sincalide and Common-Bile-Duct-Diseases

Recent developments of manometric and endoscopic instrumentation have rekindled interest in sphincter of Oddi function. As a result of human and animal studies, our understanding of normal sphincter of Oddi physiology has increased and possible motility abnormalities are being identified. Manometric studies have shown that the sphincter of Oddi is characterized by prominent phasic contractions which are super-imposed on a low tonic pressure. The phasic contractions are orientated mainly in an antegrade direction; however, both simultaneous and retrograde contractions are registered. Cineradiography has demonstrated that the phasic contractions have a propulsive function, expelling small volumes of fluid from the common bile duct into the duodenum. Intravenously administered cholecystokinin-octapeptide normally inhibits the phasic contractions and reduces the sphincter tone. Motility abnormalities may occur if the sphincter of Oddi exhibits abnormally high tone, alteration in the direction of the phasic contractions, abnormal changes in the contraction frequency, or abnormal responses to hormonal stimulation. Preliminary human studies demonstrate disorders in sphincter of Oddi motility patterns, suggesting that motility abnormalities may be associated with choledocholithiasis, dyskinesia and idiopathic relapsing pancreatitis.

Topics: Ampulla of Vater; Animals; Common Bile Duct Diseases; Duodenum; Humans; Manometry; Morphine; Movement; Muscle Contraction; Sincalide; Spasm; Sphincter of Oddi; Time Factors

The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111-185 MBq (3-5 mCi) technetium-99m mebrofenin after 6-8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (+/-SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%+/-31%) than in controls (61%+/-36%) and the opioid group (61%+/-25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%+/-4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%+/-18%) and the SOS group (48%+/-29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (+/-193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the s

Topics: Adult; Aged; Aged, 80 and over; Bile; Common Bile Duct Diseases; Female; Gallbladder; Humans; Injections, Intravenous; Liver; Male; Radionuclide Imaging; Reproducibility of Results; Sensitivity and Specificity; Sincalide; Sphincter of Oddi

Thirty consecutive patients with intact gallbladders and biliary pain were evaluated to determine whether gallbladder ejection fraction could identify sphincter of Oddi dysfunction. The mean gallbladder ejection fraction was 45% in patients with abdominal pain and 72% in normal controls. Gallbladder ejection fractions were then correlated with endoscopically measured sphincter of Oddi pressures in patients with abdominal pain. The mean gallbladder ejection fraction was 41% in 7 patients with elevated sphincter pressures and 46% in 23 patients with normal pressures (P = NS). Thirty-six percent of patients with elevated pressures and 33% of patients with normal pressures had abnormal gallbladder ejection fractions. Gallbladder ejection fraction had a sensitivity of 33%, a specificity of 63%, and a positive predictive value of 25% for detection of elevated pressures. Regression analysis revealed a poor correlation between sphincter pressure and gallbladder ejection fraction (r2 = 0.02). These findings suggest that gallbladder ejection fraction cannot be used to diagnose sphincter of Oddi dysfunction in patients before they undergo cholecystectomy.

Topics: Abdominal Pain; Adult; Common Bile Duct Diseases; Double-Blind Method; Female; Gallbladder; Gallbladder Emptying; Humans; Imino Acids; Male; Organotechnetium Compounds; Prospective Studies; Radionuclide Imaging; Regression Analysis; Sensitivity and Specificity; Sincalide; Sphincter of Oddi; Technetium Tc 99m Disofenin

Topics: Adult; Aged; Aged, 80 and over; Bile; Common Bile Duct Diseases; Female; Gallbladder; Humans; Liver; Male; Radionuclide Imaging; Reproducibility of Results; Sensitivity and Specificity; Sincalide; Sphincter of Oddi

Sphincter of Oddi (SO) manometry is at present the "gold standard" investigation for patients with suspected biliary SO dysfunction. Non-invasive scintigraphy in cholecystectomised patients using a complex scoring system or the transit time from the hepatic hilum to the duodenum (HDTT) have been promoted as sensitive and specific alternatives.. To evaluate the scintigraphic scoring system and HDTT in patients with suspected biliary SO dysfunction undergoing SO manometry.. Cholecystectomised patients undergoing SO manometry for persistent biliary-type pain, as defined by the Rome II criteria, for which all other causes had been excluded, were prospectively studied. Scintigraphy with cholecystokinin octapeptide infusion was performed within a month prior to manometry. Scoring of the scans and measurement of HDTT was performed by independent blinded observers. Manometry of the biliary sphincter was performed per-endoscopically and defined as abnormal if basal pressure was > or = 40 mm Hg.. Thirty two patients were enrolled (30 females, mean age 45.1 years). Three patients were excluded from analysis because manometry from the bile duct was not technically possible. Eight patients had abnormal manometry. Scintigraphic scoring had a sensitivity of 25-38%, a specificity of 86-89%, positive predictive value (PPV) of 40-60%, and a negative predictive value (NPV) of 75-79%. The coefficient of variation for interobserver variation in scores was 0.72. HDTT sensitivity was 13%, specificity 95%, PPV 50%, and NPV 74%.. Our findings indicate that scintigraphy using these methods of analysis correlates poorly with manometry in post cholecystectomy patients with suspected biliary SO dysfunction.

Topics: Adult; Aged; Common Bile Duct Diseases; Female; Humans; Male; Manometry; Middle Aged; Observer Variation; Postcholecystectomy Syndrome; Predictive Value of Tests; Pressure; Prospective Studies; Radionuclide Imaging; Sensitivity and Specificity; Sincalide; Sphincter of Oddi

Topics: Common Bile Duct Diseases; Gastrointestinal Agents; Humans; Manometry; Radionuclide Imaging; Sensitivity and Specificity; Sincalide; Sphincter of Oddi

Topics: Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct Diseases; Gastrointestinal Agents; Humans; Manometry; Radionuclide Imaging; Sensitivity and Specificity; Sincalide; Sphincter of Oddi

Endoscopic manometry is considered useful to identify dysfunction of the sphincter of Oddi (SO) and to predict in which patients good results can be expected after endoscopic sphincterotomy, but this has not been definitively demonstrated.. Endoscopic manometry of the SO was used in a group of 30 patients with benign papillary stenosis (BPS), in comparison with 30 control subjects. During endoscopic manometry an intravenous bolus of cholecystokinin octapeptide was given to 12 patients and to 10 controls. In 24 BPS patients endoscopic sphincterotomy was performed.. No significant differences were observed between controls and patients with regard to median values of SO basal (20 and 21.5 mmHg) and peak pressure (123 and 126 mmHg), wave amplitude (100 mmHg), frequency (4 waves/min), and propagation of the common bile duct/duodenum gradient (12.5 and 12.1 mmHg). In two BPS patients a paradoxic response to CCK-OP was observed. Endoscopic sphincterotomy, performed in 24 BPS patients (17 with SO basal pressure less than 40 mmHg and 7 with more than 40 mmHg), gave good results in 23, without any complication. No differences were observed in the results of the endoscopic sphincterotomy among patients with basal pressure more than 40 mmHg and those with less than 40 mmHg.. On the basis of this study, manometric data do not seem helpful for diagnosis of BPS or to discriminate which patients can be treated with endoscopic sphincterotomy.

Topics: Case-Control Studies; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct Diseases; Constriction, Pathologic; Female; Humans; Male; Manometry; Pressure; Sincalide; Sphincter of Oddi; Sphincterotomy, Endoscopic

Biliary manometry, the "gold standard" for the diagnosis of sphincter of Oddi dysfunction, is associated with technical and methodological problems. The lack of a suitable experimental model has hindered efforts to solve these problems. We report here on the first practical animal model for endoscopic biliary manometry, similar in technique to the procedure in humans. Piglets were sedated and intubated with a standard human duodenoscope. A standard water-perfused manometry catheter was inserted into the bile duct. The biliary sphincter was identified by a zone of high-pressure activity with superimposed phasic contractions. The sphincter responded normally to the administration of cholecystokinin and morphine by relaxation and contraction, respectively. This model should be useful for training in biliary manometry, and facilitate technical innovations in the field. Since it is relatively atraumatic, it may also be better than existing surgical models for studying the normal physiology and pharmacology of the sphincter of Oddi.

Topics: Animals; Catheterization; Common Bile Duct Diseases; Disease Models, Animal; Duodenoscopy; Gastroenterology; Injections, Intravenous; Male; Manometry; Morphine; Research; Sincalide; Sphincter of Oddi; Swine

Sphincter of Oddi (SO) dysfunction presents with vague abdominal pain and/or abnormal liver function tests, and is presumably due to SO stenosis or spasm. Clinical, laboratory, and imaging methods of diagnosis have been less than ideal. Initially, we determined normal quantitative hepatobiliary scintigraphy (QHBS) parameters both pre- and post-sincalide administration. Thirty-one "normals" were analyzed, and post-sincalide common bile duct (CBD) dynamics could be satisfactorily determined in 29 (94%) subjects. Normal values at sincalide-augmented QHBS are reported. Next, 10 patients suspected of having SO dysfunction were studied prospectively using SO manometry and QHBS. The two tests were in agreement in seven cases (4: normal CBD dynamics, 3: abnormal). In one case of advanced SO stenosis, QHBS was abnormal, but SO manometry could not be performed. In the two remaining cases, SO manometry and QHBS gave discordant results. Of greatest importance, no significant correlation existed between the quantitative parameters of these two tests. Sincalide-augmented QHBS is possible and may, in the future, be of value in the diagnosis of SO dysfunction and/or partial CBD obstruction.

Topics: Adult; Ampulla of Vater; Common Bile Duct Diseases; Female; Humans; Imino Acids; Male; Manometry; Organotechnetium Compounds; Reference Values; Sincalide; Sphincter of Oddi; Technetium Tc 99m Disofenin; Tomography, Emission-Computed

Topics: Ampulla of Vater; Common Bile Duct Diseases; Humans; Manometry; Sincalide; Sphincter of Oddi; Tomography, Emission-Computed

Biliary scintigraphy and ultrasound imaging were performed in 52 patients with suspected biliary tract pathology. Results were correlated with the findings of direct cholangiography. Several new innovations in scintigraphic technique were used. The combination of ultrasound imaging and scintigraphy correctly identified biliary tract obstruction in 17 of 19 patients, 12 of whom had dilated bile ducts on ultrasonography. Intrahepatic cholestasis was correctly diagnosed in 11 of 13 patients. Accurate discrimination between intrahepatic and extrahepatic cholestasis was achieved in 28 of 32 patients (88%) with the combined studies. Scintigraphy also provided a correct diagnosis of acute cholecystitis in all 9 patients with surgically confirmed disease. Eleven additional patients with gallbladder or pancreatic disease had normal bile ducts at scintigraphy, which was confirmed with cholangiography. When combined with ultrasound imaging, modern biliary scintigraphy can (a) provide excellent discrimination between intrahepatic and extrahepatic cholestasis and (b) help determine the need for subsequent invasive diagnostic studies in selected patients.

Topics: Adult; Aged; Biliary Tract; Cholangiography; Cholecystitis; Cholestasis, Extrahepatic; Cholestasis, Intrahepatic; Common Bile Duct Diseases; Female; Gallbladder Diseases; Humans; Imino Acids; Male; Middle Aged; Pancreatic Diseases; Prospective Studies; Radionuclide Imaging; Sincalide; Technetium; Technetium Tc 99m Disofenin; Ultrasonography

Sphincter of Oddi (SO) manometry was conducted in 48 subjects who had previously undergone cholecystectomy. Ten of these subjects had no detectable biliary or pancreatic disease and served as controls. The other 38 patients were presumed to have SO dysfunction and had presented with episodes of severe biliary-type pain with either dilatation of the bile duct on a retrograde cholangiogram, transient changes in liver function tests, or both of these abnormalities. A triple-lumen low-compliance manometric system was used to record the SO basal pressure, SO phasic contraction amplitude, SO wave frequency, direction of wave propagation, and SO response to intravenously administered cholecystokinin-octapeptide 20 ng/kg. Satisfactory manometric recordings were obtained from 32 of 38 patients and of these, 25 patients showed one or more abnormalities when compared with data from the 10 controls. The abnormalities included excess of retrograde contractions (12), high frequency of SO phasic contractions (11), elevation of the SO basal pressure (8), and paradoxical cholecystokinin-octapeptide response (10). The study has demonstrated a spectrum of manometric abnormalities in the SO of patients with suspected SO dysfunction.

Topics: Adult; Aged; Ampulla of Vater; Catheters, Indwelling; Common Bile Duct Diseases; Duodenoscopy; Female; Humans; Male; Manometry; Middle Aged; Muscle Contraction; Pressure; Sincalide; Sphincter of Oddi; Time Factors