis in the absence of gallstones or other structural abnormalities. Pancreatic sphincter manometry can help distinguish which patients would benefit from endoscopic pancreatic sphincterotomy. Recurrent stenosis of the opening after endoscopic treatment in these patients may necessitate a surgical (open) approach.

Biliary and gallbladder dyskinesia

Gallbladder and biliary dyskinesia are conditions that are becoming increasingly recognized due to improved technology. They are motility disorders that affect the gallbladder and sphincter of Oddi (SO), respectively. Gallbladder dyskinesia presents with typical biliary pain in the absence of gallstones. Work-up includes laboratory tests and imaging to rule out gallstones. Further investigation leads to a functional radionuclide study to investigate gallbladder ejection fraction. An ejection fraction of less than 40% is considered abnormal, and patients should be referred for cholecystectomy. Symptom relief after the procedure has been seen in 94% to 98% of patients. The term sphincter of Oddi dysfunction (SOD) describes a collection of pain syndromes that are attributed to a motility disorder of the SO. SOD can be further subdivided into biliary and pancreatic SOD. Patients typically have had a prior cholecystectomy and present with episodic biliary pain. The initial work-up includes laboratory tests and imaging to rule out other structural causes of abdominal pain, such as retained gallstones. Imaging and laboratory studies further subdivide patients into types of SOD. SO manometry (SOM) is the gold standard for assessing biliary dyskinesia and can help stratify patients into one of two groups: SO stenosis versus SO dyskinesia. Those with stenosis (type I SOD) are the most likely to respond to treatment with endoscopic biliary sphincterotomy (EBS). As the vast majority of type I patients (>/= 90%) benefit from EBS, SOM is not necessary. Pancreatic SOD patients can be similarly divided into one of three groups. These patients present with recurrent bouts of abdominal pain and/or pancreatitis in the absence of gallstones or other structural abnormalities. Pancreatic sphincter manometry can help distinguish which patients would benefit from endoscopic pancreatic sphincterotomy. Recurrent stenosis of the opening after endoscopic treatment in these patients may necessitate a surgical (open) approach.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type I, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with type I SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type I SOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Systematic review: sphincter of Oddi dysfunction – non‐invasive diagnostic methods and long‐term outcome after endoscopic sphincterotomy

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended. To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy. A systematic review of English language articles and abstracts containing relevant terms was performed. Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous. Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.