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Hépato-Gastro & Oncologie Digestive

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Sphincter of Oddi dysfunction: pathophysiology, epidemiology, and therapeutic management Volume 30, issue 4, April 2023

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Authors
1 Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Pôle hépato-digestif, Service d’hépato-gastro-entérologie, 1 place de l’hôpital, 67000 Strasbourg
2 Institut Hospitalo-Universitaire de Strasbourg, Strasbourg
3 Université de Strasbourg, Faculté de médecine de Strasbourg, Inserm U1110, Institut de recherche sur les maladies virales et hépatique, Strasbourg
* Correspondance : P. Mayer

Biliary and pancreatic diseases comprise a rich and varied corpus of pathologies. A particular entity is the dysfunction of the sphincter of Oddi. It is a diagnosis of elimination and is difficult to identify. It is most common in cholecystectomised patients who present with recurrent biliary pain. An equivalent on the pancreatic side is responsible for recurrent episodes of pancreatitis.

The association of biliary or pancreatic pain, biological abnormalities ­(cytolysis and cholestasis or hyperlipasemia) and biliary or pancreatic duct dilatation on imaging allows the diagnosis of sphincter of Oddi dysfunction. It is always ­necessary to rule out the more common causes of biliary or pancreatic pain. Once the diagnosis has been made on clinical, biological and imaging grounds, sphincter of Oddi dysfunction is classified into three types according to the Milwaukee classification. This classification is used to guide therapy. The reference test is endoscopic manometry of the sphincter of Oddi, which measures the pressure in the biliary and/or pancreatic sphincters. Unfortunately, this type of test is ­invasive and carries a significant risk of iatrogenic acute pancreatitis (11%). Biliary scintigraphy can replace manometry if it shows a prolonged transit time of bile between the hilum and the duodenum. Unfortunately, there is no equivalent to scintigraphy for investigating pancreatic sphincter of Oddi dysfunction. Pancreatic MRI with injection of secretin, which stimulates pancreatic secretion, may be an alternative but needs further investigation.

Treatment of sphincter of Oddi dysfunction with biliary obstruction must be ­primarily medical. Trimebutine can be suggested as a background treatment. The use of nitrates should be reserved for painful crises. Calcium channel blockers have also been studied in this indication. If medical treatment fails and with the exception of type III sphincter of Oddi dysfunction according to the Milwaukee classification, endoscopic sphincterotomy has a good effect on pain and in many cases allows it to disappear. The management of sphincter of Oddi dysfunction with pancreatic expression is more complex. Medical treatment remains a first step, but if it fails, double biliopancreatic sphincterotomy does not eliminate the pain in a large number of cases. Moreover, in this specific indication, endoscopic cholangiopancreatography exposes the patient to a higher risk of acute pancreatitis than in other pathologies, which requires good patient information on the benefits and risks involved, a trained operator and, finally, the application of the usual means of preventing post ERCP pancreatitis.