Sphincter Of Oddi Dysfunction Research Articles

Secretin-Enhanced MRCP: How and Why-AJR Expert Panel Narrative Review.

Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.

Biliary type-II sphincter of Oddi dysfunction with a pancreatic duct dilation: a case report and review of the\xa0literature

BackgroundThe double-duct sign is defined as dilation of both the common bile duct and pancreatic duct, which usually indicates pancreatic malignancy. However, benign causes have also been reported to cause a double-duct sign.Case presentationWe present the case of a 59-year-old Caucasian female patient admitted to the Gastroenterology Department with intermittent right epigastric abdominal pain and an intact gallbladder. A double-duct sign was seen on endoscopic ultrasound. The suspicion of pancreatic malignancy was excluded through follow-up investigations. Biliary type II sphincter of Oddi dysfunction was diagnosed with an association of the double-duct sign. Sphincterotomy was performed to reduce pain, and there was no recurrence of symptoms during follow-up.ConclusionsThis is the third reported case in the literature of the double-duct sign associated with sphincter of Oddi dysfunction. This case emphasizes that the double-duct sign is not always caused by a local malignancy. The literature review of the reported cases has been summarized to help in the diagnosis of future similar cases.

The Next EPISOD: Trends in Utilization of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction from 2010-2019

For years, the endoscopic management of the disorder formerly known as Type III Sphincter of Oddi Dysfunction (SOD) had been controversial. In 2013, the results of the Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial demonstrated that there was no benefit associated with endoscopic sphincterotomy for patients with Type III SOD. We aimed to assess the utilization of endoscopic sphincterotomy for patients with SOD in a large population database from 2010-2019. We searched a large electronic health record (EHR)-based dataset incorporating over 300 individual hospitals in the United States (Explorys, IBM Watson health, Armonk, NY). Using Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) we identified patients with a first-ever diagnosis of "disorder of Sphincter of Oddi" annually from 2010-2019. Subclassification of SOD types was not feasible using SNOMED-CT codes. Stratified by year, we identified the proportion of patients with newly-diagnosed SOD undergoing endoscopic sphincterotomy and those receiving newly-prescribed medical therapy. A total of 39,950,800 individual patients were active in the database with 7,750 index diagnoses of SOD during the study period. The incidence rates of SOD increased from 2.4 to 12.8 per 100,000 persons from 2010-2019 (P < .001). In parallel, there were reductions in the rates of biliary (34.3% to 24.5%) and pancreatic sphincterotomy (25% to 16.4%), respectively (P < .001). Sphincter of Oddi manometry (SOM) was infrequently utilized, <20 times in any given year, throughout the study duration. There were no significant increases in new prescriptions for TCAs, nifedipine, or vasodilatory nitrates. Among a wide range of practice settings which do not utilize routine SOM, a sudden and sustained decrease in rates of endoscopic sphincterotomy for newly-diagnosed SOD was observed beginning in 2013. These findings highlight the critical importance of high-quality, multi-center, randomized controlled trials in endoscopy to drive evidence-based changes in real-world clinical practice.

Sphincter of Oddi dysfunction in the post-cholecystectomy period

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.

S0079 Prophylactic Rectal Indomethacin and Prophylactic Pancreatic Duct Stents (PPS) for Prevention of Post-ERCP Pancreatitis Are Underutilized in Average and High-Risk Patients Undergoing ERCP

INTRODUCTION: Incidence of Post-ERCP pancreatitis (PEP) ranges from 1% to 10% in unselected patients and as high as 25% to 30% in high-risk patients. Rectal indomethacin (RI) administered before or immediately after an ERCP is associated with a 35% to 65% reduction in the incidence of PEP. Prophylactic pancreatic duct stent (PPS) placement in high risk patients is also regarded as the most effective mechanical prophylactic approach to reduce the incidence and severity of PEP. We sought to investigate utilization rate of prophylactic RI and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. METHODS: We performed a retrospective analysis in the IBM Explorys database, a pooled, national, de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States. We examined demographics, high-risk features [history of acute pancreatitis at least 30 days before ERCP, sphincter of Oddi dysfunction (SOD), sphincterotomy] and incidence of PEP in patients with cumulative risk factors. The subjects were risk-stratified as either average-risk (absence of any of the studied risk factors) or high risk (presence of at least one risk factor). PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. RESULTS: Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8%) had a PEP prophylaxis. RI and PPS accounted for 82.4% and 12.9% respectively. About 4.8% of patients had both RI and PPS within a day of ERCP procedure. Young individuals (< 40 years) had significantly higher RI use (32.1% vs 26.8%, P < 0.0001) than older individuals but lower PPS placement than older individuals (2.6% vs 4.7%, P < 0.0001). Women had higher RI use compared to men (29.2% vs 25.8%, P < 0.0001) but lower PPS placement (4.6% vs 5.2%, P = 0.016) than men. Individuals with three risk factors had the highest PEP rates: female + young + SOD: 20%; female + AP + sphincterotomy: 11.8%, followed by individuals with two risk factors: female + SOD: 11.1% and young + sphincterotomy: 10.7%. CONCLUSION: Only a third of all patients undergoing ERCP received prophylaxis in the form of RI and PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.

S0081 Virtual Reality Can Reduce Pain and Opioid Use in Sphincter of Oddi Dysfunction (SOD) Type III: A Prospective Pilot Study

INTRODUCTION: Patients with classic SOD III have chronic debilitating pain not amenable to pharmacologic or endoscopic therapy. Our previous studies have shown benefits of virtual reality (VR) for pain management through immersive three-dimensional (3D) multisensory experiences, but only in short-term inpatient settings. To evaluate the impact of VR for chronic pain in patients with SOD III in an outpatient setting. METHODS: In this prospective pilot cohort study, adults who met the criteria for conventional SOD III (biliary-type pain for ≥3 months without abnormal liver enzymes or imaging) with an average pain score of ≥3 out of 10 for at least 3 episodes per week were enrolled. The study was divided into four 2-week periods: pre-intervention, early VR intervention, late VR intervention, and post-intervention. Subjects were given Samsung Gear Oculus headsets during the intervention period (early and late) with preloaded 21 VR experiences and were instructed to view one 3D VR experience at least 3 times a day for 10–15 minutes each. Throughout the study, subjects filled out daily questionnaires including pain scores on a numeric rating scale (0–10), pain medication use (opioids, NSAIDs, etc.), their VR experience, and hospitalizations. RESULTS: 9 patients were included with a median age of 47 (IQR, 41–51) years, 100% female, and a median disease duration of 8 (IQR, 5–9) years. Overall pain medication use decreased from 67% to 40% in the pre-intervention vs. post-intervention period. Opiate use also decreased from 40% to 20% in the same period. On univariate analysis, post-intervention pain scores decreased by 2.02 points out of 10 (95% CI: −2.55 to −1.49; P-value < 0.001; Table 1 and Figure 1) compared to pre-intervention pain scores. After adjusting for anti-depressant use in multivariable analyses, post-intervention pain scores remained significantly decreased by 1.99 points (95% CI: −2.60 to −1.39; P < 0.001). There were no adverse events or hospitalizations. Furthermore, 6/6 (100%) of patients had a positive VR experience. CONCLUSION: This is the first study evaluating VR for management of patients with SOD III. We showed that pain scores not only declined throughout the VR intervention period, but also in the post-intervention period, suggesting a possible sustained therapeutic benefit. Pain medication use, including opioids, was also reduced at the end of the study. Future large controlled trials should evaluate the role of VR in treating patients with SOD III.Table 1.: Univariate analysis of pain scores revealed multiple factors for significant pain score reduction including VR, older age, higher BMI, anxiety/depression, and use of anti-depressantsFigure 1.: Pain scores significantly improved during the VR intervention period and was sustained into the post-intervention period when compared to pre-intervention pain scores.

S1567 Pancreatico-Pleural and Enteric Fistulas: A Rare Complication of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

INTRODUCTION: Pancreatico – pleural and enteric fistulas (PPEF) are rare complications of pancreatitis, where a tract is created draining pancreatic fluid into the pleural cavity and/or bowel. Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a 5-10% risk of pancreatitis. CASE DESCRIPTION/METHODS: A 66-year-old female with past medical history of hypertension and asthma presented for abdominal pain with nausea and vomiting. One-day prior she underwent an ERCP. She was treated conservatively for post-ERCP (pERCP) pancreatitis. Subsequently she was admitted for pancreatitis three times over a period of 3 months. Vitals were within normal limits. Physical examination was significant for diffuse abdominal tenderness and normoactive bowel sounds. Laboratory data was significant for a lipase of 2858, and a WBC of 12.39. Otherwise, complete metabolic panel, and CBC were normal. Initial computerized tomography (CT) showed acute pancreatitis with a large pseudocyst (Figure 1). Interval CT showed pancreatic duct dilation, a pancreatico-enteric fistula tract and a new left pleural effusion with air within the fluid suggestive of a pancreatico-pleural fistula (Figure 2). The patient was managed conservatively. At 3-month follow up, the patients symptoms had resolved, and a repeat CT showed resolution of pancreatitis, fistula and pleural effusion (Figure 3). DISCUSSION: Magnetic resonance cholangiopancreatography is the diagnostic imaging of choice for visualizing pancreatic fistulas. Thoracentesis with a lipase-rich pleural fluid can help aid in the diagnosis.Modalities of treatment are endoscopic stenting of the disrupted pancreatic duct, conservative management with octreotide (to suppress pancreatic exocrine function) with or without chest tube drainage, or surgical intervention with distal pancreatectomy and pancreatico-jejunostomy in those with complete ductal obstruction. Thirty to 60% of patients can be managed successfully with conservative management. Sphincter of oddi dysfunction, young age, repeated cannulation attempts with sphincterotomy, and history of pancreatitis are risk factors for pERCP pancreatitis. Prophylactic rectal indomethacin and pancreatic stenting in patients at high risk of pERCP pancreatitis have been shown to decrease incidence rates. PPEF uncommonly arise together and require a high index of suspicion. The diagnosis can be made via imaging, endoscopy or with a thoracentesis. Management is usually conservative, but endoscopic or surgical procedures may be warranted.Figure 1.: CT abdomen and pelvis showing acute pancreatitis with a pancreatic tail/body large pseudocyst (Green arrow).Figure 2.: Interval CT Chest, abdomen and pelvis showing dilated pancreatic duct (Blue arrow), resolving pancreatic pseudocyst(White arrow), pancreatico-enteric fistula tract (Red arrow), and a new left pleural effusion with air within the fluid (Yellow arrow) suggestive of a pancreatico-pleural fistula.Figure 3.: A 3-month Interval CT abdomen, pelvis and chest showing complete resolution of acute pancreatitis and fistula tract (Panel A), and resolution of pleural effusion (Panel B).

Association of cholelithiasis with hypothyroidism

Hypothyroidism causes dyslipidemia and stasis of bile and sphincter of oddi dysfunction causing cholelithiasis and choledocholithiasis. Therefore patients with hypothyroidism should be screened for gall stones which can be managed prior to development of complications. A case control study was done comparing 110 cases and 110 controls were sampled. A significant portion of cases were diagnosed with subclinical hypothyroidism. With an odds ratio of 14.3. Female sex, age greater than 50 years, obesity, dyslipidemia, non-vegetarian diet were also significant risk factors for cholelithiasis. The bile leak and need for drain placement was found to be higher in hypothyroid patients as compared to euthyroid patients undergoing laparoscopic cholecystectomy.

S0102 Evaluation of the Effect of Aggressive Hydration on the Incidence of Post-ERCP Pancreatitis

INTRODUCTION: Post ERCP pancreatitis (PEP) is a significant complication with increased morbidity, occasional mortality and increased healthcare costs with an incidence of 9.7% and up to 14.7% in high risk patients. Aggressive hydration during peri-procedure period and for an additional 8 hours post procedure has been shown to reduce the risk of PEP. Our aim was to assess the effect of aggressive hydration for 24 hours post ERCP on the incidence of PEP. METHODS: At our institution, we instituted aggressive hydration therapy (20 ml/Kg bolus of isotonic IVF during procedure followed by 3–5 ml/Kg for 24 hrs) for every hospitalized patient between the ages of 18 to 70 years undergoing ERCP. After 24 hours, IVF were discontinued if patients were able to tolerate oral intake. Patients were monitored for signs of volume overload (lower extremity swelling, pulmonary edema, shortness of breath and rise in BP). We retrospectively reviewed all inpatient ERCPs performed between 10/2017 and 10/2018. Patients with advanced CKD, CHF, COPD with supplemental oxygen, pregnant, or septic were excluded. Patients were high risk for PEP: females <50 years of age, normal serum bilirubin, prior history of pancreatitis, sphincter of Oddi dysfunction, pre-cut sphincterotomy, PD sphincteroplasty, PD cannulation, and PD injection. All high-risk patients received 100 mg rectal indomethacin, unless contraindicated. Stent was placed in PD if cannulated. Average risk patients received rectal indomethacin at the discretion of the endoscopist. PEP was defined based on the Cotton’s criteria. Severity of pancreatitis was defined based on the revised Atlanta criteria. RESULTS: There were a total of 278 inpatient ERCPs between 10/2017 and 10/2018. A total of 164 patients met the inclusion criteria. Fifty-nine patients were considered average risk and 105 were high risk (Table 1). The overall PEP rate in the study cohort was 7.3%. In high risk group overall PEP rate was 9.5% and 3.4% in average risk group. The rate of moderate-severe PEP in the study cohort was 1.8% and in high risk patients was 1.9% (Tables 2 and 3). Four patients developed mild rise in BP while 2 patients developed lower extremity swelling. There were no cases of volume overload necessitating stoppage of IVF in either groups. CONCLUSION: In conclusion, extending aggressive hydration to 24 hours post ERCP helps reduce the incidence of PEP, especially moderate to severe PEP. Further randomized controlled studies are needed to collaborate our study findings.Table 1.: Characteristics of PatientsTable 2.: Characteristics of average risk patients with PEPTable 3.: Characteristics of high risk patients with PEP

Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis.

BACKGROUND : Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most serious complication of ERCP. Our aim was to estimate the nationwide incidence, temporal trends, and mortality of PEP in the United States and to establish risk factors associated with PEP development. METHODS : This was a retrospective cohort study analyzing Nationwide Inpatient Sample data from 2011 to 2017 using International Classification of Diseases codes. The primary outcomes were trends in PEP incidence and predictors of PEP development. Secondary outcomes were in-hospital mortality, length of hospital stay, and admission to the intensive care unit. RESULTS : Of 1 222 467 adult patients who underwent inpatient ERCP during the study period, 55 225 (4.5 %) developed PEP. The hospital admission rate of PEP increased by 15.3 %, from 7735 in 2011 to 8920 in 2017 (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.04 - 1.46; P = 0.02). The overall rate of mortality increased from 2.8 % of PEP cases in 2011 to 4.4 % in 2017 (OR 1.62, 95 %CI 1.10 - 2.38; P = 0.01). Multiple patient-related (alcohol use, cocaine use, obesity, chronic kidney disease, heart failure), procedure-related (therapeutic ERCP, sphincterotomy, pancreatic duct stent placement, sphincter of Oddi dysfunction), and hospital-related (teaching hospitals, hospitals located in the West and Midwest) factors that impact the occurrence of PEP were identified. CONCLUSIONS : Our study showed rising hospital admission and mortality rates associated with PEP in the United States. This calls for a greater recognition of this life-threatening complication and amelioration of its risk factors, whenever possible.

Litholytic agents as an alternative treatment modality in patients with biliary dyspepsia.

Biliary dyspepsia presents as biliary colic in the absence of explanatory structural abnormalities. Causes include gallbladder dyskinesia, sphincter of Oddi dysfunction, biliary tract sensitivity, microscopic sludges, and duodenal hypersensitivity. However, no consensus treatment guideline exists for biliary dyspepsia. We investigated the effects of medical treatments on biliary dyspepsia.We retrospectively reviewed the electronic medical records of 414 patients who had biliary pain and underwent cholescintigraphy from 2008 to 2018. We enrolled patients who received litholytic agents and underwent follow-up scans after medical treatment. We divided the patients into the GD group (biliary dyspepsia with reduced gallbladder ejection fraction [GBEF]) and the NGD group (biliary dyspepsia with normal GBEF). We compared pre- and post-treatment GBEF and symptoms.Among 57 patients enrolled, 40 (70.2%) patients had significant GBEF improvement post-treatment, ranging from 34.4 ± 22.6% to 53.8 ± 26.8% (P < .001). In GD group (n = 35), 28 patients had GBEF improvement after medical treatment, and value of GBEF significantly improved from 19.5 ± 11.0 to 47.9 ± 27.3% (P < .001). In NGD group (n = 22), 12 patients had GBEF improvement after medical treatment, but value of GBEF did not have significant change. Most patients (97.1% in GD group and 81.8% in NGD group) had improved symptoms after medical treatment. No severe complication was reported during treatment period.Litholytic agents improved biliary colic in patients with biliary dyspepsia. Therefore, these agents present an alternative treatment modality for biliary dyspepsia with or without gallbladder dyskinesia. Notably, biliary colic in patients with gallbladder dyskinesia resolved after normalization of the GBEF. Further prospective and large-scale mechanistic studies are warranted.

Update on Eluxadoline for the Treatment of Irritable Bowel Syndrome with Diarrhea: Patient Selection and Perspectives.

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder characterized by chronic abdominal pain associated with changes in bowel habits. It is the most common GI problem seen by gastroenterologists. IBS is a heterogenous disorder encompassing a spectrum of underlying mechanisms and clinical presentations. The pathophysiology of diarrhea-predominant form of IBS (IBS-D) remains poorly understood, and current available therapeutic options for IBS-D are limited. Eluxadoline is a novel, locally acting mixed μ- and κ-opioid receptor agonist and δ-receptor antagonist approved by the Food and Drug Administration (FDA) for treatment of adults with IBS-D. Data from two phase III clinical trials showed that approximately 25–30% of the eluxadoline-treated patients achieved composite clinical response, defined by a reduction of abdominal pain and improvement in stool consistency. Patients who achieve composite response during the first month of therapy were significantly more likely to demonstrate sustained clinical response. The most common adverse events reported with eluxadoline use were constipation, nausea and abdominal pain. The risk of abuse, dependence, or withdrawal is low. Serious adverse events associated with eluxadoline include sphincter of Oddi spasm (SOS) and pancreatitis particularly in patients without a gallbladder. Development of pancreatitis is likely secondary to SOS, but it remains unclear why pancreatitis occurs so quickly after initial doses. This adverse event profile helps guide proper selection of IBS-D patients for eluxadoline use, with important contraindications including absence of a gallbladder, biliary duct obstruction or sphincter of Oddi dysfunction, alcoholism, history of pancreatitis, or structural diseases of the pancreas. With the recent clinical trials demonstrating its efficacy, eluxadoline provides an additional option to the few existing pharmacologic interventions available for IBS-D. In this review, we discuss the drug development, efficacy and safety of eluxadoline, as well as selection criteria for identifying appropriate candidates for this medication.

Endoscopic Ultrasound Versus Endoscopic Retrograde Cholangiography As A Diagnostic Tool For Patients With Dilated Common Bile Duct Of Undetermined Etiology Detected By Abdominal Ultrasound

Abstract Background Common bile duct dilatation could result from various etiologies: choledochocholithiasis, common bile duct stricture, cholangiocarcinoma, periampullary diverticulum, pancreatic head mass, Oddi sphincter dysfunction and papillary stenosis, etc. A dilated common bile duct could denote a hidden pathological biliary condition; on the other hand it occurs in cases with advanced age or postcholecystectomy status in the absence of pathological affection. Objective The aim of this study is to compare between the accuracy of endoscopic ultrasound and endoscopic retrograde cholangiography as a diagnostic tool for patients with dilated common bile duct in whom abdominal ultrasonography could not demonstrate the cause of dilation. Methods This study was conducted on eighty (80) patients who underwent EUS and ERCP to compare between the accuracy of both as a diagnostic tool in whom TUS couldn’t demonstrate the cause of CBD dilatation, the study was performed as a retrospective analysis of prospectively collected data at TBRI (Theodor Bilharz Research Institute) after approval was obtained from the ethics and indications committee of TBRI. The study protocol was approved by the medical ethics committee of Ain Shams University and TBRI. Results In the current research study it was revealed that among 80 study subjects there were 24 cases having stone (30%), 26 cases having stricture(32.5%), benign cases were only 2 (2.5%), prominent CBD with no obstruction were4 cases (5%). Conclusion Endoscopic ultrasound is a complementary imaging modality after transabdominal ultrasound for assessment of CBD dilatation and have a crucial role in the benign and malignant periampullary tumors diagnosis additional research studies are required to be performed in a multicentric fashion considering racial and ethnic differences.

Применение гимекромона при заболеваниях желчевыводящих путей: возможности и перспективы

Pharmacological treatment of biliary dyskinesia is to a great extend aimed at reducing smooth muscle spasms and recovering gallbladder motility. Prolonged courses of myotropic antispasmodics are used as the basic therapy. Hymecromone is notable to its predominantly spasmolytic action on the bile ducts and the sphincter of Oddi without any significant effect on the gallbladder contractility, and therefore it is safe in patients with cholecystolythiasis. Hymecromone decreases the severity of cholestasis, prevents the formation of cholesterol crystals and therefore, the development of cholelithiasis. It is effective both as a monotherapy and in combination with ursodeoxycholic acid for treatment of biliary sludge and prevention of the progression of gallstone disease. Its local action on the biliary tract and low systemic bioavailability after oral intake increases the treatment safety. Experimental studies demonstrated the antifibrotic and antihyperglycaemic effect of the drug. Key words: biliary dysfunction, cholelithiasis, sphincter of Oddi dysfunction, biliary sludge, hymecromone, ursodeoxycholic acid

Sphincter of Oddi dysfunction during hepatitis B

Sphincter of Oddi dysfunction during hepatitis B

Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents

Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3–5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.

Gallstones and Biliary Tract Disease

Gallstones (cholelithiasis) are hardened deposits of digestive fluid that can form in the gallbladder and bile ducts. Gallstones range in size from as small as a grain of sand to as large as a billiard ball. Some people develop a single gallstone, whereas others develop many. Gallstone disease or disorders may encompass biliary pain, acute and chronic cholecystitis, choledocholithiasis, and gallstone pancreatitis. Gallstones (cholelithiasis) and biliary tract diseases constitute a common and costly health problem in the United States. This chapter reviews the formation of the two principal types of stone, the cholesterol stone and the pigment stone, that form in the gallbladder and biliary tract. The prevention of gallstones is discussed. The diagnosis, differential diagnosis, treatment, and complications of acute cholecystitis are presented. Diagnosis and treatment of chronic cholecystitis, asymptomatic cholelithiasis, choledocholithiasis, Mirizzi syndrome, and gallbladder polyps are also discussed. Common bile duct stricture, primary sclerosing cholangitis, recurrent pyogenic cholangitis, choledochal cyst, and sphincter of Oddi dysfunction are summarized. This review contains 6 figures, 19 tables, and 111 references. Keywords: Gallbladder, gallstones, cholecystectomy, biliary sludge, cholangitis, choledocholithiasis, cholecystitis, endoscopic retrograde cholangiopancreatography

Modern paradigm of functional diseases of gastrointestinal tract: focus on functional dyspepsia, sphincter of Oddi dysfunction and irritable bowel syndrome

The article presents data on changes in the perception of functional gastrointestinal disorders introduced by the Rome IV criteria. Particular attention is paid to the functional dyspepsia, gallbladder and sphincter of Oddi disorders, the Rome IV criteria.

Endoscopic Therapy for Recurrent Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of a normal anatomical and functional gland, however, a chronic disease at early stage may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The etiology of RAP can be identified in up to 70% of cases; for the remaining cases the term “idiopathic” is used. Most common causes include bile duct stone disease, sphincter of Oddi dysfunction, anatomical ductal variants interfering with pancreatic juice outflow, genetic mutations, any obstruction of the main pancreatic duct or pancreatico-biliary junction, and alcohol consumption. Patients with RAP have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. Endoscopic therapy has been found effective in those cases in whom a mechanical obstruction is found. The efficacy of endoscopic therapy in patients with a history of RAP depends on two main factors: whether or not the bouts of acute pancreatitis occur in a normal pancreas or in a setting of chronic pancreatitis, and whether or not a cause can be identified and removed. Because occult bile stone disease and sphincter of Oddi dysfunction account for the majority of cases, cholecystectomy, and eventually endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. However, in the last years concerns the efficacy of endotherapy in sphincter of Oddi dysfunction have been raised. Pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis caused by pancreatic ductal obstruction, independently from the cause of obstruction, in symptomatic pancreas divisum and in some cases of genetic mutations.

44 Trends in ERCP Utilization for Sphincter of Oddi Dysfunction: The Real World Impact of EPISOD and Rome IV

INTRODUCTION: The widespread clinical adaptation of landmark clinical trials and practice guidelines is often unclear. The EPISOD trial, a randomized, sham-controlled trial, demonstrated that endoscopic sphincterotomy in patients with Type III Sphincter of Oddi dysfunction (SOD) did not result in clinical improvement. The results of this study were presented at the 2013 National Meeting of the American College of Gastroenterology and published in May 2014. Subsequently, the updated 2016 Rome IV criteria removed Type III SOD from the functional biliary disorder classification. Though patients with Type III SOD make up a minority of all SOD patients, we aimed to assess the utilization of ERCP for patients with SOD in a large population database from 2012–2017. METHODS: We searched electronic health record (EHR)-based disparate data from a cloud-based dataset which incorporates over 300 individual hospitals in the United States (Explorys Inc, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a first-ever diagnosis of “disorder of Sphincter of Oddi” or “spasm of Sphincter of Oddi” annually from 2012–2017. Because the dataset uses SNOMED codes, it was not feasible to sub-classify the types of SOD. Stratified by year, we identified the proportion of patients undergoing ERCP with sphincterotomy and those receiving tricyclic antidepressants (TCA). A Mantel-Haenszel test was used. RESULTS: The number of index cases of SOD and rates of ERCP utilization are outlined in Table 1. From 2013 (the presentation of EPISOD data) to 2016, there was a significant trend demonstrating lower rates of ERCP for newly-diagnosed SOD (P = 0.018). A divergent increase in TCA utilization was concomitantly seen from 2013–2015, but the trend was not statistically significant (P = 0.29). Following the publication of the ROME IV criteria, rates of ERCP utilization for newly-diagnosed SOD significantly increased (P = 0.048) (Figure 1). CONCLUSION: Following the presentation of the EPISOD data, there was a significant 3-year linear decrease in ERCP utilization for all-comers newly-diagnosed with SOD. Concomitantly, a divergent yet insignificant increase in TCA usage was observed. In 2016, after the Rome IV criteria narrowed the diagnosis of SOD, an expected increase in ERCP utilization was observed. These findings call for ongoing observation to see if these trends are durable.