Pain and an intact gallbladder: Is the sphincter of oddi to blame?

1716

SELECTED

viously

shown,

of the crural

transient

It seems

which,

would

much

fundoplication vention

LES relaxation

diaphragm,

LES relaxation,

GASTROENTEROLOGY

SUMMARIES

is accompanied

along

with

also be reduced

less likely

that

shortening

the vagal inhibitory

LES relaxation

of neural

innervation

than purely mechanical

well above the fundal the rate of decrease relaxations

wrap and are unlikely

in LES pressure

were unaffected

profile of LES relaxation most consistent accept

that

was a higher

with a simple

the reduction

is neurally

mediated,

fundic distension.

in triggering

possibly

complex

of transient

of further

is

we would

Eight

of 35 (23%) had no improvement

initial

responders,

15 maintained

tectomy

with responses

having

of excellent

Six patients

a good response

details of medical cium channel ments.

one The

were not given but included

cal-

Hz blockers,

Five of the initial

tomy with responses

with

a fair response.

ursodiol,

8 nonresponders

of excellent

patients.

cholecystitis

sphincterotomy

in

H. HOLLOWAY

ALAN C. IRELAND JAMES TOOULI JOHN

DENT

resulted

with

and medical

in improvement

Overall,

tis in five patients quiring

Choudhy U, Raffolo T, Jamidar P, Hawes R, Lehman G (Division napolis, with

Indiana). intact

Indiana

Sphincter

gallbladder:

sphincterotomy.

of Oddi

dysfunction

therapeutic

Gastrointest

University,

in patients

response

Endosc

India-

1993;39:492-495

hospitalization

ment

of Oddi

dysfunction

is an accepted

with

manometry

endoscopic

has also been reported

pain but intact, stone-free a retrospective

cause of ab-

which responds

sphincterotomy.

Abnormal

in patients

gallbladders.

report of the response

to treatsphincter

with biliary type

The investigators to endoscopic

give

tients

with

During

baseline

sphincter

intact

gallbladders

this same time,

pressure

was found

during

707 patients

in 35 pa-

a period underwent

of 2 years. manometry,

4-10

we are not told how many of these had intact gall-

bladders.

Patients

will respond

Patients

diagnoses

with biliary-type

normal gallbladder

tic dilemmas.

Potential

source of discomfort, ultrasonography, (although Oddi

sources

of their

gallstones

dysfunction.

agrees

that

often includes is probably

patient

What

which

nonbiliary

decide to pursue

the biliary

were

Ultrasonography

is the preferred

method

in 2%-7%

of studies (The biliary

New York: Churchill

tal analysis were not routinely

cholecystogram

were classi-

of sphincter

of

Oddi dysfunction: 1 of 35 was type I, 18 of 35 were type II, and 16 of 35 were type III patients. Pain scores were obtained before treatment and at each follow-up interval on a O-10 linear pain scale. Pain response was classified as excellent (pain score, O), good (pain score, l-3), fair (pain score, 4-6), or poor (pain score, 7-10). Patients who had either no response or relapse after sphincterotomy tectomy.

were offered empiric

diagnosis

to

step when

the

tract as a potential

for the diagnosis

ultrasound.

classification

of

of pain,

trial for irritable

difficult

or therapeutic

are reported

Milwaukee

cholecystitis

sources

a treatment

excluded, although scintigraphic examinations with ejection fraction of the gallbladder and duodenal bile aspirates for crysPatients

a nonbiliary

on transcutaneous

or chronic

the most

is the next diagnostic

and clinician

include

reflux or peptic ulcer disease, should be ruled

bowel exclude.

ultrasono-

and therapeu-

causes pain), and sphincter

out first. This evaluation syndrome,

pain

gallbladder

how this entity

Everyone

diagnostic

that were missed

a nonfunctioning

it is unclear

pain and an intact,

pose difficult

of 98%, although

fied by the modified

re-

in one patient.

to the various therapeutic

with an overall accuracy

performed.

pancreati-

days), and bleeding

source of pain?

although

with other gastrointestinal

(34%): mild pancreati-

days), moderate

but not transfusion

such as gastroesophageal

sphincter-

otomy in 35 of these patients. Elevated

the

were not

(July/ Comment.

pain after cholecystectomy,

outcome

although

The investigators conclude that better diagnostic techniques are needed to sort out which patients with biliary-type pain

graphically

Sphincter

between

alternatives.

August).

dominal

(hospitalized

and intact gallbladders

to endoscopic

l-3

only

response

were small. Complications

(hospitalized

tis in six patients

However,

of patients,

severe but occurred in 12 of 35 patients

PAIN AND AN INTACT GALLBLADDER: IS THE SPHINCTER OF ODDI TO BLAME?

cholecystecin 9 patients

(43%) had a sustained

classification

in each category

showed

endoscopic

subsequent

management

There was no correlation

and the Milwaukee

treated medi-

pathology

in 68% of patients.

35 patients

to sphincterotomy.

chose cholecystec-

nonresponders

in 35 patients

15 of the initial

numbers

all

and other treat-

in one, good in three, and

chronic

tomy in 11 patients

of Gastroenterology/Hepatology,

medically

and five having

treatment

blockers,

in one, good in three, and

were treated

Gallbladder

It has yet

status,

whereas 12 had relapses. Of the 12 relapsers, six chose cholecys-

cally all had a poor response.

study.

(77%)

in pain. Of the 27

poor in one. The three remaining

controls

No. 6

a good response).

a good or excellent

LES relaxations

to reveal all its secrets. RICHARD

27 of the 35 patients and 12 with

in the degree of

by which fundoplication

and deserving

LES to the

This change

effect. However,

because of a reduction

The mechanisms

reflux are clearly

of transient

of follow-up,

(15 pain-free

poor in two.

Second,

the only change

nadir pressure.

mechanical

for swallow-

enter the esophagus

and the duration

by fundoplication;

after or pre-

to be damaged.

1 month

were improved

effects. First,

fibers to the LES that are responsible

and, most likely, transient LES relaxation

induced

After

of transient

by fundoplication.

incomplete

is caused by impairment

of esophageal

by inhibition

triggering

Vol. 106,

cholecys-

although raphy

is unknown

on duodenal

stones (Hepatology nique is unclear with

ultrasonography patients study

with

1986; 6: 118stones

(Gut

120). Recently,

(Gastroenterology

clinical

Crystal

122). The sensitivity

for crystals

history

One

Dis Sci

that endoscopic

gallbladder

yet negative

1993; 104:A358).

of patients Dig

it has been suggested

analysis of missed

of this tech-

in 30%-82%

1990;31:1407-1410,

test,

ultrasonog-

may also be indicative

has a high yield of diagnosing a strong

An oral

diagnostic

after negative

1985;201:640-647).

aspirates

with evidence

documented

1992; 37:116-

(Ann Surg

or bile duct

In: Abdominal

1987:81-90).

as an alternative

of this examination

of stones

examinations

system.

Livingstone,

can be obtained

the usefulness

false-negative

stones in

transcutaneous

approach

is simply

June 1994

SELECTED SUMMARIES

to perform although

cholecystectomy many surgeons

without

prior

are reluctant

diagnostic

to proceed

justification,

because

cystectomy,

of medical

or an attempt

or smooth

muscle

ar medical

relaxants.

therapy

with bile salt dissolurion

Many questions

remain.

and legal concerns. Quantitative

GRACE H. ELTA, M.D.

cholescintigraphy

tic tool with low gallbladder 91% response

is often chosen as the next diagnos-

ejection

to cholecystectomy the sensitivity

8 of 14 patients

(57%) with normal

to cholecystectomy.

Other

features

1990;85:986-990). Sphincter

investigators

ogy

type pain pressure

with sphincter response

in patients

accounts

44%

number

wirh cholecystectomy cysteccomy

that abnormalities

The best initial

abstract

type pain and intact

metrics

in another

these two groups

mals have suggested No

severe

and 1 patient described, higher

complications

(Gastroenterology

emphasize

tios when managing Despite

in patients

outcome

the predictive

somewhat

disappointing,

difficult

patient

these patients. or should sphincter

group

and sphincter

with

1075).

is

These ra-

in a large number

sphincter

esophageal

cell death).

High-pressure

analysis,

approach

liquid

stimulated

suppression (programmed

chromatography-fraction-

from tumor explants

inhibited

the prolifera-

normal peripheral

lymphoid

only with

cells of nonlymphoid

origin.

did not inhibit to mitogens,

activation

blood lym-

cells in a dose-dependent

lymphoid

initially

in the presence

lymphocytes Kinetic activity

synthesized

DNA

analysis showed

lymphocyte

but this was down-regulated

fragmentation

the

the

after 48 hours analysis showed

that

also became

evident

of and

in the

factor. The

one of the mechanisms

by which

propose

some tumors

evade immunosurveillance function

changes

immunosuppressive

investigators

apoptosis

to inhibition

morphological

of apoptosis

of the tumor-derived

undergo

that

under the influence of the factor were arrested

proliferation,

lymphocyte

markof the

24 hours postmito-

of the factor. Flow cytometric

that lymphocytes

factor

in response

of surface activation

of interleukin-2.

immunosuppressor

lymphocytes

cytotoxic

cells and not with

The immunosuppressive

of normal

as shown by expression

ers and production

cells

were found to pro-

irreversible

This activity was not caused by a nonspecific

manometrics

Comment. tumor

dysfunction.

is to exploit a normal

by selectively

inducing

them

to either

or enter a state of anergy with down-regulaproliferation.

was

ever, a feature

cholecystectomy

in this

evasion

rescue

studies

or endoscopic

are needed examinations

stones

with

to

these

in

recent

oral

ejection

fractions

or

on these diagnostic

results,

may be sphincterotomy,

chole-

of many

the host

forms

is the induction tumors,

1350, Cancer Immunol Res 1993;60:247-267).

Intriguing

How-

to resist

gastrointestinal

Immunother

In

elaborated

carcinomas,

have been

J Immunol

1979;122:

1987;24:225-230,

In rare instances,

fied as one of the known cytokines,

factors

of

One of

immunosuppression.

1987;138:2161-2168,

or

mechanisms

have been evolved by rumors. of immunosuppressive

including

(J Immunol

response.

is the ability

of local or systemic

years, a multiplicity

by human

system is capable of rejecting

(Sci Am 1993;266:82-89). of cancer

immune

of immunosurveillance

described

ultrasonography

The fact that the immune

cells is now well recognized

circumvent

gallbladder

and transformed

carcinomas

profound,

effect and occurred

clinical

D epending

An imsquamous

1993; 15 1: 1- 10 (November).

and induces apoptosis

and transformed

College,

Ireland).

from esophageal

in normal

squamous

proliferation

68% good to excellent Further

derived

apoptosis

University

Maynooth,

lineage. J Immunol

of lymphoid

DNA

for

risk/benefit

induces

Human

presence

As previously

ofOddi

and use of diagnosric

for abnormal

therapeutic

an intact

it is an important

we first look for “missed”

of Oddi dysfunction?

the best initial

5 of 35 pa-

pancreatitis

weigh

carcinoma

tion of lymphocyte

is gratifying.

bile crystal

gall-

in the Gl phase of the cell cycle. In addition

pancreatitis,

sphincterotomy

of this study,

the overall

order

Should

we look

undergoing

value of abnormal

sphincterotomy

the proper

cholecystogram,

bleeding.

to moderate

after sphincterotomy

Although

determine

by a

retrograde

although

1991; 101:1068-

nature

with intact gallbladders

after

in pa-

and

and Surgery,

College,

factor

genie stimulation,

in ani-

such patients.

of patients

outcome

Studies

suppressive

tumor-derived

mano-

overlap between

endoscopic

the need to carefully

the retrospective

first report of clinical

fractions

may be controlled

seen from

of mild

with

1991;32:690-693).

requiring

incidence

chole-

it appears

sphincter

6 of 35 had moderate

had nontransfusion

choledocholithiasis

be required

sphincterotomy

dysfunction

of Immunology

Cork; and St. Patricks

manner.

may occur con-

1991;37:256). (Gut

were

than that occurring

because

(Departments

phocytes

response

in 88 patients

and sphincterotomy,

31%

of Oddi

tion of mitogenically

a significant

found low ejection

pressures

distention

mild pancreatitis,

this

initially

approach,

wirh significant

that sphincter

cholangiopancreatography

undoubtedly

A MECHANISM FOR ESOPHAGEAL TUMOR-DERIVED IMMUNOSUPPRESSION

ated supernatants

after cholecys-

and abnormal

Endosc

complications

tients developed

(83%)

and sphincter

half of the patients

to the

of sphincterotomy

unclear

gallbladders

(Gastrointesr

local reflex to gallbladder

will

of endoscopic

duce a factor that mediates

The 77%

similar

improved

from Indianapolis

in half of the patients

report

Clinic (Gastrointest

therapeutic

remains

of the gallbladder

A previous

at scintigraphy

gallbladders.

the combination

or sphincterotomy,

comitantly.

sphincter

of lymphoid

in 35 patients

In both studies,

and relapsers

elevated

rescue led to a final good co excellent

in 68% of the patients.

with

mune

and whether

is remarkably

with 3 of 10 (33%) relapsing.

and

The current

10 of 12 patients

study,

this

sphincterotomy

rate

pressures

Gastroenterol-

symptoms

from the Cleveland

pain

gallbladders

whether

and intact

in which

In the current

sphincter

sphincterotomy.

relapse

in 12 patients

cause of biliary

intact

known

after

of the nonresponders

biliary

with

for the patients’

outcome

1993;39:311)

tectomy.

or

scintigraphy

1991; lOO:A321,

to endoscopic

race with

responded

outcome

gallbladder

Abnormal

of Oddi dysfunction

results reported

tients

trial

efficacy

bladder.-Editor)

(Am J Gastroenterol

is an accepted

It is nor

the clinical

Endosc

study,

(Gastroenterology

they will respond describes

because

randomized the

O’Mahony AM, O’Sullivan GC, O’Connell Jq Cotter TG, Collins JK

dysfunction

1984;87:759-762).

(A prospective to establish

also responded

and clinical

cholecystitis

wirh prior cholecystectomy.

sphincter

fractions

fraction

of chronic

of a

have failed to find a correla-

ejection

have also been documented biliary

predictive

1991; 101:786-

performed.

of Oddi

in patients

ejection

In the current

was not routinely

reported

of this test has been questioned

rhe gallbladder

rhe histological

fractions

(Gastroenterology

793). However,

tion between

1717

Adv Cancer

the factor has been identi-

most notably,

transforming

growth