Sphincter of oddi (pancreatic) hypertension and recurrent pancreatitis

Abstract

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two- to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.

Sphincter of Oddi dysfunction and pancreatitis

“…Evidence that SOD may be a cause of IARP is supported by the resolution of pancreatitis after sphincterotomy, with up to 80% improvement in patients with IARP after biliary sphincterotomy [79] . Tarnasky et al [80] showed that biliary sphincterotomy reduced pancreatic basal pressure to within the normal range in 30% of patients immediately after the procedure and 20% after longer term follow up, presumably by ablation of the common channel sphincter, and hence a reduction in the length of the residual pancreatic portion.…”

Gallstone pancreatitis: When is endoscopic retrograde cholangiopancreatography truly necessary?

“…In elderly high-risk patients with gallstone-induced pancreatitis, EST removal of stones from the common bile duct may be sufficient [47]. Whether placement of a pancreatic duct stent concomitantly with EST, which has been reported to lower post-ERCP pancreatitis rates [48,49], is beneficial for patients who undergo EST for biliary pancreatitis is doubtful and needs further evaluation. An algorithm for the treatment of acute gallstone pancreatitis is presented in Figure 2.…”

Clinical significance of sphincter of Oddi Dyskinesia

“…However, manipulation of the papilla (manometry, ERCP, or biliary sphincterotomy) in patients with a hypertensive pancreatic sphincter is associated with an unacceptably high rate of pancreatitis of 20% to 26% [1,55••]. Also, the clinical approach of opening only the biliary sphincter is still associated with a high risk of pancreatitis [1]. However, if biliary sphincterotomy is combined with pancreatic sphincterotomy, the pancreatitis rate drops to about half, and if the drainage of the pancreatic duct is secured by a pancreatic stent, the risk of pancreatitis is reduced from 26% to 6% [55••,56,57].…”

“…However, if biliary sphincterotomy is combined with pancreatic sphincterotomy, the pancreatitis rate drops to about half, and if the drainage of the pancreatic duct is secured by a pancreatic stent, the risk of pancreatitis is reduced from 26% to 6% [55••,56,57]. Thus, it is now generally accepted practice with a hypertensive pancreatic sphincter to place a protective stent or perform a combined sphincterotomy in the initial session [1].…”

“…In conjunction with the typical SOD-type pain, different additional abnormalities may be present, including increased laboratory values for the pancreatobiliary system (ie, alkaline phosphatase, bilirubin, gammaglutamyltransferase, amylase, and lipase) and dilation of the biliary or pancreatic system [3]. Abnormalities in the papilla of the pancreatic sphincter of Vater can lead to elevated pancreatic enzymes or recurrent pancreatitis [1,4].…”