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1. PRECHOLECYSTECTOMY

In a small group of patients (mostly women) with biliary pain, conventional radiographic studies of the upper gastrointestinal tract and gallbladder—including cholangiography—are unremarkable. Emptying of the gallbladder may be markedly reduced on gallbladder scintigraphy following injection of cholecystokinin; cholecystectomy may be curative in such cases. Histologic examination of the resected gallbladder may show chronic cholecystitis or microlithiasis. An additional diagnostic consideration is sphincter of Oddi dysfunction.

2. POSTCHOLECYSTECTOMY

Following cholecystectomy, some patients complain of continuing symptoms, ie, right upper quadrant pain, flatulence, and fatty food intolerance. The persistence of symptoms in this group of patients suggests the possibility of an incorrect diagnosis prior to cholecystectomy, eg, esophagitis, pancreatitis, radiculopathy, or functional bowel disease. Choledocholithiasis or bile duct stricture should be ruled out. Pain may also be associated with dilatation of the cystic duct remnant, neuroma formation in the ductal wall, foreign body granuloma, anterior cutaneous nerve entrapment syndrome, or traction on the bile duct by a long cystic duct.

The clinical presentation of right upper quadrant pain, chills, fever, or jaundice suggests biliary tract disease. EUS is recommended to demonstrate or exclude a stone or stricture. Biliary pain associated with elevated liver biochemical tests or a dilated bile duct in the absence of an obstructing lesion suggests sphincter of Oddi dysfunction. Biliary manometry may be useful for documenting elevated baseline sphincter of Oddi pressures typical of sphincter dysfunction when biliary pain is associated with elevated liver biochemical tests (twofold) or a dilated bile duct (greater than 10 mm) (“sphincter disorder,” formerly type II sphincter of Oddi dysfunction), but is not necessary when both are present (“sphincter stenosis,” formerly type I sphincter of Oddi dysfunction) and is associated with a high risk of pancreatitis. In the absence of either elevated liver biochemical tests or a dilated bile duct (“functional pain,” formerly type III sphincter of Oddi dysfunction), a nonbiliary source of symptoms should be suspected, and biliary sphincterotomy does not benefit this group. (Analogous criteria have been developed for pancreatic sphincter dysfunction.) Biliary scintigraphy after intravenous administration of morphine and MRCP following intravenous administration of secretin have been studied as screening tests for sphincter dysfunction. Endoscopic sphincterotomy is most likely to relieve symptoms in patients with a sphincter disorder or stenosis, although many patients continue to have some pain. In some cases, treatment with a calcium channel blocker, long-acting nitrate, phosphodiesterase inhibitor (eg, vardenafil), duloxetine, or tricyclic antidepressants or possibly injection of the sphincter with botulinum toxin may be beneficial. The rate of psychosocial comorbidity with sphincter of Oddi dysfunction does not appear to differ from that of the general population. In refractory cases, surgical sphincteroplasty or removal of the cystic duct remnant may be considered.

WHEN TO REFER

Patients with sphincter of Oddi dysfunction should be referred for diagnostic procedures.

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Cotton  PB  et al. The EPISOD study: long-term outcomes. Gastrointest ...

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