Use of (99m)Tc-DISIDA biliary scanning with morphine provocation for the detection of elevated sphincter of Oddi basal pressure

Abstract

Background: Endoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive.

Aim: To investigate the role of (99m)Tc-DISIDA scanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with endoscopic biliary manometry.

Subjects and methods: A total of 34 patients with a clinical diagnosis of type II (n = 21) or III (n = 13) sphincter of Oddi dysfunction were studied. Biliary scintigraphy with 100 MBq of (99m)Tc-DISIDA was carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent endoscopic biliary manometry.

Results: Eighteen (nine type II, nine type III) of the 34 (53%) patients had sphincter of Oddi basal pressures above the upper limit of normal (40 mm Hg). In the standard DISIDA scan without morphine, no significant differences were observed in time to maximal activity (Tmax) or percentage excretion at 45 or 60 minutes between those with normal and those with abnormal biliary manometry. However, following morphine provocation, median percentage excretion at 60 minutes was 4.9% in those with abnormal manometry and 28.2% in the normal manometry group (p = 0.002). Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated sphincter of Oddi basal pressure by the morphine augmented DISIDA scan was 83% and specificity was 81%. Also, 14 of the 18 patients with abnormal manometry complained of biliary-type pain after morphine infusion compared with only two of 16 patients in the normal manometry group (p = 0.001).

Conclusions: (99m)Tc-DISIDA with morphine provocation is a useful non-invasive investigation for types II and III sphincter of Oddi dysfunction to detect those with elevated sphincter basal pressures who may respond to endoscopic sphincterotomy.

Figure 1

Time to maximal activity (Tmax) in patients with normal (group I) and elevated (>40 mm Hg) (group II) sphincter of Oddi basal pressure after ^99mTc-DISIDA scanning, with and without morphine provocation. The shaded box indicates the interquartile range and the vertical line the upper and lower adjacent values (the upper or lower quartile ±1.5 times the interquartile range).

Figure 2

Percentage of maximal activity cleared from the biliary system at 60 minutes (E60) in patients with normal (group I) and elevated (>40 mm Hg) (group II) sphincter of Oddi basal pressure after ^99mTc-DISIDA scanning, with and without morphine provocation. The shaded box indicates the interquartile range and the vertical line the upper and lower adjacent values (the upper or lower quartile ±1.5 times the interquartile range).