Can patient and pain characteristics predict manometric sphincter of Oddi dysfunction in patients with clinically suspected sphincter of Oddi dysfunction?

Abstract

Background Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as “suspected” sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of “manometric” SOD are important to avoid unnecessary ERCP, but are unknown. Objective To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM). Design Prospective, cross-sectional. Setting Tertiary. Patients A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial. Interventions Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires. Main Outcome Measurements Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome. Results The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis). Limitations Generalizability. Conclusions Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. (Clinical Trial registration number: NCT00688662.) (Gastrointest Endosc 2014;79:765-72.)

Effect of Endoscopic Sphincterotomy for Suspected Sphincter of Oddi Dysfunction on Pain-Related Disability Following Cholecystectomy

“…As reported elsewhere, abnormal sphincteric pressures were not influenced by the type of sedation or anesthesia and did not correlate with the patient’s clinical characteristics. 27 …”

Sphincter of Oddi Dysfunction

“…In the initial landmark trial demonstrating efficacy of biliary sphincterotomy, patients with type II disease had a marked difference in response rate when they had abnormal basal sphincter pressures. 41 A second trial confirmed similar clinical success in patients with type II disease with elevated baseline manometric results or abnormal pressures following cholecystokinin provocation. 34 Thus, the concept of manometric-directed endoscopic therapy was conceived.…”

“…39 Patient demographics, pancreaticobiliary enzyme levels, presence of gallbladder disease, pain patterns, use of narcotics, underlying functional disorders, and psychological comorbidities have not been found to correlate with manometric results. 41 Several other limitations of SOM preclude its universal use on all patients with suspected SOD, including (1) need for center expertise and challenging manometry catheter placement; (2) variation in pressure measurements from different types of catheter equipment, variable sphincter lumen size, probe position, and point in time when a spasm is captured; and (3) undue risk involved in catheter insertion during diagnostic ERCP. Measurement of liver enzymes and biliary dilation may be sufficient, if not superior, to manometry for diagnosis and predicting response to therapy.…”

Functional Pancreatic Sphincter Dysfunction in Children

“…Rome III characterized FPSD pain in upper abdominal location and separated by pain‐free intervals (Table 1) (8). Many adults with manometry‐defined FPSD, however, experience more frequent or daily abdominal pain (17). Whether this pain pattern is applicable to children is unknown given that young children are less capable of articulating pain characteristics.…”