The patient with pain; suspected gallbladder and sphincter dysfunction

Abstract

Before the days of sophisticated imaging techniques, ERCP was frequently and effectively used to investigate patients with biliary/pancreatic pain and to diagnose and exclude common diseases such as bile duct stones and chronic pancreatitis. The situation is quite different now.Nowadays, most patients with upper abdominal pain have basic laboratory tests taken and undergo upper endoscopy (after careful clinical enquiry and physical examination). If this is negative, abdominal scanning is indicated, by ultrasound in some countries, more likely by computed tomography (CT) in the United States. If that is negative and suspicion persists, MRCP is recommended. These scans provide excellent information about the biliary tree and pancreas, and should also detect problems in surrounding organs, such as aortic aneurysm and renal tumors. This review concerns patients in whom all of these tests are unrevealing.The appropriate next steps are influenced by clinical features, such as age and the type of pain, and any associated complaints, such as weight loss.Epigastric pain, especially if persistent, is suggestive of a pancreatic origin. The best next step is EUS, which can detect small tumors and less severe cases of pancreatitis. EUS is also valuable in looking for small stones in the gallbladder or bile ducts. If EUS is negative, there is no role for ERCP. The chances of finding anything are less than the risk of causing pancreatitis.Intermittent pain in the right upper quadrant (and/or epigastrium) suggests biliary disease, specifically dysfunction of the gallbladder or sphincter of Oddi, and suspicion is enhanced if the liver tests bump with attacks of pain. This is where the algorithm of investigation gets more controversial, since hard data are scarce [1].Gallbladder dysfunction. It is presumed that incoordination of gallbladder emptying can cause pain. Cholescintigraphy (hepatobiliaryiminodiacetic acid,