Manometric biliary sphincter hypertension (BSH) in pancreas divisum

B. C. Pineau, P. R. Tamasky, W. Coyle, W. Knapple, J. T. Cunningham, R. H. Hawes, P. B. Cotton

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Abstract

A majority of patients with abdominal pain only undergoing minor papilla therapy for pancreas divisum (PD) fail to obtain clinical benefit. Biliary sphincter stenosis has previously been reported in patients with PD leading some authors to advocate routine choledochal sphincteroplasty in addition to minor sphincteroplasty when surgical therapy is contemplated.1 AIM: To determine the incidence of BSH in the setting of pancreas divisum. METHODS: Between July 1994 and December 1995, 57 patients with PD were referred for ERCP evaluation. Twenty nine patients who underwent biliary manometry to evaluate possible sphincter of Oddi dysfunction (SOD) were reviewed. Six patients were excluded (4 prior biliary sphincterotomy, 2 failed manometry). Of the remaining 23 patients (6M, 17F, age 17-72), 10 had recurrent acute pancreatitis (RAP), 2 prior acute pancreatitis (AP), 2 chronic relapsing pancreatitis, and 9 had abdominal pain only. Four patients had prior accessory papilla therapy and ten patients had a prior cholecystectomy(CCX) (2 mos-11 yrs interval). ERCP with SO manometry (SOW) using meperidine and midazolam sedation was performed using a water perfused triple-lumen catheter with one port sacrificed for aspiration. SOM was considered abnormal if basal SO pressure (BSOP) was ≥ 40 mmHg in both perfusion ports. RESULTS: BSH was identified in sixteen of 23 patients (70%). Ten of 15 patients (67%) with clinical pancreatitis (RAP,AP,CRP) vs six of eight (75%) with pain only had elevated biliary basal sphincter pressures. Nine of ten patients (90%) with prior cholecystectomy had SOD versus seven of 13 (54%) with gallbladder in situ. Biliary BSP ≥ 40 mmHg All Patients Post CCX No CCX AP,ARP,CRP 10/15(67%) 4/4(100%) 6/11(44%) Pain only 6/8(75%) 5/6(83%) 1/2(50%) Total 16/23(70%) 9/10(90%) 7/13(54%) SUMMARY: In this population of patients with PD, manometrically proven BSH was a frequent occurence. No obvious differences were seen between the different clinical presentations. CONCLUSION: Patients with PD have a high incidence of BSH which could contribute to their symptomatology. This may explain the lack of response to minor papilla therapy in patients with PD and pain only. Further studies are needed to assess whether endoscopic biliary sphincterotomy may be of benefit.

Original languageEnglish (US)
Number of pages1
JournalGastrointestinal endoscopy
Volume43
Issue number4
DOIs
StatePublished - Jan 1 1996

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology

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