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OBSCURE DIAGNOSIS CLINICAL


accompanied by abnormally raised liver enzymes, dilation of the bile duct, or evidence of delayed emptying on biliary scintigraphy. It may be a cause of persistent post-cholecystectomy symptoms.


A predominance of pancreatic problems, especially recurrent episodes of acute pancreatitis, is known as pancreatic-type SOD. Each type of SOD is further divided into types I, II and III (see table 1, right).3 This classification helps predict the pathology and the likelihood of successful treatment. Type I is thought to result from a fixed stenosis, and responds best to therapy. An episodic dysmotility is the presumed underlying abnormality in the other types, and does not often respond as well to treatment.


Diagnosis Biliary-type SOD should be considered and excluded in patients with the post-cholecystectomy syndrome. Pancreatic-type SOD should be excluded in patients with recurrent acute pancreatitis of unexplained aetiology. The role of SOD in chronic pancreatitis is unclear. A careful history is essential, and the description of pain should match the Rome III diagnostic criteria (Table 2, below).4


CT and MRCP can demonstrate dilatation of the biliary and pancreatic ducts. MRCP with intravenous secretin injections can particularly demonstrate pancreatic duct dilatation, because of raised sphincter pressures. An endoscopic ultrasound (EUS) may achieve the same end. A quantitative cholescintigraphy (HIDA scan) may demonstrate a delayed biliary transit. The gold standard for diagnosing SOD is an ERCP with manometry of the biliary and pancreatic sphincters, although many would say that this is not essential for the diagnosis of type I SOD. ERCP with manometry is indicated if the pain is disabling, non-invasive investigations have not shown structural abnormalities, and conservative therapy has not helped. The variables customarily assessed at manometry are basal pressure and amplitude, duration, frequency, and propagation pattern of the phasic waves. A basal sphincter pressure higher than 40mmHg is the manometric criterion used to diagnose SOD.


Table 1 Milwaukee classification of sphincter of Oddi dysfunction


Biliary-type SOD Type I • Typical biliary-type pain • Liver enzymes (AST, ALT or ALP) more than two times the normal limit documented on at least two occasions during episodes of pain • Dilated common bile duct more than 12mm in diameter • Prolonged biliary drainage time of over 45 minutes, although this is difficult to measure and often eschewed in clinical practice


Type II • Biliary-type pain, and one or two of the above criteria


Type III • Biliary-type pain only


Treatment


Endoscopic sphincterotomy is the treatment of choice for type I SOD. The question of whether dual sphincterotomies (biliary and pancreatic) should be carried out remains unanswered. There is, however, a particularly high risk of post-ERCP pancreatitis of 30% or more, although the placement of a pancreatic stent at the time of the procedure appears to reduce this risk. Such treatments are best carried out in tertiary units by expert gastroenterologists. For patients with type II SOD, manometry should be done before considering sphincterotomy, and the results of sphincterotomy are less consistent. Patients with type III SOD are even more difficult, with response rates to sphincterotomy ranging from 8% to 65%. Medical therapy should be tried before proceeding to manometry. PPIs, spasmolytic drugs, calcium channel blockers such as nifedipine, and psychotropic agents have all been tried with varying degrees of success. Injections of botulinum toxin, which can cause a chemical sphincterotomy for up


Pancreatic-type SOD Type I • Pancreatic-type pain • Amylase or lipase more than two times the upper normal limit on at least two occasions during episodes of pain • Dilated pancreatic duct, with the head at over 6mm, or the body more than 5mm • Prolonged pancreatic drainage time of over nine minutes, although this is difficult to measure and often eschewed in clinical practice


Type II • Pancreatic-type pain, and one or two of the above criteria


Type III • Pancreatic-type pain only


to three months, or the placement of a pancreatic stent – usually removed after six weeks – do not provide lasting relief, but can be used to identify patients who may benefit from a sphincterotomy. A recent study in patients with


abdominal pain after cholecystectomy and suspected SOD casts doubt on the efficacy of endoscopic sphincterotomy.5 In patients undergoing ERCP with manometry, sphincterotomy versus sham did not reduce disability due to pain. Manometry results were not associated with the outcome, and no clinical subgroups appeared to benefit from sphincterotomy more than others. In a small sub-group of patients who


have experienced significant but short-lived relief with sphincterotomy or stenting, surgical transduodenal sphincteroplasty may be considered. In exceptional circumstances, where the pancreatic head is badly scarred and sphincteroplasty has failed or is unlikely to succeed, there may be grounds for surgical resection of the pancreatic head.


Mr Satya Bhattacharya is a consultant hepato-pancreato-biliary surgeon at Barts Health NHS Trust and The London Clinic


Table 2 Rome III diagnostic criteria for functional gallbladder and SOD


Must include episodes of pain located in the epigastrium or right upper quadrant and all of the following: • Episodes lasting 30 minutes or longer • Recurrent symptoms occurring at different intervals (not daily) • The pain builds up to a steady level • The pain is moderate to severe enough to interrupt the patient’s daily


64 February 2016 Pulse


activities or lead to an emergency department visit • The pain is not relieved by bowel movements • The pain is not relieved by postural change • The pain is not relieved by antacids • Exclusion of other structural disease that would explain the symptoms


Supportive criteria The pain may present with one or more of the following: • Pain is associated with nausea and vomiting • Pain radiates to the back or right infra-subscapular region • Pain awakens from sleep in the middle of the night


Chronic testicular pain Go online to read other articles in the series, including the diagnosis of chronic testicular pain


pulsetoday.co.uk/ obscuredx


References 1 Toouli J. What is sphincter of Oddi dysfunction? Gut 1989;30:753-61 2 Oddi R. D’une disposition a sphincter speciale de l’ouverture du canal cholidoque. Arch Ital Biol 1887;8:317-22 3 Hogan WJ, Geenen JE. Biliary dyskinesia. Endoscopy 1988;20 Suppl 1:179-183 4 Behar J, Corazziari E, Guelrud M et al. Functional gallbladder and sphincter of Oddi disorders. Gastroenterology 2006;130:1498–509 5 Cotton PB, Durkalski V, Romagnuolo J et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy. JAMA 2014;311:2101-9


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