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Sphincter of Oddi manometry and bile crystals
Letters to the Editor
early termination of a prospective randomised trial. Eur J Cancer 1992;28A:1005-6. 8. Nishimura Y, Nagata K, Katano S, Hirota S, Nakamura K, Higuchi F, et al. Japanese Society for Esophageal Diseases. Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese society for esophageal diseases. Int J Radiat Oncol Biol Phys 2003;56:1327-32. PII: S0016-5107(04)02022-X
Response: We thank Dr. Azar for his comments regarding CRT and the placement of SEMS for palliation of patients with advanced esophageal carcinoma. We acknowledge that SEMS placement is associated with complications, especially in patients who survive for long periods. However, we disagree that SEMS placement should not be performed before RT or CRT has failed or is refused. There are some data that suggest that the frequency of severe complications is higher in patients who have RT or CRT before SEMS placement.1-3 In addition, we feel that the main goal of palliative treatment of patients with advanced esophageal carcinoma is to relieve dysphagia, an often distressing symptom. Rapid resolution of symptoms with minimal inconvenience to patients with a potentially short life expectancy is important. Dysphagia is more quickly relieved by SEMS placement than by RT.4 SEMS placement frequently can be performed as an outpatient procedure and quickly provides nutritional support in a more ‘‘physiologic’’ manner than PEG feeding. As stated in our case report, advances in SEMS technology should allow insertion of removable SEMS in selected patients. After CRT, redundant SEMS could be removed endoscopically from patients with a good response, thereby reducing the potential for complications. Adrian I. Thuraisingam, MRCP Arrowe Park Hospital Wirral, United Kingdom Howard L. Smart, FRCP Royal Liverpool University Hospital Liverpool, United Kingdom
REFERENCES 1. Klinsman KJ, DeGregorio BT, Katon RM, Morrison K, Saxon RR, Keller FS, et al. Prior radiation and chemotherapy increase the risk of life threatening complications after insertion of metallic stents for esophagogastric malignancy. Gastrointest Endosc 1996;43:196-203. 2. Siersema PD, Hop WC, Dees J, Tilanus HW, van Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study. Gastrointest Endosc 1998;47:113-20. 3. Bethge N, Sommer A, Kleist D, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy. Gastrointest Endosc 1996;44:283-6. 4. Cwikiel M, Cwikiel W, Albertsson M. Palliation of dysphagia in patients with malignant oesophageal strictures. Compari862
GASTROINTESTINAL ENDOSCOPY
son of results of radiotherapy, chemotherapy and esophageal stent treatment. Acta Oncol 1996;35:75-9. PII: S0016-5107(04)02023-1
Sphincter of Oddi manometry and bile crystals To the Editor: We read with interest the report of the study of Rashdan et al.,1 which found a low frequency of biliary crystals or microlithiasis,2,3 in a group of patients undergoing sphincter of Oddi manometry for suspected sphincter of Oddi dysfunction. That low proportion of patients with microlithiasis (3.5%) is in contrast to the higher percentage with microlithiasis (69%) in our study of patients with unexplained upper abdominal pain.2 Dahan et al.4 and Baig et al.5 also found higher percentages of microlithiasis (40% and 38%, respectively) in studies of patients with upper abdominal pain and negative transabdominal US examinations. Rashdan et al.1 offer some explanations for the low proportion of patients with microlithiasis in their patient population. We favor an explanation for the differences that is supported by outcomes data. It is extremely likely that the patients in our study and those of Baig et al.5 represent a different population group from that of Rashdan et al.1 This is based on the good clinical outcomes after cholecystectomy found in the former two studies. In a subsequent study,6 we documented good quality of life outcomes after cholecystectomy in patients with positive combined EUS and stimulated biliary drainage and otherwise unexplained upper abdominal pain. Rashdan et al.1 mention that many patients with suspected sphincter of Oddi dysfunction have undergone cholecystectomy. This is in keeping with the evidence that sphincter of Oddi dysfunction is a primary motor disorder in some patients7 and not necessarily associated with a structural change in the sphincter or with gallbladder disease. The experience of one of us (J.D.) with sphincter of Oddi manometry also is consistent with this view. Patients with suspected sphincter of Oddi dysfunction but normal manometry may have a nonbiliary etiology for their pain. The study by Rashdan et al.1 is certainly thought provoking. Clinical outcomes data for patients in their study who had abnormal manometric findings and who underwent endoscopic sphincterotomy would be most interesting. James E. Dill, MD, FACP Bobbie P. Dill BSN, RN, C Sioux Falls, South Dakota REFERENCES 1. Rashdan A, Fogel E, McHenry L Jr, Lehman G, Sherman S. Frequency of biliary crystals in patients with suspected sphincter of Oddi dysfunction. Gastrointest Endosc 2003;58: 875-8. 2. Dill JE, Hill S, Callis J, Berkhouse L, Evans P, Martin D, et al. Combined endoscopic ultrasound and stimulated biliary VOLUME 60, NO. 5, 2004
News & Notices
3.
4.
5.
6.
7.
drainage in cholecystitis and microlithiasis: diagnosis and outcomes. Endoscopy 1995;27:424-7. Levy MJ. The hunt for microlithiasis in ideopathic acute recurrent pancreatitis: should we abandon the search or intensify our efforts? Gastrointest Endosc 2002;55:296-93. Dahan P, Andant C, Levy P, Amouyal P, Amouyal G, Dumont M, et al. Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography. Gut 1996;38: 277-81. Baig Z, Samad S, Yarema W, et al. Stimulated biliary drainage (SBD) in the detection of microlithiasis and chronic cholecystitis [abstract]. Am J Gastroenterol 1997;92:1630. Dill JE, Dill BP. Quality of life outcomes following endoscopic ultrasound for dyspepsia/unexplained upper abdominal pain. Acta Endoscopica 2000;30:231-5. Chathadi KV, Elta GH. Motility and dysmotility of the biliary tract. Semin Gastrointest Dis 2003;14:199-207. PII: S0016-5107(04)02020-6
Response: We appreciate the interest and comments of Dr. Dill and Ms. Dill regarding our study.1 The intent of our study was to determine whether there was an association between biliary crystals and sphincter of Oddi dysfunction (SOD). The 3.5% frequency of microlithiasis in patients with type II and type III SOD was similar to the 5% reported by Quallich et al.2 The low frequency of microlithiasis in our series has several potential explanations. We suspect there is some selection bias, because all patients in our study and those of Quallich et al.2 underwent sphincter of Oddi manometry. We would anticipate that the frequency of biliary crystals would be higher if patients with type I SOD (these patients have evidence of a structural disorder of the sphincter of Oddi) were investigated. The sensitivity of abdominal imaging also plays a role, because patients with any evidence of gallbladder sludge or small stones were excluded from our study. This was not a consecutive series of patients, and the decision to collect bile was at the discretion of the endoscopist. The number of patients who had bile salt dissolution therapy was unknown. Finally, the retrospective nature of our study further limited the strength of our conclusions. We agree that more outcome studies that address the response to sphincter ablation of patients with type II and type III SOD are warranted.3 We also applaud the efforts of Dr. Dill et al.4 to use EUS to evaluate the gallbladder as a source of pancreaticobiliary pain. Stuart Sherman, MD Evan Fogel, MD Lee McHenry, MD Glen Lehman, MD Division of Gastroenterology/Hepatology Indiana University Medical Center Indianapolis, Indiana REFERENCES 1. Rashdan A, Fogel E, McHenry L, Lehman G, Sherman S. Frequency of biliary crystals in patients with suspected VOLUME 60, NO. 5, 2004
sphincter of Oddi dysfunction. Gastrointest Endosc 2003;58: 875-8. 2. Quallich LG, Stern MA, Rich M, Chey WD, Barnett JL, Elta GH. Bile duct crystals do not contribute to sphincter of Oddi dysfunction. Gastrointest Endosc 2002;5:163-6. 3. Sherman S. What is the role of ERCP in the setting of abdominal pain of pancreatic or biliary origin (suspected sphincter of Oddi dysfunction)? Gastrointest Endosc 2002;56: S258-66. 4. Dill JE, Hill S, Callis J, Berkhonse L, Evans P, Martin D, et al. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis: diagnosis and outcomes. Endoscopy 1995;27:424-7. PII: S0016-5107(04)02021-8
NEWS & NOTICES 17th European Intensive Course of Endoscopy This course will be held December 6-7, 2004, in Strasbourg, France. Some of the topics to be covered include tumors of hepatic hilum, imaging techniques and therapeutic modalities in complications of hepato-biliary parasites, superficial lesions of the gut, and adenocarcinoma of the pancreas. For more information, e-mail [email protected]; phone 33-1-64-3333-33; fax 33-1-64-33-40-31. 4th Annual Essentials in Colorectal Diseases: A Course for the Practicing Physician This course will be held January 8-9, 2005, at the Naples Beach Hotel and Golf Club in Naples, Florida. It has been approved for AMA PRA credit. For more information, contact Cleveland Clinic Florida, Dept. of Continuing Medical Education, 6101 Pine Ridge Rd., Naples, FL 34119; phone 239-348-4366 or tollfree 877-675-7223 x4366; fax 239-348-4287; e-mail [email protected].
Update in Medicine 2005: Focus on Gastroenterology/Rheumatology—University at Sea This course will be held February 19-26, 2005 on a 7-day cruise of the Western Carribean. The agenda includes updates in GERD, IBD, IBS, hepatitis C, celiac disease, rheumatoid arthritis, osteoarthritis, new rheumatologic medications, osteoporosis, and other topics. The clinical faculty is from George Washington University. For more information, contact Continuing Education, Inc., 5700 4th Street GASTROINTESTINAL ENDOSCOPY
863
early termination of a prospective randomised trial. Eur J Cancer 1992;28A:1005-6. 8. Nishimura Y, Nagata K, Katano S, Hirota S, Nakamura K, Higuchi F, et al. Japanese Society for Esophageal Diseases. Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese society for esophageal diseases. Int J Radiat Oncol Biol Phys 2003;56:1327-32. PII: S0016-5107(04)02022-X
Response: We thank Dr. Azar for his comments regarding CRT and the placement of SEMS for palliation of patients with advanced esophageal carcinoma. We acknowledge that SEMS placement is associated with complications, especially in patients who survive for long periods. However, we disagree that SEMS placement should not be performed before RT or CRT has failed or is refused. There are some data that suggest that the frequency of severe complications is higher in patients who have RT or CRT before SEMS placement.1-3 In addition, we feel that the main goal of palliative treatment of patients with advanced esophageal carcinoma is to relieve dysphagia, an often distressing symptom. Rapid resolution of symptoms with minimal inconvenience to patients with a potentially short life expectancy is important. Dysphagia is more quickly relieved by SEMS placement than by RT.4 SEMS placement frequently can be performed as an outpatient procedure and quickly provides nutritional support in a more ‘‘physiologic’’ manner than PEG feeding. As stated in our case report, advances in SEMS technology should allow insertion of removable SEMS in selected patients. After CRT, redundant SEMS could be removed endoscopically from patients with a good response, thereby reducing the potential for complications. Adrian I. Thuraisingam, MRCP Arrowe Park Hospital Wirral, United Kingdom Howard L. Smart, FRCP Royal Liverpool University Hospital Liverpool, United Kingdom
REFERENCES 1. Klinsman KJ, DeGregorio BT, Katon RM, Morrison K, Saxon RR, Keller FS, et al. Prior radiation and chemotherapy increase the risk of life threatening complications after insertion of metallic stents for esophagogastric malignancy. Gastrointest Endosc 1996;43:196-203. 2. Siersema PD, Hop WC, Dees J, Tilanus HW, van Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study. Gastrointest Endosc 1998;47:113-20. 3. Bethge N, Sommer A, Kleist D, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy. Gastrointest Endosc 1996;44:283-6. 4. Cwikiel M, Cwikiel W, Albertsson M. Palliation of dysphagia in patients with malignant oesophageal strictures. Compari862
GASTROINTESTINAL ENDOSCOPY
son of results of radiotherapy, chemotherapy and esophageal stent treatment. Acta Oncol 1996;35:75-9. PII: S0016-5107(04)02023-1
Sphincter of Oddi manometry and bile crystals To the Editor: We read with interest the report of the study of Rashdan et al.,1 which found a low frequency of biliary crystals or microlithiasis,2,3 in a group of patients undergoing sphincter of Oddi manometry for suspected sphincter of Oddi dysfunction. That low proportion of patients with microlithiasis (3.5%) is in contrast to the higher percentage with microlithiasis (69%) in our study of patients with unexplained upper abdominal pain.2 Dahan et al.4 and Baig et al.5 also found higher percentages of microlithiasis (40% and 38%, respectively) in studies of patients with upper abdominal pain and negative transabdominal US examinations. Rashdan et al.1 offer some explanations for the low proportion of patients with microlithiasis in their patient population. We favor an explanation for the differences that is supported by outcomes data. It is extremely likely that the patients in our study and those of Baig et al.5 represent a different population group from that of Rashdan et al.1 This is based on the good clinical outcomes after cholecystectomy found in the former two studies. In a subsequent study,6 we documented good quality of life outcomes after cholecystectomy in patients with positive combined EUS and stimulated biliary drainage and otherwise unexplained upper abdominal pain. Rashdan et al.1 mention that many patients with suspected sphincter of Oddi dysfunction have undergone cholecystectomy. This is in keeping with the evidence that sphincter of Oddi dysfunction is a primary motor disorder in some patients7 and not necessarily associated with a structural change in the sphincter or with gallbladder disease. The experience of one of us (J.D.) with sphincter of Oddi manometry also is consistent with this view. Patients with suspected sphincter of Oddi dysfunction but normal manometry may have a nonbiliary etiology for their pain. The study by Rashdan et al.1 is certainly thought provoking. Clinical outcomes data for patients in their study who had abnormal manometric findings and who underwent endoscopic sphincterotomy would be most interesting. James E. Dill, MD, FACP Bobbie P. Dill BSN, RN, C Sioux Falls, South Dakota REFERENCES 1. Rashdan A, Fogel E, McHenry L Jr, Lehman G, Sherman S. Frequency of biliary crystals in patients with suspected sphincter of Oddi dysfunction. Gastrointest Endosc 2003;58: 875-8. 2. Dill JE, Hill S, Callis J, Berkhouse L, Evans P, Martin D, et al. Combined endoscopic ultrasound and stimulated biliary VOLUME 60, NO. 5, 2004
News & Notices
3.
4.
5.
6.
7.
drainage in cholecystitis and microlithiasis: diagnosis and outcomes. Endoscopy 1995;27:424-7. Levy MJ. The hunt for microlithiasis in ideopathic acute recurrent pancreatitis: should we abandon the search or intensify our efforts? Gastrointest Endosc 2002;55:296-93. Dahan P, Andant C, Levy P, Amouyal P, Amouyal G, Dumont M, et al. Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography. Gut 1996;38: 277-81. Baig Z, Samad S, Yarema W, et al. Stimulated biliary drainage (SBD) in the detection of microlithiasis and chronic cholecystitis [abstract]. Am J Gastroenterol 1997;92:1630. Dill JE, Dill BP. Quality of life outcomes following endoscopic ultrasound for dyspepsia/unexplained upper abdominal pain. Acta Endoscopica 2000;30:231-5. Chathadi KV, Elta GH. Motility and dysmotility of the biliary tract. Semin Gastrointest Dis 2003;14:199-207. PII: S0016-5107(04)02020-6
Response: We appreciate the interest and comments of Dr. Dill and Ms. Dill regarding our study.1 The intent of our study was to determine whether there was an association between biliary crystals and sphincter of Oddi dysfunction (SOD). The 3.5% frequency of microlithiasis in patients with type II and type III SOD was similar to the 5% reported by Quallich et al.2 The low frequency of microlithiasis in our series has several potential explanations. We suspect there is some selection bias, because all patients in our study and those of Quallich et al.2 underwent sphincter of Oddi manometry. We would anticipate that the frequency of biliary crystals would be higher if patients with type I SOD (these patients have evidence of a structural disorder of the sphincter of Oddi) were investigated. The sensitivity of abdominal imaging also plays a role, because patients with any evidence of gallbladder sludge or small stones were excluded from our study. This was not a consecutive series of patients, and the decision to collect bile was at the discretion of the endoscopist. The number of patients who had bile salt dissolution therapy was unknown. Finally, the retrospective nature of our study further limited the strength of our conclusions. We agree that more outcome studies that address the response to sphincter ablation of patients with type II and type III SOD are warranted.3 We also applaud the efforts of Dr. Dill et al.4 to use EUS to evaluate the gallbladder as a source of pancreaticobiliary pain. Stuart Sherman, MD Evan Fogel, MD Lee McHenry, MD Glen Lehman, MD Division of Gastroenterology/Hepatology Indiana University Medical Center Indianapolis, Indiana REFERENCES 1. Rashdan A, Fogel E, McHenry L, Lehman G, Sherman S. Frequency of biliary crystals in patients with suspected VOLUME 60, NO. 5, 2004
sphincter of Oddi dysfunction. Gastrointest Endosc 2003;58: 875-8. 2. Quallich LG, Stern MA, Rich M, Chey WD, Barnett JL, Elta GH. Bile duct crystals do not contribute to sphincter of Oddi dysfunction. Gastrointest Endosc 2002;5:163-6. 3. Sherman S. What is the role of ERCP in the setting of abdominal pain of pancreatic or biliary origin (suspected sphincter of Oddi dysfunction)? Gastrointest Endosc 2002;56: S258-66. 4. Dill JE, Hill S, Callis J, Berkhonse L, Evans P, Martin D, et al. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis: diagnosis and outcomes. Endoscopy 1995;27:424-7. PII: S0016-5107(04)02021-8
NEWS & NOTICES 17th European Intensive Course of Endoscopy This course will be held December 6-7, 2004, in Strasbourg, France. Some of the topics to be covered include tumors of hepatic hilum, imaging techniques and therapeutic modalities in complications of hepato-biliary parasites, superficial lesions of the gut, and adenocarcinoma of the pancreas. For more information, e-mail [email protected]; phone 33-1-64-3333-33; fax 33-1-64-33-40-31. 4th Annual Essentials in Colorectal Diseases: A Course for the Practicing Physician This course will be held January 8-9, 2005, at the Naples Beach Hotel and Golf Club in Naples, Florida. It has been approved for AMA PRA credit. For more information, contact Cleveland Clinic Florida, Dept. of Continuing Medical Education, 6101 Pine Ridge Rd., Naples, FL 34119; phone 239-348-4366 or tollfree 877-675-7223 x4366; fax 239-348-4287; e-mail [email protected].
Update in Medicine 2005: Focus on Gastroenterology/Rheumatology—University at Sea This course will be held February 19-26, 2005 on a 7-day cruise of the Western Carribean. The agenda includes updates in GERD, IBD, IBS, hepatitis C, celiac disease, rheumatoid arthritis, osteoarthritis, new rheumatologic medications, osteoporosis, and other topics. The clinical faculty is from George Washington University. For more information, contact Continuing Education, Inc., 5700 4th Street GASTROINTESTINAL ENDOSCOPY
863