Endoscopic Approach to the Patient with Motility Disorders of the Bile Duct and Sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Key points

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Sphincter of Oddi dysfunction (SOD) is a clinical syndrome with variable presentation that is characterized by pancreatobiliary pain and biochemical and radiographic abnormalities.
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The optimal method to diagnose SOD in symptomatic type II and III patients is manometry.
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Manometry should be conducted using standardized techniques.
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Therapeutic options for SOD include medical, surgical, and endoscopic modalities.
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If an endoscopic approach is chosen for suspected SOD, patients should be informed of the risk/benefit ratio, and the endoscopist should minimize the risk of complications.

Definition

Sphincter of Oddi dysfunction (SOD) refers to a clinical syndrome that occurs because of abnormal sphincter of Oddi (SO) contractility. As a result, flow of biliary or pancreatic juice is obstructed through a dyskinetic or stenotic SO. Pancreatobiliary pain, pancreatitis, abnormal liver function tests, or abnormal pancreatic enzymes are common characteristics of SOD. SO dyskinesia refers to a motor abnormality that is more commonly caused by a hypertonic than a hypotonic sphincter. In contrast, SO stenosis is a structural abnormality, probably from inflammation and subsequent fibrosis. These abnormalities are clinically indistinguishable and are grouped together as SOD. The Hogan-Geenen SOD classification system was designed to classify biliary-type pain ( Table 1 ). A pancreatic classification system has also been developed, but is less commonly used ( Box 1 ). Both systems have been modified since their initial design, because the measurements of biliary and pancreatic drainage times, which were originally criteria, have generally been abandoned. A variety of less accurate terms, such as papillary stenosis, biliary dyskinesia, and postcholecystectomy syndrome, are listed in the literature to describe this entity. However, postcholecystectomy syndrome is a misnomer, because SOD may occur with the gallbladder in situ.

Table 1

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