Hypertensive Pancreatic Sphincter

Abstract

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis or pancreatic-type pain. Endoscopic manometry as performed at endoscopic retrograde cholangiography is the most commonly used method to identify sphincter dysfunction. Noninvasive testing, such as secretin-stimulated ultrasound analysis of duct diameter, is less reliable and of relatively low sensitivity. Two-thirds of patients with sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. Patients with suspected or documented sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but warrant evaluation of their pancreatic sphincter if symptoms persist after therapy. Whether such pancreatic and biliary sphincters should be treated at the first treatment session is controversial. Pancreatic sphincterotomy is associated with a complication rate very similar to that of biliary sphincterotomy except that the pancreatitis rate is two- to fourfold higher. Prophylactic pancreatic stenting diminishes such pancreatitis by approximately 50%.

Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction

“…Recurrent pancreatitis can result from dysfunction of the biliary sphincter segment, the pancreatic sphincter zone, or both 6 , . 7 , 11 –13 , 17 , 18 Most manometric studies recorded sphincter pressure in one duct only (biliary or pancreatic); unfortunately some do not report which duct was addressed. Those series evaluating both ducts, however, report higher frequencies (50–72%) of basal sphincter tone abnormalities of at least one duct in idiopathic pancreatitis patients 6 , .…”

“…With non‐invasive techniques for the detection of pancreatic sphincter dysfunction (secretin stimulation during either ultrasonography or magnetic resonance cholangio‐pancreatography), discrepant results have been reported if correlated with manometric data 33 –35 . Therefore, some authorities do not accept or recommend these tests when making therapeutic decisions 17 . Further, endoscopic transpapillary stent placement in the pancreatic duct has been used to select patients with idiopathic pancreatitis for sphincter ablation but this technique requires cannulation of the pancreatic duct (with its potential risk to induce pancreatitis) and ductal irregularities may result from pancreatic stent placement 36 .…”

“…If recurrence of acute pancreatitis was documented during a 3‐month period after botulinum toxin treatment (botulinum toxin non‐responder) or during the later course (botulinum toxin responder), endoscopic sphincter of Oddi manometry was repeated (the manometric recordings were analysed blindly with respect to the former manometric data and the duration of the symptomatic response to botulinum toxin) and selective pancreatic sphincterotomy was performed over a guide‐wire, irrespective of the manometric finding 11 , . 17 Further, a straight 7 French pancreatic stent was inserted for several days in order to reduce the risk of post‐sphincterotomy pancreatitis 30 . If biliary sphincter hypertension was known from the index manometry before botulinum toxin treatment, a biliary sphincterotomy was added in the same session.…”

“…Perfusion manometry of the pancreatic duct, however, is associated with a substantial risk to induce acute pancreatitis (up to 29%) especially when patients with presumed sphincter of Oddi are studied 12 , . 14 –17 Only after the introduction of modified techniques, reducing the risk of procedure‐related pancreatitis, has manometric evaluation of the pancreatic sphincter segment become acceptable 17 –20 . The only proof that sphincter of Oddi is the cause of recurrent pancreatitis in these patients is cure from further episodes after sphincter ablation.…”

Efficacy of biliary scintigraphy in suspected sphincter of oddi dysfunction

“…A significant proportion (perhaps as high as 65%) of patients with biliary SOD have concomitant pancreatic sphincter dysfunction, defined by elevated pancreatic basal sphincter pressure [51]. Currently, the diagnosis of pancreatic sphincter dysfunction is made solely by ESOM, and scintigraphy has no role in the diagnosis of this subset of SOD patients.…”