Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction: effect of papillotomy

Abstract

Aim: To characterize functional biliary pain and other gastrointestinal (GI) symptoms in postcholecystectomy syndrome (PCS) patients with and without sphincter of Oddi dysfunction (SOD) proved by endoscopic sphincter of Oddi manometry (ESOM), and to assess the post-endoscopic sphincterotomy (EST) outcome.

Methods: We prospectively investigated 85 cholecystectomized patients referred for ERCP because of PCS and suspected SOD. On admission, all patients completed our questionnaire. Physical examination, laboratory tests, abdominal ultrasound, quantitative hepatobiliary scintigraphy (QHBS), and ERCP were performed in all patients. Based on clinical and ERCP findings 15 patients had unexpected bile duct stone disease and 15 patients had SOD biliary type I. ESOM demonstrated an elevated basal pressure in 25 patients with SOD biliary-type III. In the remaining 30 cholecystectomized patients without SOD, the liver function tests, ERCP, QHBS and ESOM were all normal. As a control group, 30 'asymptomatic' cholecystectomized volunteers (attended to our hospital for general cardiovascular screening) completed our questionnaire, which is consisted of 50 separate questions on GI symptoms and abdominal pain characteristics. Severity of the abdominal pain (frequency and intensity) was assessed with a visual analogue scale (VAS). In 40 of 80 patients having definite SOD (i.e. patients with SOD biliary type I and those with elevated SO basal pressure on ESOM), an EST was performed just after ERCP. In these patients repeated questionnaires were filled at each follow-up visit (at 3 and 6 mo) and a second look QHBS was performed 3 mo after the EST to assess the functional response to EST.

Results: The analysis of characteristics of the abdominal pain demonstrated that patients with common bile duct stone and definite SOD had a significantly higher score of symptomatic agreement with previously determined biliary-like pain features than patient groups of PCS without SOD and controls. In contrary, no significant differences were found when the pain severity scores were compared in different groups of PCS patients. In patients with definite SOD, EST induced a significant acceleration of the transpapillary bile flow; and based on the comparison of VASs obtained from the pre- and post-EST questionnaires, the severity scores of abdominal pain were significantly improved, however, only 15 of 35 (43%) patients became completely pain free. Post-EST severity of abdominal pain by VASs was significantly higher in patients with predominant dyspepsia at initial presentation as compared to those without dyspeptic symptoms.

Conclusion: Persistent GI symptoms and general patient dissatisfaction is a rather common finding after EST in patients with SOD, and correlated with the presence of predominant dyspeptic symptoms at the initial presentation, but does not depend on the technical and functional success of EST.

Figure 1

Flow chart of our patient selection and diagnostic strategy.

Figure 2

Abdominal pain characteristics in different postcholecystectomy patient groups based on the results of our questionnaire. Note that significant match of symptom characteristics with the predefined biliary type pain observed predominantly in patients with common bile duct stone and in patients with definite SOD. ^aP < 0.05 vs SOD negative PCS and controls.

Figure 3

Severity of abdominal pain (sum of frequency and intensity) determined by VAS in different postcholecystectomy patient groups. Note that patients with postcholecystectomy pain syndrome but without any objective signs of SOD (including negative ESOM/QHBS) have severity scores equivalent to those with common bile duct stone disease. ^aP < 0.05 vs control.

Figure 4

Comparison of the severity of dyspeptic symptoms (sum of frequency and intensity) determined by VAS in patients with definite SOD and in postcholecystectomy controls. Note that in patients with definite SOD, dyspeptic symptoms were rather frequent coexisting symptoms accompanied with typical biliary pain, although no significant differences detected as compared to “asymptomatic” cholecystectomized controls.

Figure 5

Effect of endoscopic sphincterotomy on the quantitative parameters of hepatobiliary scintigraphy in patients with definite SOD. Note that all parameters depicts significant improvement of the transpapillary bile flow after papillotomy. ^aP < 0.05 vs before EST.

Figure 6

Dramatic and significant symptomatic improvement of patients with definite SOD determined by the comparison of severity scores (sum of frequency and intensity) of abdominal pain before and after papillotomy documented on the questionnaires (VAS). ^aP < 0.05 vs before EST.

Figure 7

Effect of the severity of the concomitant dyspeptic symptoms in patients with biliary-type pain and definite SOD on the post-papillotomy outcome. ^aP < 0.05 vs those without dyspeptic symptoms.

Figure 8

Comparison of post-papillotomy quantitative hepatobiliary scintigraphic parameters in patient groups with different symptomatic outcome. Lack of statistically significant differences excluded endoscopic technical problems (incomplete papillotomy) in patients with poor symptomatic outcome and persisting biliary pain.