Right Upper Quadrant Abdominal Pain: Is It Sphincter of Oddi Dysfunction?

Educational Objectives

The goal of this program is to improve the management of sphincter of Oddi dysfunction. After hearing and assimilating this program, the clinician will be better able to:

1. Plan a diagnostic workup for patients presenting with right upper quadrant pain.

2. Use endoscopic retrograde cholangiopancreatography in the management of sphincter of Oddi dysfunction.

3. Choose treatment strategies for patients with sphincter of Oddi dysfunction types 2 and 3.

Summary

Differential diagnosis of right upper quadrant or epigastric pain: choledocholithiasis; recurrent acute pancreatitis; early chronic pancreatitis; peptic ulcer disease; dyspepsia; nonulcer dyspepsia; gastroparesis; focal pain of abdominal wall; irritable bowel syndrome (IBS); hepatic abscess; malignancy

Diagnostic workup: history — location of pain, presence of focal pain, and triggers (eg, food, movement); change in bowel habits; loss of weight; previous cholecystectomy (eg, date, presence of stones, effect on abdominal pain); medications (eg, opioid, tricyclic antidepressant, and other antidepressant agents); social history (eg, smoking, abuse of alcohol); physical examination — signs suggesting nonbiliary causes; localized or diffuse tenderness; location of tenderness; Carnett sign (pain unchanged or increased when patient tenses abdominal wall) suggests abdominal wall as source of pain; laboratory studies — liver function tests (LFTs) during and before or after episodes of pain; measurement of pancreatic enzymes; ultrasonography and computed tomography (CT) — view images rather than depend on report; determine diameter of common bile duct (normally ≈1 mm per decade; after cholecystectomy, possibly 1 to 2 mm larger than normal); presence of intrahepatic ductal dilation indicates true obstruction; look for signs of intestinal obstruction, masses, and chronic pancreatitis

Special procedures: consider upper endoscopy if appropriate symptoms present (eg, weight loss, early satiety); endoscopic ultrasonography (EUS) noninvasive test to image bile duct and pancreas; also consider endoscopic retrograde cholangiopancreatography (ERCP) with or without manometry, biliary scan, and study of gastric emptying

Choledocholithiasis: American Society of Gastroenterology (ASG) developed guidelines for risk; very strong risk factors stone revealed by ultrasonography, ascending cholangitis, and serum bilirubin >4 mg/dL; strong risk factors dilated common bile duct (>6 mm with intact gallbladder) and bilirubin 1.8 to 4 mg/dL; moderate risk factors elevation of LFTs other than bilirubin, older age, and clinically diagnosed gallstone pancreatitis; presence of one very strong risk factor or both strong risk factors indicates high likelihood of choledocholithiasis; absence of risk factors indicates low risk; risk intermediate in large number of patients; Adams et al (2015) found overall accuracy of ASG guidelines only 61%; make decision to test further according to overall clinical picture and discussion with patient

Sphincter of Oddi dysfunction (SOD): type 1 — aspartate aminotransferase (AST) level abnormal or alkaline phosphatase level >2 times normal, common bile duct dilated, and drainage of contrast during ERCP delayed >45 min; type 2 — ≥1 abnormalities in results of laboratory tests or imaging; type 3 — no abnormalities in results of laboratory tests or imaging; management — ERCP, sphincterotomy, and balloon sweep of common bile duct recommended for patients with type 1; manometry proposed for patients with types 2 and 3

Sphincter of Oddi manometry: pressure catheter inserted into common bile duct during ERCP; pressure measured during multiple sweeps of bile duct and sphincter; basal sphincter pressure ≥40 mm Hg associated with pain; sphincterotomy — may be recommended for patients with high pressure; patients with type 1 SOD (with or without high pressure) respond well; those with type 2 and high pressure tend to respond well; those with normal pressure less likely to respond; response in patients with type 3 SOD unknown

Controversies in management of SOD: agree-on definition of normal pressure lacking; manometry lacks reproducibility; clinical history and findings of manometry poor predictors of response to sphincterotomy (particularly in patients with type 2 and 3); complications of ERCP preclude liberal use of sphincterotomy; risk for post-ERCP pancreatitis high in patients with suspected SOD (study from University of Minnesota found incidence ≈20% compared with 10% in other patients); incidence of severe pancreatitis and organ damage high in patients with SOD; case series found sphincterotomy not effective in patients with type 3 SOD

Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial: randomized controlled trial of patients who had undergone cholecystectomy and had pain, normal or near-normal results of LFTs, and nondilated bile duct (majority SOD type 3); found rate of success in alleviating pain low; findings same for patients who underwent biliary sphincterotomy alone or dual sphincterotomy; results of manometry did not predict success; at 1-yr follow-up, sphincterotomy found not superior to sham procedure; risk for pancreatitis in patients undergoing sphincterotomy significant; conclusions — manometry not useful in these patients; no clinical features predict outcome; SOD type 3 should be abandoned as diagnosis

Patients previously diagnosed with SOD type 3: now considered to have chronic functional abdominal pain; differential diagnosis — gastroparesis, visceral hypersensitivity, narcotic bowel syndrome, chronic pancreatitis, and IBS; available noninterventional therapies — long-term management of pain with opioids not optimal; low-fat diet; diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (low-FODMAP diet); antispasmodic and tricyclic antidepressant agents; support and reassurance that malignancy not present; ERCP and/or sphincterotomy — should be considered for patients in whom other treatments unsuccessful; explain benefits (likely small) and risks (substantial) of ERCP to patients

SOD type 2: survey found 42% of gastroenterologists consider pathophysiologic mechanisms of SOD type 2 unclear; majority of remainder consider causes mechanical and functional; ≈33% perform manometry, ≈33% sphincterotomy, and ≈33% EUS or ERCP; risk, lack of reliable results, and lack of availability cited as reasons for not performing manometry

Clinical approach: determination of biliary vs nonbiliary source of pain — focus history on triggers, location, radiation, and time of pain (eg, nocturnal); consider SOD only in patients who have undergone cholecystectomy; note presence of stones in gallbladder, triggers of pain that led to cholecystectomy, and whether current pain resembles pain before cholecystectomy; biliary pain suggested by history — obtain LFTs and imaging; note trends in serial LFTs; speaker favors sphincterotomy in patients with type 1 and 2 SOD; advises EUS for patients without objective findings; performs ERCP only if intervention required (eg, presence of stones or sludge); less inclined to perform ERCP in patient with normal bile duct and pancreas; nonbiliary pain suggested by history — consider repeat endoscopy (to rule out peptic ulcer disease), gastric emptying study, and treatment for IBS; attempt — to elicit Carnett sign; long-term abdominal wall pain treated by injection of triamcinolone and bupivacaine into wall (rate of success in patients with Carnett sign high); ERCP may be performed in patients with signs and symptoms that suggest biliary pain

Illustrative case 1: 63-yr-old woman presents with right upper quadrant pain radiating to back for 2 yr; underwent ERCP with removal of stone in common bile duct 7 yr ago; unable to determine whether pain similar to original biliary pain; examination reveals tenderness in right upper quadrant; laboratory findings normal; CT reveals no biliary dilation; magnetic resonance cholangiopancreatography (MRCP) reveals common bile duct 8-9 mm (possible dilation); SOD type 3 likely; EUS reveals hyperechoic densities in common bile duct (suggesting sludge or small stones); ERCP reveals patent sphincterotomy; stones removed; pain relieved

Illustrative case 2: 42-yr-old woman with remote history of cholecystectomy (presence of stones and nature of pain unknown) has undergone multiple ERCPs because of pain and minor elevations in results of LFTs (sludge removed and symptoms improved); now presents with epigastric and right upper quadrant pain; episodic elevation of AST and alanine aminotransferase found; CT and MRCP reveal no common duct stones or strictures; ERCP reveals stricture of sphincterotomy; sphincterotomy extended; bile duct not dilated; procedure confers no relief

Readings

Adams MA et al: Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends. Gastrointest Endosc 2015 Jul;82(1):88-93; Cotton PB et al: Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA 2014 May;311(20):2101-9; Rabindra R et al: Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists. Endosc Int Open 2016 Sep; 4(9): E941–E946; Yaghoobi M et al: Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study. Endoscopy 2015 Oct;47(10):884-90. doi: 10.1055/s-0034-1392418. Epub 2015 Jul 10.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Kwon was recorded at the Gastroenterology Update: A Case-Based Approach to Common GI Problems, presented by the University of Michigan Medical School and held October 7-8, 2016, in Dearborn, MI. For information on the next Gastroenterology Update, please visit medicine.umich.edu. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS640101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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