Abstract
Background
Acalculous biliary pain may be due to gallbladder dyskinesia or sphincter of Oddi (SO) hypertension. These two etiologies are difficult to differentiate because the gallbladder ejection fraction may be low and the SO manometry results may be abnormal in both. Cholecystectomy is advised for patients with biliary dyskinesia, but it often exacerbates biliary pain for patients with SO hypertension. The biliary pain response to relaxation of the SO using botulinum toxin may indicate appropriate treatment for patients with acalculous biliary pain.
Methods
The protocol-based management of 25 patients with acalculous biliary pain and two gallbladder ejection fraction estimations less than 40% who had 100 units of botulinum toxin injected into their SO musculature to relax the sphincter has been audited. Patients whose pain was temporarily relieved after botulinum toxin injection were offered endoscopic biliary sphincterotomy, and patients who failed to experience benefit after botulinum toxin injection were assessed for laparoscopic cholecystectomy.
Results
Botulinum toxin was injected into the SO of 25 patients, with 11 experiencing temporary biliary pain relief. Of these patients, 10 consented to undergo endoscopic biliary sphincterotomy, with relief of biliary pain in all cases. A total of 14 patients had a negative response to botulinum toxin treatment, with 10 of these patients progressing to laparoscopic cholecystectomy, which resulted in biliary pain relief in eight cases.
Conclusion
Botulinum toxin-induced relaxation of the SO may help to direct appropriate therapy for patients with acalculous biliary pain. The data from this study supports the establishment of a randomized clinical trial.
Similar content being viewed by others
References
Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J (2006) Functional gallbladder and sphincter of Oddi disorders. Gastroenterology 130:1498–1509
Rastogi A, Slivka A, Moser AJ, Wald A (2005) Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain. Dig Dis Sci 50:1391–1401
Gurusamy KS, Junnarkar S, Farouk M, Davidson BR (2009) Cholecystectomy for suspected gallbladder dyskinesia. Cochrane Database Syst Rev (1):CD007086
Yap L, Wycherley AG, Morphett AD, Toouli J (1991) Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterology 101:786–793
Sherman S, Lehman GA (2001) Sphincter of Oddi dysfunction: diagnosis and treatment. J Pancreas (Online) 2:382–400
Funch-Jensen P, Drewes M, Madacsy L (2006) Evaluation of the biliary tract in patients with functional biliary symptoms. World J Gastroenterol 12:2839–2845
Shaffer E (2003) Acalculous biliary pain: new concepts for an old entity. Dig Liver Dis Suppl 3:S20–S25
Canfield AJ, Hetz SP, Schriver JP, Hovenga TL, Cirangle PT, Burligame BS (1998) Biliary dyskinesia: a study of more than 200 patients and review of the literature. J Gastrointest Surg 2:443–448
Ozden N, DiBaise JK (2003) Gallbladder ejection fraction and symptom outcome in patients with acalculous biliary-like pain. Dig Dis Sci 5:890–897
Ahmed F, Fogel EL (2008) Right upper quadrant pain and a normal abdominal ultrasound. Clin Gastroenterol Hepatol 6:1198–1201
Pasricha PJ, Miskovsky EP, Kalloo AN (1994) Intrasphincteric injection of botulinum toxin for suspected sphincter of Oddi dysfunction. Gut 35:1319–1321
Wehrmann T, Seifert H, Seipp M, Lembcke B, Caspary WF (1998) Endoscopic injection of botulinum toxin for biliary sphincter of Oddi dysfunction. Endoscopy 30:702–707
Murray W, Kong S (2010) Botulinum toxin may predict the outcome of endoscopic sphincterotomy in episodic functional post cholecystectomy biliary pain. Scand J Gastroenterol 45:623–627
Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP (1989) The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter of Oddi dysfunction. N Engl J Med 320:82–87
LaFerla G, Gordon S, Archibald M, Murray WR (1986) Hyperamlylasaemia and acute pancreatitis following endoscopic retrograde cholangiopancreatography. Pancreas 1:160–163
Varadarajulu S, Hawes RH, Cotton PB (2003) Determination of sphincter of Oddi dysfunction in patients with prior normal manometry. Gastrointest Endosc 58:341–344
Drossman DA (2006) The functional gastrointestinal disorders and the Rome III process. Gastroenterology 130:1377–1390
Disclosure
William R. Murray has no conflicts of interests or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Murray, W.R. Botulinum toxin-induced relaxation of the sphincter of Oddi may select patients with acalculous biliary pain who will benefit from cholecystectomy. Surg Endosc 25, 813–816 (2011). https://doi.org/10.1007/s00464-010-1260-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-010-1260-2