BILIARY DYSFUNCTION
Prof.
J. Reichen
Gallbladder
dysfunction
Based on the Rome II
criteria (1) all of the following criteria
must be met:
Episodes of severe steady pain located
in the epigastrium
and right upper quadrant and all of the following:
- Episodes lasting 30 minutes or more
- Symptoms once or more in the past
12
months
- The pain is steady, interrups
daily
activity and/or leads
to consultation
- No evidence of structural
abbnormalities
- Abnormal gallbladder emptying
|
More extensive rigourous
criteria for the
characterization of the pain are given in a recent review (2). The
recommended workup (1) includes
- Sonography to rule out structural
lesions
and/or stones
- CCK biliary scintigraphy to assess
gallbladder emptying
- If gallbladder emptying is normal, ERCP
with microscopic
examination of bile should be considered.
|
Treatment options
include cholecystectomy which will reveal
pathological gallbladders in 45 - 70 % and relief of symptoms in 80 -
90
% (3-5); in similar patients not undergoing cholecystectomy
improvement
of symptoms usually does not occur (5). Nowadays, laparoscopic
cholecystectomy
is the treatment of choice; 94 % had relief of symptoms (6). Medical
therapy
including motility agents, ursodeoxycholate or nonsteroidal
antiinflammatory
agents have not been subjected to rigorous trials in this setting.
Gallbladder
contraction in response to CCK is pathological; in contrast to
cholesterol
gallstone disease this is due to a defect in the contractile apparatus
(7).
Sphincter of Oddi dysfunction
Based on the Rome II
criteria (1) all of the following
criteria must be met:
Episodes of severe steady pain located
in the epigastrium
and right upper quadrant and all of the following:
- Episodes lasting 30 minutes or more
- Symptoms once or more in the past 12
months
- The pain is steady, interrups daily
activity and/or leads
to consultation
- No evidence of structural
abbnormalities
|
In addition the pain
may be associated with one or more
of the following:
- Elevated liver and/or pancreatic enzymes
and/or
conjugated
bilirubin (4)
- Acute recurrent pancreatitis (8). This is
particularly germane in patients with MDR deficiciencies who present
with recurrent biliary colic and/or pancreatitis (9,10).
Based on biliary
manometry three types of SOD have
been
described; the results of 8 trials and case series to treatment with
the
original references can be found in (8):
| Type |
I
|
II
|
III
|
| Definition |
Pain + 3 criteria*
|
Pain + 1 or 2 criteria*
|
Pain only
|
|
Baseline pressure>40 mmHg
|
70 - 100 %
|
40 - 86 %
|
20 - 55 %
|
| Benefit from papillotomy |
55 - 91 %
|
p>40 mmHg: 80 - 90 %
p<40 mmHg: 30 - 35 %
|
p>40 mmHg: 8 - 56 %
|
The criteria used were the following:
- ALT and alkaline phosphatase over twice
upper
limit of normal
- Dilated bile duct on sonography
- Delayed drainage of contrast material at
ERCP
Recently, a randomized controlled trial demonstrated,
that only patients with the manometric presentation of stenosis
benefitted
from sphincterotomy (11):
Patients improving after sphincterotomy or sham
operation
(1)
| Type |
SO stenosis
|
SO dyskinesia
|
normal manometry
|
| sphincterotomy |
11/13
|
4/11
|
8/13
|
| sham |
5/13
|
5/10
|
8/19
|
| p = |
0.041
|
0.670
|
0.473
|
Recommended work-up
(1) includes
- Liver and pancreatic enzymes,
conjugated
bilirubin
- Biliary scintigraphy (1,2)
- Biliary manometry is the gold-standard
but
should be restricted
to experienced endoscopists
- Pain provocation tests are
useless (12).
|
Treatment options
include the following:
- Spasmolytic agents in particular nitrates
and dipyrone
may be useful; no randomized trials exist. Nonsteroidal
antiinflammatory drugs are superior to spasmolytics (13) and equal to
meperidine in controlled trials (14).
- Calcium antagonists - actually nifedipine -
have
been shown
to reduce episodes of pain in randomized trials (15).
- Recently, injection of botulinus toxin has
been
described
with good results (16).
- Sphincterotomy provides good relief in
selected
patients
(1, 2). A recent review concluded that this decision is based best on
manometry (17).
- Ursodeoxycholate in patients with MDR3
deficiences and the like (9, 10).
References
- Corazziari E, Shaffer EA, Hogan WJ, Sherman
S,
Toouli J.
Functional disorders of the biliary tract and pancreas. Gut 1999;
45:48-54.
- Behar J, Corazziari E, Guelrued M et al.
Functional gallbladder and sphincter of Oddi disorders.
Gastroenterology 130: 1498-1509.
- Misra DC, Blossom GB, Fink Bennett D,
Glover
JL. Results
of surgical therapy for biliary dyskinesia. Arch Surg 1991; 126:957-960.
- Yap L, Wycherley AG, Morphett AD, Toouli J.
Acalculous biliary
pain: cholecystectomy alleviates symptoms in patients with abnormal
cholescintigraphy.
Gastroenterology 1991; 101:786-793.
- Yost F, Margenthaler J, Presti M et al.
Cholecystectomy is
an effective treatment for biliary dyskinesia. Am J Surg 1999; 178:
462-465.
- Patel NA et al. Therapeutic efficacy of
laparoscopic cholecystectomy
in the treatment of biliary dyskinesia. Am J Gastroenterol 2004; 187:
209-212
- Amaral J, Xiao ZL, Chen Q et al.
Gallbladder
muscle dysfunction
in patients with chronic acalculous disease. Gastroenterology 2001;
120:
506-511.
- Lin OS, Soetikno RM, Young HS. The utility
of
liver function
test abnormalities concomitant with biliary symptoms in predicting a
favorable
response to endoscopic sphincterotomy in patients with presumed
sphincter
of Oddi dysfunction. American Journal of Gastroenterology 93,
1833-1836.
1998.
- Rosmorduc O, Hermelin B, Poupon R. MDR3 gene
defect in adults with symptomatic intrahepatic and gallbladder
cholesterol cholelithiasis. Gastroenterology 2001; 120:1459-1471.
- Rosmorduc O, Hermelin B, Boelle PY et al.
ABCB4 gene mutation-associated cholelithiasis in adults.
Gastroenterology 2003; 125: 452-459.
- Allescher HD. Clinical impact of sphincter
of
Oddi dyskinesia.
Endoscopy 30 (Suppl. 2), A231-A236. 1998.
- Geenen JE, Hogan WJ, Dodds WJ, Toouli J,
Venu
RP. The efficacy
of endoscopic sphincterotomy after cholecystectomy in patients with
sphincter
of Oddi dysfunction. N Engl J Med 1989; 320:82-87.
- Al Waili N, Saloom KY. The analgesic effect
of
intravenous tenoxicam in symptomatic treatment of biliary colic: a
comparison with hyoscine N-butylbromide. Eur J Med Res 1998; 3: 475-479.
- Dula DJ, Anderson R, Wood GC. A prospective
study
comparing i.m. ketorolac with i.m. meperidine in the treatment of acute
biliary colic. J Emerg Med 2001; 20: 121-124.
- Khuroo MS, Zargar SA, Yattoo GN. Efficacy
of
nifedipine therapy
in patients with sphincter of Oddi dysfunction: a prospective-
double-blind-
randomized- placebo-controlled- cross over trial. Br J Clin Pharmacol
1992;
33:477-485.
- Pasricha PJ, Miskovsky EP, Kallo AN.
Intrasphincteric injection of botulinum toxin for suspected sphincter
of Oddi dysfunction. Gut 1996; 35: 1329-1331.
- Freeman ML, Gill M, Overby C, Cen YY.
Predictors of outcomes after biliary and pancreatic sphincterotomy for
sphincter of Oddi dysfunction. J Clin Gastroenterol 2007; 41: 94-102.
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