PURPOSE: Biliary dyskinesia was considered as a wastebasket of quasi-biliary disease which could not be clearly explained under the basis of morphologic pathology. This entity was a source of confusion because of misconception and poor understanding. Recent introduction of biliary manometric technique enlightened some of these disorders. We evaluated the cholangiographic morphology of these disorders to clarify and to characterize the some characteristic findings, subsequently in order to help the diagnosis. MATERIALS AND METHODS: Five cases were confirmed by this technique as sphincter of Oddi dysfunction for last 13 months. All patients were female and age range was 53 to 75 years old. All patients were suffered from intermittent and recurrent biliary type pain. RESULTS: ERCP showed five common findings. The common bile duct was dilated over 12ram in all patients. Different from recurrent pyogenic cholangiohepatitis, intrahepatic ducts were proportionally dilated as extrahepatic ducts, in four patients and they branched normally and ductal wall was smooth. Transient or persistent meniscus sign was observed in four patients. All patients showed delayed emptying of contrast media from the common bile duct into the duodenum. Following IV injection of cholecystokinin, persistent meniscus disappeared and contrast media inflowed into the duodenum. CONCLUSION: Identification of all or some characteristic cholangiographic findings may eliminate a cumbersome and painful biliary manometric test for the diagnosis of sphincter of Oddi dysfunction.
Aged ; Biliary Dyskinesia ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystokinin ; Common Bile Duct ; Contrast Media ; Diagnosis ; Duodenum ; Female ; Humans ; Manometry* ; Pathology ; Sphincter of Oddi Dysfunction* ; Sphincter of Oddi*

Functional dyspepsia is a very common disease and there are two types of dyspepsia. One is functional dyspepsia in the gastrointestinal tract and the other is pancreatobiliary dyspepsia. Biliary dyspepsia is caused by biliary tract disease and can even cause biliary pain. Acalculous biliary pain (ABP) is biliary colic without gallstones, it is caused by functional biliary disorder or structural disorders such as microlithiasis, sludges or parasitic infestation like Clonorchiasis. The endoscopic ultrasonography is helpful tool for differential diagnosis of ABP. Although sphincter of Oddi manometry (SOM) is performed for the confirmative diagnosis of sphincter of Oddi dysfunction (SOD), several non-invasive tests have been studied because of some practical limitations and invasiveness of SOM itself. In fact, the most clinically used easy test to diagnose functional biliary disorder is quantitative hepatobiliary scintigraphy and it can distinguish gallbladder dyskinesia, SOD, or combined type. Initial treatment of functional biliary disorder is adequate dietary control and medication, but if the symptoms worsened or recurred frequently, laparoscopic cholecystectomy could be performed with gallbladder dyskinesia. If SOD is suspected, additional SOM should be considered and endoscopic sphincterotomy (EST) can be done according to the outcome. If the SOM is not available, the patient could be diagnosed by stimulated ultrasound.
Biliary Dyskinesia ; Biliary Tract Diseases ; Cholecystectomy, Laparoscopic ; Clonorchiasis ; Colic ; Diagnosis ; Diagnosis, Differential ; Dyspepsia* ; Endosonography ; Gallstones ; Gastrointestinal Tract ; Humans ; Manometry ; Radionuclide Imaging ; Sphincter of Oddi ; Sphincter of Oddi Dysfunction ; Sphincterotomy, Endoscopic ; Ultrasonography

To assess the reproducibility of Sphincter of Oddi(SO) manometry, percutaneous manometry of SO was performed repeatedly in 10 subjects with biliary diseases(9 intrahepatic stone cases and 1 bile duct cancer case). Time interval for measurement of SO manometry was 3 to 7(mean 5) days. Mean manometric parameters of SO phasic contraction in the 1st and 2nd studies were not significantly different. However, as a result of manometric records, a diagnosis of dyskinesia was made in the 1st study from 4 patients(tachyoddia in 3 cases and increased retrograde propagation in one case). Among them, the diagnosis was reproduced in the 2nd study from 2(tachyoddia in 2 cases) out of 4 patients. In conclusion, abnormal manometric findings were poorly reproducible. Thus, more prolonged measurement of SO manometry or a dynamic test which stimuli or inhibit the SO activity may be necessary for accurate diagnosis of biliary dyskinesia and better reproducibility of SO manometry.
Bile Duct Neoplasms ; Biliary Dyskinesia ; Diagnosis ; Dyskinesias ; Humans ; Manometry* ; Sphincter of Oddi*

PURPOSE: The purpose of this study was to compare outcomes for surgical treatment with those for medical treatment of GB dyskinesia. METHODS: Retrospective analysis of medical records and telephone interviews of 67 patients diagnosed with GB dyskinesia was done at Pohang St. Mary's Hospital between January 2004 and December 2009. Group 1 (n=18) patients received laparoscopic cholecystectomy. Group 2 (n=49) patients received medical treatment. GB dyskinesia was the diagnosis if the patient had typical biliary colic symptoms without GB stones or other GI disease, and if the ejection fraction was less than 35% on Tc-99m-DISIDA scans. RESULTS: The average age of patients diagnosed with GB dyskinesia was 45.8 years old. The sex ratio was 15:52 (male:female). The average symptom duration was 25.4 days. All had RUQ and, or epigastric pain. There were no significant between group differences in age, sex ratio, symptom duration, symptoms, follow up period, and ejection fraction. In group 1, patient symptoms improved after treatment in 16 cases (88.9%); in group 2, patient symptoms improved in 19 cases (38.8%). Surgical treatment was significantly more effective than medical treatment. The reasons for choosing medical treatment were predominantly the preference of the doctors. CONCLUSION: Surgical treatment is a more effective treatment for GB dyskinesia than medical treatment. Therefore, laparoscopic cholecystectomy should be considered as the 1st line treatment of choice for GB dyskinesia.
Biliary Dyskinesia ; Cholecystectomy, Laparoscopic ; Colic ; Dyskinesias ; Follow-Up Studies ; Gallbladder ; Humans ; Interviews as Topic ; Medical Records ; Retrospective Studies ; Sex Ratio

Perendoscopic biliary manometry may not represent the overall sphincter of Oddi (SO) motility, as the recording time is relatively short and it is possibly influenced by the presence of an endoscope in duodenum and air inflation. Percutaneous transhepatic biliary manometry of SO permits long-term recordings without patient discomfort and risk of complications. We investigated the change of human SO motility and the correlation between SO motility and migrating motor complex (MMC) of the small bowel in a fasting state by long-term simultaneous manometric examination of SO and small bowel. During long-term manometry, MMC-like cyclic activities of SO were observed, which consiered to be MMC of SO. It coordinated well with MMC of the small bowel, except that SO was not quiescent during phase I MMC of the small bowel. In addition, the basal pressure of SO changed in accordance with the phases of SO motility. Percutaneous transhepatic biliary manometry also permits prolonged manometric studies to investigate normal physiologic reflexes such as gastroduodeno-sphincteric, cholecysto-sphincteric and choledocho-sphincteric reflexes, and the influence of cholecystectomy on SO motility in humans.
Biliary Dyskinesia/*diagnosis/physiopathology ; Female ; Gastrointestinal Motility ; Humans ; Male ; Manometry/*methods ; Middle Aged ; Muscle Contraction ; Myoelectric Complex, Migrating ; Pressure ; Sphincter of Oddi/*physiopathology ; Time Factors

BACKGROUND/AIMS: Published studies suggest that socioeconomic factors contribute to increasing cholecystectomy rates for biliary dyskinesia (BD). The aim of this study was to identify factors driving admissions and operations for BD by examining regional variability in hospitalizations and cholecystectomies for this disorder. METHODS: Annual hospitalizations and cholecystectomy rates for biliary diseases were assessed using the State Inpatient Databases of the Agency for Healthcare Research and Quality based on diagnosis codes for biliary dyskinesia, cholecystolithiasis and cholecystitis. RESULTS: Annual admissions for BD varied nearly sevenfold among different states within the United States. Hospitalizations for gallstone disease and its complication showed less variability, differing 2-fold between states. Nearly 70% of admissions for BD and about 85% of admissions for gallstone disease resulted in cholecystectomies. Higher admission rates for BD were best predicted by high overall hospitalization rates, admission rate for gallstone disease and the physician workforce within a state. Cholecystectomy rates for BD were higher in states with low population density and high rates of cholecystectomy for gallstone disease. CONCLUSIONS: These data suggest that established medical practice patterns significantly contribute to the variability in admissions and operations for biliary dyskinesia. The findings also indicate that lower thresholds for operative interventions are an important determinant in the approach to this disorder. Considering the benign course of functional illnesses, the bar for surgical interventions should be raised rather than lowered; in addition active conservative treatment options should be developed for these patients.
Biliary Dyskinesia ; Cholecystectomy ; Cholecystolithiasis ; Delivery of Health Care ; Gallstones ; Gastrointestinal Diseases ; Health Services Research ; Hospitalization ; Humans ; Inpatients ; Population Density ; Socioeconomic Factors ; United States

Inspite of the benign disease process, the management of intrahepatic duct stones is difficult because of complications such as recurrent ascending cholangitis, liver abscess, sepsis, secondary liver cirrhosis, cholangiocarcinoma, and high recurrence rates. Also they are sometimes difficult to remove completely due to their anatomical locations. The principles of their surgical management are composed of complete removal of the stone and prevention of biliary stasis. The commonly used biliary drainage procedures are transduodenal sphincteroplasty, choledochoduodenostomy, and Roux-en-Y choledochojejunostomy. The results of biliary drainage procedures in 82 patients at the Department of Surgery, Taejon St. Mary's Hospital, from January 1985 through December 1994 were reviewed, including a follow-up study. The incidence of biliary drainage procedures, including hepatic resections, was 18.9% of the 433 patients operated on for cholelithiasis. The male- to- female ratio was 1 : 1.5; the sixth decade was the most common age. The common clinical symptoms and physical signs were right upper quadrant and epigastric pain and tenderness (89.0%), jaundice (56%), and fever and chills (47.4%). Fifty-six percent of the cases involved the first incidence of a biliary operation, 34.1% a second incidence, and 9.7% a third. The biliary stones were located at only the intrahepatic area (31.7%), both the intrahepatic and the extrahepatic areas (35.3%), or both the gall bladder and the extrahepatic area (29.0%). Of the intrahepatic stones, the left lobe was involved in 45.5% of the cases, the right lobe in 9%, and both lobes in 45.5%. The indications for biliary drainage procedures were acute obstructive cholangitis (36.5%), recurrent stones (34.1%), biliary dyskinesia (21.9%), and liver abscess (7.3%). The types of biliary drainage procedures were choledochoduodenostomy (43.9%), Roux-en-Y choledochojejunostomy (21.9%), left hepatic lobectomy (14.6%), left lateral hepatic segmentectomy (8.5%), Roux-en-Y hepaticojejunostomy (8.5%), right hepatic lobectomy (1.2%), and transduodenal sphincteroplasty (1.2%). The early postoperative complications were wound infection (24.3%), pulmonary complications (19.5%), anastomosis leakage (2.4%), etc. The operative mortality was 1.2%. The late complications during the follow-up period were recurrent stones (11 cases), ascending cholangitis (8 cases), and liver abscess (5 cases).
Biliary Dyskinesia ; Chills ; Cholangiocarcinoma ; Cholangitis ; Choledochostomy ; Cholelithiasis ; Cholestasis ; Daejeon ; Drainage* ; Female ; Fever ; Follow-Up Studies ; Humans ; Incidence ; Jaundice ; Liver Abscess ; Liver Cirrhosis ; Mastectomy, Segmental ; Mortality ; Postoperative Complications ; Recurrence ; Sepsis ; Sphincterotomy, Transhepatic ; Urinary Bladder ; Wound Infection

To date, endoscopic manometry is the best method for evaluating the function of the sphincter. Sphincter of Oddi manometry (SOM) remains the gold standard to correctly diagnose the sphincter of Oddi dysfunction (SOD) and stratify therapy. Several dynamic abnormalities relating to the intensity, frequency, and propagation of sphincter contractions have been described. However, their clinical use generally has been abandoned in favor of basal sphincter pressure alone, because this measurement is stable over time, and has stronger interobserver reliablility, reproducibility on repeating testing, and is associated with the responsiveness to therapy. A significant elevated risk of pancreatitis was attributed to the technique. The risk of pancreatitits associated with manometric evaluation of the pancreatic sphincter is markedly reduced when manometry is performed with continous aspiration from the pancreatic duct via one of the 3 catheter lumens. This section reviews indications, conscious sedative drugs, techniques, and the appropriate interpretations of SOM.
Catheters ; Contracts ; Manometry ; Pancreatic Ducts ; Pancreatitis ; Sphincter of Oddi ; Sphincter of Oddi Dysfunction

BACKGROUND/AIMS: The reproducibility of sphincter of Oddi manometry (SOM) measurements and results of SOM after sphincterotomy has not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. METHODS: The recently published Evaluating Predictors and Interventions in sphincter of Oddi dysfunction (EPISOD) study included 214 subjects with post-cholecystectomy pain, and fit the criteria of sphincter of Oddi dysfunction type III. They were randomized into 3 arms, irrespective of manometric findings: sham (no sphincterotomy), biliary sphincterotomy, and dual (biliary and pancreatic). Thirty-eight subjects had both biliary and pancreatic manometries performed twice, at baseline and at repeat endoscopic retrograde cholangiopancreatography after 1-11 months. Sham arm was examined to assess the reproducibility of manometry, and the treatment arms to assess whether the sphincterotomies were complete (elevated pressures were normalized). RESULTS: Biliary and pancreatic measurements were reproduced in 7/14 (50%) untreated subjects. All 12 patients with initially elevated biliary pressures in biliary and dual sphincterotomy groups normalized after biliary sphincterotomy. However, 2 of 8 subjects with elevated pancreatic pressures in the dual sphincterotomy group remained abnormal after pancreatic sphincterotomy. Paradoxically, normal biliary pressures became abnormal in 1 of 15 subjects after biliary sphincterotomy, and normal pancreatic pressures became abnormal in 5 of 15 patients after biliary sphincterotomy, and in 1 of 9 after pancreatic sphincterotomy. CONCLUSIONS: Our data suggest that SOM measurements are poorly reproducible, and question whether we could adequately perform pancreatic sphincterotomy.
Arm ; Cholangiopancreatography, Endoscopic Retrograde ; Humans ; Manometry* ; Sphincter of Oddi Dysfunction ; Sphincter of Oddi* ; Sphincterotomy, Endoscopic

We evaluated the clinical characteristics of patients with SO dyskinesia(n=16) who were confirmed by ERCP manometry during past 5 years. They were 14 male and 2 female and mean age was 52-year-old(range, 32-75). According to the criteria suggested by Hogan and Geenen, 13 patients were classified into biliary type and 3 patients into pancreatic type. Among the patients with biliary type(n=13), 12 patients fulfilled the criteria for group II dysfunction of SO and 1 patient for group III. Among the patients with pancreatic type(n=3), all fulfilled the criteria for group II. The manometric abnormalities were increased basal pressure(n=4), tachyoddia(n=7), increased retrograde propagation(n=3), tachyoddia and increased retrograde propagation(n=l), and tachyoddia and increased basal pressure(n=l). As treatment, 12 patients received conventional endoscopic sphincterotomy and 3 patients received endoscopic pancreatic sphincterotomy in addition to conventional endoscopic sphincterotomy. Satisfactory results (complete absence or marked reduction of pain) were obtained in 13(87%) out of 15 patients by endoscopic treatment. In conclusion, SO dyskinesia is not so common disease and the detection of patients with SO dyskinesia may increase by frequent application of ERCP manometry.
Cholangiopancreatography, Endoscopic Retrograde ; Dyskinesias ; Female ; Humans ; Male ; Manometry ; Sphincter of Oddi Dysfunction* ; Sphincter of Oddi* ; Sphincterotomy, Endoscopic