The role of ERCP and its use in patients with post-cholecystectomy pain syndromes and recurrent idiopathic pancreatitis has been ever increasing over the last several years. Primarily has been the interest in the actions of the ampulla of vater and its associated muscle structures, and the possible role of motility dysfunctions of these muscle structures that may be a cause of pathology.

Utilizing a standard ERCP scope, and with the aid of specialized motility catheters, direct ampullary pressure measurements can now be obtained at the time of ERCP in such patients. With appropriate manometric findings, therapeutic sphincterotomy can then be carried out, thus cutting the muscles suspected and the cause of the dysfunction.

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Current Medical Literature on MRCP vs. ERCP

1. Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept. Guelrud M, Morera C, Rodriguez M, Jaen D, Pierre R Gastrointest Endosc 1999 Aug;50(2):194-9.
   BACKGROUND: The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition. METHODS: We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians. RESULTS: An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p less than 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild post-procedural pancreatitis. CONCLUSIONS: Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.
   
   
2. Diagnosis and treatment of sphincter of Oddi dysfunction Tzovaras G, Rowlands BJ, Br J Surg 1998 May;85(5):588-95
   Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives. METHODS: A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject. RESULTS AND CONCLUSION: Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.
   
   
3. Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction Eversman D, Fogel EL, Rusche M, Sherman S, Lehman GA Gastrointest Endosc 1999 Nov;50(5):637-41.
   Sphincter of Oddi manometry as performed at ERCP is the most accepted method to evaluate for sphincter of Oddi dysfunction. To fully assess for sphincter of Oddi dysfunction, both the pancreatic and the bile ducts must be evaluated. We assessed the frequency of pancreatic and biliary sphincter abnormalities in a large series of patients. METHODS: A total of 593 patients underwent manometry of the biliary and pancreatic ducts at one endoscopic retrograde cholangiopancreatography session. Basal sphincter pressure greater than or equal to 40 mm Hg was considered abnormal. Phasic waves were not evaluated. Manometric abnormalities were correlated with the clinical presentation as categorized using a modified Geenen/Hogan classification. RESULTS: Of 360 patients with intact sphincters, 18.9% had abnormal pancreatic sphincter basal pressure alone, 11.4% had abnormal biliary basal sphincter pressure alone, and in 31.4% the basal pressure was abnormal for both sphincters; thus, 60.1% of the patients had sphincter dysfunction. The frequency of sphincter of Oddi dysfunction did not differ whether typed by biliary or pancreatic criteria: approximately 65% type II and 59% type III. Of patients without pancreatitis, 55.9% had an abnormal basal sphincter pressure, whereas sphincter dysfunction was present in 72.3% of those with idiopathic pancreatitis and 53.9% of patients with chronic pancreatitis. Of patients with an ablated biliary sphincter, 45.9% had abnormal basal pancreatic sphincter pressure and only 0.6% had an abnormal biliary sphincter pressure alone. Abnormal pressure in both sphincters was found in 9.3%. CONCLUSION: If both portions of the sphincter of Oddi are studied simultaneously, abnormalities are found very commonly (55% to 72%). Assessment of both sides of the sphincter is necessary. Classifying patients according to both pancreatic and biliary sphincter segments is cumbersome, and may be replaced by an overall type. Using this modified classification, the frequency of sphincter of Oddi dysfunction is similar in both type II and type III patients (59% to 67%). invasiveness and flexibility are less onerous for patients. For the use of screening as well as scrutiny, MRCP has played an important role in diagnosing various pathologies in this field. The usefulness of MRCP is not limited to anatomical evaluations; it can also yield physiologic and functional information. From a cost-performance basis, MRCP is undoubtedly superior to direct methods. Coupled with a cutting-edge MR system, MRCP has the potential to limit the use of invasive transpapillary and percutaneous methods merely to interventional purposes. In the near future, the emergence of interventional MR scanners will make MRCP even more competitive, and the replacement will be accelerated.
   
   
4. Sphincter of Oddi manometry before and after laparoscopic cholecystectomy. Middelfart HV, Matzen P, Funch-Jensen P Endoscopy 1999 Feb;31(2):146-51
   In animal studies cholecystectomy has been found to alter the normal effect of cholecystokinin (CCK) on sphincter of Oddi (SO) function. This could be of importance with regard to the development of postcholecystectomy biliary pain. We therefore investigated the effect of laparoscopic cholecystectomy on SO motility before and after infusion with CCK. PATIENTS AND METHODS: A prospective study of SO motility, under basal conditions and during CCK (ceruletide) infusion, was carried out in eight women with uncomplicated gallstone disease, before and after laparoscopic cholecystectomy. RESULTS: Laparoscopic cholecystectomy increased common bile duct pressure (P = 0.01) and decreased the frequency of phasic contractions (P=0.05). However, the inhibitory effect of CCK was preserved as infusion of CCK was associated with a significant reduction in SO phasic amplitude and frequency, both before and after cholecystectomy. CONCLUSIONS: Following laparoscopic cholecystectomy an indisputable inhibitory effect of CCK in the SO was found. Common bile duct pressure increased and minor modifications in basal SO motility were seen.
   
   
5. The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of Oddi dysfunction Lin OS, Soetikno RM, Young HS. Am J Gastroenterol 1998 Oct;93(10):1833-6
   We sought to study the utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with Geenen class II sphincter of Oddi dysfunction. METHODS: We reviewed the clinical course and liver function test results of 24 Geenen-Hogan class II postcholecystectomy patients with biliary colic secondary to sphincter of Oddi dysfunction who did not undergo sphincter of Oddi manometry before treatment with endoscopic sphincterotomy. RESULTS: Twenty of the 24 patients had an average of 1.4 episodes of abnormal liver function tests associated with biliary colic; eight patients had dilated common bile duct on cholangiogram. Eighteen of the 20 patients with abnormal liver function tests (90%) were pain-free after sphincterotomy; in contrast, only one of four patients (25%) without liver function test changes responded to sphincterotomy. Fisher exact analysis showed that abnormal liver function tests was a significant predictor for favorable response to sphincterotomy with a two-tail p value of 0.018. Of the eight patients with bile duct dilatation, six (75%) responded favorably to sphincterotomy, whereas 13 of 16 patients (81%) without dilatation also responded to sphincterotomy. Analysis of common bile duct dilatation as a predictive factor showed no significance (p=1.00). CONCLUSIONS: We conclude that the occurrence of abnormal liver function tests during biliary colic may be used to select patients for endoscopic sphincterotomy. Sphincter of Oddi manometry may not be needed in these cases.
   
   
6. The role of sphincter of Oddi manometry in the diagnosis and therapy of pancreatic disease Kuo WH, Pasricha PJ, Kalloo AN. Gastrointest Endosc Clin N Am 1998 Jan;8(1):79-85
   Endoscopic manometry of the sphincter of Oddi (SO) is now an accepted technique in the diagnosis and therapy of biliary disease. Its role in the evaluation of pancreatic sphincter function for pancreatic diseases, however, is evolving. There are now preliminary data to suggest that pancreatic SO manometry may identify a subgroup of patients with pancreatic sphincter dysfunction that may benefit from endoscopic therapy. Further prospective clinical trials are sorely needed to evaluate the response of endoscopic therapy based on pancreatic SO basal pressure or pancreatic ductal pressure.
   
   
7. [Dysfunction of the sphincter of Oddi in cholecystectomy patients] Herman F, Delforge M, Bastens B, Masy V, Lilet H, Brassine A Rev Med Liege 1998 Apr;53(4):193-8
   Sphincter of Oddi dysfunction (SOD) is an obstructive syndrome of the papilla not resulting from a stone. It may cause recurrent biliary type pain to cholecystectomized patients. SOD is caused by sphincter dyskinesia or benign stenosis. Diagnosis is usually based on symptoms, serum biochemistry, endoscopic retrograde cholangiopancreatography and Sphincter of Oddi manometry. The latter is the best means of evaluating Sphincter of Oddi dynamics. However, because of the many inconveniences of Sphincter of Oddi manometry and of its high morbidity rate, it is seldom used. Non-invasive techniques, such as cholescintigraphy, have been developed to replace Sphincter of Oddi manometry in diagnosing SOD. Patients can be cured by sphincterotomy. Certain drugs could also be effective but few controlled studies have been carried out of date.
   
   
8. Ethanol inhibits sphincter of Oddi motility Tierney S, Qian Z, Lipsett PA, Pitt HA, Lillemoe KD, J Gastrointest Surg 1998 Jul-Aug;2(4):356-62
   Patients with alcohol-induced liver disease are at increased risk for pigment gallstones, which are known to be particularly associated with biliary stasis. Although the effects of ethanol on the sphincter of Oddi are thought to contribute to alcoholic pancreatitis, the precise effects of ethanol on the biliary component of the sphincter of Oddi are unclear. In the prairie dog the common bile and pancreatic ducts enter the duodenum separately, facilitating pressure measurement in the sphincter choledochus in isolation. We therefore used this model to test the hypothesis that ethanol administration alters sphincter of Oddi motility. Twenty-six male prairie dogs fed a nonlithogenic diet were studied. With the animals under alpha-chloralose anesthesia, a side-hole pressure-monitored perfusion catheter was positioned in the sphincter of Oddi and femoral arterial and venous catheters were placed. Sphincter of Oddi phasic wave frequency (F), amplitude (A), and motility index (MI = F x A) and arterial blood pressure were monitored at 10-minute intervals before (baseline), during 20-minute intravenous infusions of 15 mg/kg (n = 9), 150 mg/kg (n = 10), and 1.5 g/kg (n = 7) ethanol and for 20 minutes after ethanol infusion. The 15 mg/kg dose of ethanol had no effect, the 150 mg/kg dose tended to reduce sphincter of Oddi motility, and significant reductions in sphincter of Oddi amplitude and motility index were seen at the 1.5 g/kg dose. These data demonstrate that ethanol infusion inhibits both sphincter of Oddi amplitude and motility index and that this effect persists for at least 20 minutes following ethanol infusion. Ethanol may contribute to gallstone formation by altering biliary sphincter motility.
   
   
9. Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results Etzkorn KP , Diab F , Brown RD , Dodda G , Edelstein B , Bedford R , Venu RP Gastrointest Endosc 1998 May;47(5):363-7
   Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period. METHODS: Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry. RESULTS: The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures. CONCLUSIONS: ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.
   
   
10. Endoscopic biliary manometry in cholecystectomized patients with and without choledocholithiasis. Ugljesic M , Bulajic M , Milosavljevic T , Stimec B Hepatogastroenterology 1998 May-Jun;45(21):651-5
    Direct study of the function of the sphincter of Oddi became possible recently with the advent of endoscopic manometry. A dysfunction of the bilio-pancreatic sphincter apparatus has been implicated in some bilio-pancreatic disorders. The purpose of this study was to examine the relation between dysfunction of the sphincter of Oddi and the formation of common bile duct stones. METHODOLOGY: Endoscopic biliary manometry was performed on 45 cholecystectomized patients. Endoscopic retrograde cholangiography showed choledocholithiasis in 26 patients while 19 patients were free of common bile duct stones. Nine healthy subjects served as controls. RESULTS: Manometric investigation showed a significant increase in the percentage of retrograde phasic contractions of the sphincter of Oddi (SO) in patients with choledocholithiasis compared to the control group (p less than 0.05). Also, a significantly higher frequency of SO phasic contractions was found in the group of patients with choledocholithiasis when compared to the cholecystectomized group without common bile duct stones (p less than 0.05), but there was no difference when compared with the control group. Markedly increased SO basal pressure was found in 5 patients with choledocholithiasis as well as in one cholecystectomized patient without choledocholithiasis (greater than x + 3SD). However, the SO basal pressure, phasic SO pressure, amplitude and duration of the phasic contractions as well as the choledochal pressure did not differ significantly between the groups. CONCLUSIONS: This study demonstrates manometric abnormalities in the SO of patients with choledocholithiasis which suggests that SO dysfunction and pathophysiological mechanisms are related to the formation of common bile duct stones.
    
    
11. [Endoscopic treatment of dyskinesia of the Oddi's sphincter] Suarez Moran E Rev Gastroenterol Mex 1998 Oct-Dec;63(4 Suppl 1):S69-73
    Oddi sphincter dysfunction is manifested as a biliary- or pancreatic-type pain syndrome. At present, imaging studies are not very trustworthy for the diagnosis of this dysfunction, because of which direct endoscopic manometry offers the gold standard for confirming or ratifying the problem, supported by the Milwaukee Biliary Classification. Currently, the endoscopic approach has become the most effective alternative used for this type of diagnosis. Among the techniques may be found the following: endoscopic sphincterotomy, balloon dilation, the placing of biliary endoprostheses, and the injection of botulinic toxin in the Oddi sphincter. In our modest and short experience with six patients, of which five corresponded to group I of the Milwaukee bile classification, the above patients were treated successfully with sphincterotomy. The other two patients belonged to group type III of the Milwaukee classification, and were treated with botulinic toxin until the moment of a satisfactory response, for a period of 8 months.
    
    
12. Periampullary disorders: review of pathophysiology McGuire DE , Venu RP , Abu-Hammour A , Etzkorn KP , Brown RD Gastroenterologist 1995 Mar;3(1):20-7
    The ampulla of Vater is strategically located at the confluence of the terminal end of the bile duct and the pancreatic duct. It is entwined by smooth muscle fibers often referred to as the sphincter of Oddi. As a result, the ampulla demonstrates dynamic motor activity. A variety of structural and functional abnormalities can involve the ampulla and the periampullary region. Disorders involving the ampulla often produce remarkably similar clinical features, such as acute pancreatitis, biliary colic, or jaundice. Therefore, it is important that patients with periampullary disorders are systematically studied using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry, and endoscopic ultrasonography. Common disorders involving the periampullary region and state-of-the-art techniques for diagnosis and treatment of these disorders are discussed.
    
    
13. Sphincter of Oddi in health and disease Venu RP , Abu-Hammour A , Etzkorn KP , Logiudice JA Rev Gastroenterol Mex 1994 Apr-Jun;59(2):157-64
    Sphincter of Oddi (SO) is a dynamic structure located strategically at the confluence of the bile duct, the pancreatic duct and the duodenum. The advent of lateral viewing endoscope along with a minimally compliant pneumocapillary manometry system has greatly enhanced our ability to evaluate the SO in health and disease. These studies have shown that the SO motor function is a complex phenomenon controlled by a variety of neurohumoral agents. The sphincter also actively participates in the Migratory Motor Complex (MMC). The major function of the SO seems to be in regulating the flow of bile and pancreatic juice into the duodenum. By maintaining a basal tone, the sphincter diverts bile into the gallbladder under fasting conditions. On the other hand it functions as "a pump" as well to milk bile into the duodenum. Recent manometric studies also have unravelled a number of abnormalities involving the SO motor function often referred to as SO dysfunction. Most such patients respond favorably to sphincter ablation. Studies are underway to better define patients with SO dysfunction as well as to identify them using noninvasive investigations.

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