Gastroenterology

Gastroenterology

Volume 130, Issue 5, April 2006, Pages 1498-1509
Gastroenterology

Introduction
Functional Gallbladder and Sphincter of Oddi Disorders

https://doi.org/10.1053/j.gastro.2005.11.063Get rights and content

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Section snippets

E. Functional GB and SO Disorders

GB and SO dysfunctions are relatively rare conditions, but their main clinical presentation, pain in the upper right abdominal quadrant and in the epigastrum, is not easily distinguished from that occurring in high prevalence conditions such as gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), functional dyspepsia, and cholelithiasis and in high risk complications caused by cholecystitis and pancreatitis. In addition, SO dysfunction itself can be the cause of liver and

Definition

GB dysfunction is a motility disorder of the GB that manifests symptomatically with biliary pain as a consequence of either an initial metabolic disorder (ie, supersaturated bile with cholesterol7) or a primary motility alteration of the GB in the absence, at least initially, of any abnormalities of bile composition.8 It is likely that the latter condition, by causing bile stasis, may alter over a period of time, bile recycling and bile composition within the GB. Both conditions may eventually

Definition

SO dysfunction is the term used to define motility abnormalities of the SO associated with pain, elevations of liver or pancreatic enzymes, common bile duct dilatation, or episodes of pancreatitis. The SO is situated strategically at the duodenal junction of the biliary and pancreatic ducts. SO dysfunction may result in either biliary or pancreatic disorders. Although SO dysfunction may be present in patients with an intact GB, most of the clinical data concerning SO dysfunction has been

E3. Functional Pancreatic SO Disorder

The association between the dysfunction of the SO motility and recurrent episodes of pancreatitis has been reported in case series.40, 41 It has also been reported41, 42 that total division of the SO in manometrically identified patients with SO dysfunction results in abolition of the recurrent episodes of pancreatitis. However, randomized controlled studies are needed.

Patients report recurrent episodes of epigastric pain that are usually not distinguishable from biliary pain, although it can

Conclusion and Future Directions

Functional disorders of the GB and biliopancreatic SO cause significant clinical symptoms that are clearly associated with motility abnormalities of the GB and SO. However, several aspects of their pathophysiology and clinical symptomatology remain to be clarified.

Future investigations should include clinical studies to study the following:

  • 1

    The natural history of functional GB disorders clearly distinguished from those associated with lithogenic bile with excess cholesterol; therefore, it

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