Evaluation of results of the prostigmine-morphine test with quantitative hepatobiliary scintigraphy: a new method for the diagnosis of sphincter of Oddi dyskinesia

Abstract

Attempts have long been made to use the prostigmine-morphine provocation test for the selection of postcholecystectomy patients suffering from sphincter of Oddi (SO) dyskinesia. Since the whole procedure is based upon the evaluation of subjective complaints, this test has frequently been criticized. To improve the diagnostic value of this method, we have visualized SO spasms during prostigmine-morphine provocation by means of quantitative hepatobiliary scintigraphy (QHBS). Twenty-two cholecystectomized patients with typical postprandial biliary pain were included in this study. In the first series of studies, QHBS with technetium-99m 2,6-diethylphenylcarbamoylmethyl-diacetic acid was performed in each patient 2 days before prostigmine-morphine provocation. The time to peak activity (Tmax) and the half-time of excretion (T1/2) over the liver parenchyma (LP), hepatic hilum (HH) and common bile duct (CBD), and the duodenum appearance time (DAT), were determined and served as control values. In the second series of experiments, sphincter spasms were evoked by prostigmine-morphine administration and visualized by means of QHBS. The same parameters were evaluated and serum levels of aspartate aminotransferase (AST) were determined simultaneously at regular intervals. In 12 patients who responded to prostigmine-morphine provocation with typical biliary pain and a significant AST elevation (Nardi positive group) the hepatobiliary scintigram demonstrated a marked biliary obstruction. Tmax and T1/2 over the LP, HH and CBD were significantly increased, while DAT was significantly longer relative to the corresponding data obtained without provocation. Four of the remaining ten patients indicated atypical abdominal pain during prostigmine-morphine provocation, but the AST level remained unchanged in all ten (Nardi negative group).(ABSTRACT TRUNCATED AT 250 WORDS)

Cólico biliar inducido por morfina

“…2. Es importante actuar rápido, nitroglicerina o dinitrato de isosorbida relaja instantánea-mente el esfínter de Oddi 2,6,8 , controla el dolor y previene mayor alza de las transaminasas. En nuestro caso, la paciente solo recibió AI-NE-s, que no tienen efecto sobre el esfínter, por consiguiente, el alza en las transaminasas fue considerable y su normalización requirió varios días.…”

“…En ambas pruebas se estudia el dolor y el comportamiento de enzimas hepáticas y pancreáticas. Además, el flujo de bilis, su vaciamiento en función de la motilidad del esfínter de Oddi, puede estar visualizado y caracterizado en forma cuantitativa por cintigrafía hepatobiliar 6 .…”

Clinical significance of sphincter of Oddi Dyskinesia

“…Other diagnostic tests have been explored, including the radionuclide hydroxyiminodiacetic acid (HIDA) scan [37], scintigraphy with provocation [38,39], fatty meal ultrasound [40], ultrasound with CCK stimulation [41], and recently, injection of botulinum toxin (BTX) into the SO [42••, [43][44][45]. However, their value must be demon- Based on Hogan and Geenen [3] and Geenen et al [8].…”

The Sphincter of Oddi

“…Morphine increases both the basal and phasic pressure of the human SO and has been use in provocation studies to diagnose SOD [35][36][37]. In contrast, meperidine is routinely used in patients with biliary-type pain because of its lesser effects on the SO.…”