cholecystokinin and Common-Bile-Duct-Diseases

The availability of objective and quantitative diagnostic tests in recent years has allowed more precise documentation of biliary dyskinesia. Biliary dyskinesia consists of two disease entities situated at two different anatomical locations: sphincter of Oddi spasm, at the distal end of the common duct, and cystic duct syndrome, in the gallbladder. Both conditions are characterized by a paradoxical response in which the sphincter of Oddi and the cystic duct contract (and impede bile flow) instead of undergoing the normal dilatation, when the physiological dose of cholecystokinin is infused. Quantitative cholescintigraphy can clearly differentiate one disease entity from the other. The therapies of choice are sphincterotomy, sphincteroplasty or antispasmodics for sphincter of Oddi spasm and cholecystectomy for cystic duct syndrome. After quantitative cholescintigraphy, the final impression should identify the disease entity by name to assist the referring physician in making an appropriate therapeutic decision; a mere statement that a test is consistent with biliary dyskinesia is no longer sufficient.

Topics: Aniline Compounds; Biliary Dyskinesia; Cholecystokinin; Common Bile Duct Diseases; Cystic Duct; Gallbladder; Glycine; Humans; Imino Acids; Organotechnetium Compounds; Radionuclide Imaging; Radiopharmaceuticals; Sphincter of Oddi

Topics: Ampulla of Vater; Animals; Cholecystectomy; Cholecystokinin; Common Bile Duct Diseases; Constriction, Pathologic; Endoscopy; Gallstones; Hormones; Humans; Manometry; Sphincter of Oddi

Sphincter of Oddi dysfunction is an underdiagnosed but important clinical condition. It should be considered in the differential diagnosis of biliary pain when the gallbladder sonogram shows no evidence of gallbladder disease. Hepatobiliary scanning (Tc-99m dimethyl iminodiacetic acid) may provide valuable information in the evaluation of these patients and may be helpful in monitoring response to treatment.

Topics: Adult; Cholangiopancreatography, Endoscopic Retrograde; Cholecystokinin; Common Bile Duct Diseases; Female; Humans; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Sphincter of Oddi; Sphincterotomy, Transduodenal; Technetium Tc 99m Diethyl-iminodiacetic Acid

Postcholecystectomy patients (N = 27) with severe recurrent biliary-like pain who had no evidence of organic disease were subdivided into those with and those without objective evidence of sphincter of Oddi dysfunction (SOD) based on two separate criteria: (1) clinical criteria-elevated liver function tests and/or amylase with pain, and/or a dilated bile duct, and/or delayed drainage at ERCP (N = 14, SOD classes I and II); and (2) abnormal biliary manometry (N = 19). Prolonged (24-48 hr) ambulant recording of duodenojejunal motor activity was performed in all patients and interdigestive small bowel motor activity compared between patient subgroups and a healthy control group. Phase II motor abnormality was more frequent in patients with, compared to those without, objective clinical criteria of SOD (7/14 vs 0/13, P = 0.003). Phase III abnormality also tended to be more frequent in these patients (7/14 vs 2/13, P = 0.06). In addition, both phase III (P = 0.03) and phase II (P = 0.03) motility index (MI) was higher in patients with sphincter dyskinesia compared to controls; phase II MI was also higher in patients with sphincter stenosis (P = 0.005). Disturbances of small bowel interdigestive motor activity are more prevalent in postcholecystectomy patients with, compared to those without, objective evidence of SOD, and especially in patients with SO dyskinesia. Postcholecystectomy SOD in some patients may thus represent a component of a more generalized intestinal motor disorder.

Topics: Adult; Case-Control Studies; Cholecystokinin; Common Bile Duct Diseases; Female; Gastrointestinal Motility; Humans; Intestine, Small; Male; Manometry; Postcholecystectomy Syndrome; Sphincter of Oddi

It remains controversial whether manometric parameters recorded from the pancreatic and biliary segment of the sphincter of Oddi (SO) differ. We therefore studied 48 consecutive patients (40 women, 43 +/- 11 years) with suspected SO dysfunction, in 33 of whom successful dual-duct SO manometry was obtained. Measures of concordance between the two duct segments were moderate for basal sphincter pressure (K = 0.31) and for contractile frequency (0.35), and were low for peak pressure (0.15) and for proportion of retrograde propagation (-0.19). There was also low concordance (-0.13) for the overall manometric diagnosis, and in 48% (CI 31-66%) of patients a conflicting diagnosis (normal/abnormal) was obtained from the two ducts. There was no evidence of a differential motor effect of CCK on either duct, nor were there significant differences in the rate of manometric abnormality according to the order of initial duct cannulation. These results indicate that, if technically feasible, dual-duct manometry of the sphincter of Oddi is required for diagnostic precision.

Topics: Adult; Cholecystokinin; Common Bile Duct; Common Bile Duct Diseases; Female; Humans; Male; Manometry; Pancreatic Ducts; Postcholecystectomy Syndrome; Sphincter of Oddi

The ideal noninvasive test of sphincter of Oddi dysfunction (SOD) does not exist and the diagnosis of patients with postcholecystectomy pain often relies on invasive procedures. In this paper we describe a scintigraphic test for SOD: the scintigraphic score. This score combines quantitative and visual criteria for interpretation of hepatobiliary scans. Twenty-six consecutive postcholecystectomy patients underwent hepatobiliary imaging, ERCP, and sphincter manometry. Twelve patients had SOD and 14 had normal sphincters determined by clinical findings, ERCP, and manometric studies. All patients with normal sphincter had scores of 0-4, while patients with SOD had values of 5-12 for a perfect sensitivity and specificity of 100%. Hepatobiliary scans scored in this fashion may become the noninvasive test of choice to screen postcholecystectomy patients with suspected SOD.

Topics: Adult; Aged; Aged, 80 and over; Cholecystectomy; Cholecystokinin; Common Bile Duct Diseases; Female; Humans; Imino Acids; Male; Middle Aged; Organotechnetium Compounds; Pain, Postoperative; Radionuclide Imaging; Retrospective Studies; Sphincter of Oddi; Technetium Tc 99m Disofenin

Topics: Cholecystokinin; Common Bile Duct Diseases; Humans; Radionuclide Imaging; Sphincter of Oddi

Topics: Bile Reflux; Biliary Tract Diseases; Cholecystokinin; Common Bile Duct Diseases; Eponyms; Humans; Radionuclide Imaging

The properties of the choledochal cyst were compared with those of the normal common bile duct. Cholecystokinin-octapeptide and a high concentration of acetylcholine produced smaller contractions in the strips of the narrow portion of the cyst than in the strips of the dilated portion and the normal common bile duct. Nicotine did not cause contractions in the strip of the narrow portion of the cyst. gamma-Aminobutyric acid (GABA) induced atropine-sensitive, tetrodotoxin-sensitive contractions in the bile ducts through bicuculline-sensitive, furosemide-sensitive GABAA receptors located on the postganglionic cholinergic neuron. The GABA did not induce contractions in the narrow portion of the cyst. The number of ganglion cells was decreased markedly in the same portion. These findings suggest that the choledochal cyst has postganglionic neural dysfunction. This character may be one of the causes of cyst formation.

Topics: Acetylcholine; Cholecystokinin; Common Bile Duct; Common Bile Duct Diseases; Cysts; Egg Yolk; gamma-Aminobutyric Acid; Humans; Muscle Contraction; Nicotine

Unexplained abdominal pain after cholecystectomy has been attributed to sphincter of Oddi dysfunction, but no objective diagnostic criteria exist. Biliary excretion was quantitated by computer-assisted cholescintigraphy in 35 postcholecystectomy controls without symptoms, 9 patients with suspected sphincter of Oddi dysfunction (studied before and after sphincterotomy), and 18 patients with overt cholestasis from other causes (6 with extrahepatic obstruction and 12 with parenchymal liver disease). In patients with sphincter of Oddi dysfunction or with cholestasis, the time to attain maximal activity in the biliary system was significantly (p less than 0.05) longer, the percent of radiotracer excreted at 45, 60, and 90 min was less, and the emptying rate was slower compared with the controls. Cholecystokinin (0.02 U/kg X min) did not abolish biliary output, excluding a paradoxical response of the sphincter. After sphincterotomy, biliary activity peaked earlier and the percent excreted at 45 min increased but did not revert to normal. Relief of symptoms occurred in 8 of 9 patients. The one failure had normal emptying characteristics before sphincterotomy, and did not change after surgery. Another developed recurrent pain and a corresponding deterioration in biliary emptying on serial scans. Thus, functional obstruction at the sphincter of Oddi exists, is not due to any paradoxical response to cholecystokinin, and in the absence of overt cholestasis, can be detected by quantitative cholescintigraphy. Successful sphincterotomy may not completely restore biliary emptying to normal.

Topics: Adult; Aged; Ampulla of Vater; Cholecystectomy; Cholecystokinin; Cholestasis; Common Bile Duct Diseases; Female; Humans; Imino Acids; Male; Middle Aged; Postoperative Complications; Radionuclide Imaging; Sphincter of Oddi; Technetium; Technetium Tc 99m Disofenin

Topics: Adult; Cholangiography; Cholecystokinin; Common Bile Duct Diseases; Constriction, Pathologic; Humans; Male

We obtained cholangiographic demonstration of noncalculous acute biliary colic associated with common bile duct dilation in a 46-year-old woman with a 9-year history of postprandial right upper quadrant pain. Hepatic plexus vagectomy and cholecystectomy completely relieved her symptoms, now for a 10-year follow-up period.

Topics: Cholangiography; Cholecystectomy; Cholecystokinin; Colic; Common Bile Duct Diseases; Female; Humans; Middle Aged