0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52
236 Biliary Tract Motility DisordersSpecific Diagnostic Tests
■SO manometry=gold standard; performed during ERCP; basal
pressure and phasic wave contractions recorded from the common
bile duct and pancreatic duct segments of the sphincter of Oddi
➣patients with SO stenosis have abnormally elevated basal SO
pressure (>40 mmHg) that does not relax following administra-
tion of smooth muscle relaxants
➣patients with SO dyskinesia also have elevated basal SO pressure
but the pressure decreases following amyl nitrite or glucagon and
increases paradoxically following CCK
➣Milwaukee classification system for SOD recognizes three types
of patients:
➣Type I patients have: a) pain associated with abnormal serum
aminotransferases; b) a dilated common bile duct >10 mm on
ultrasound or >12 mm on ERCP; and c) delayed drainage of con-
trast from the common bile duct after more than 45 minutes in
the supine position
➣Type II patients have one or two of the above 3 criteria
➣Type III patients have none of the above criteriaOther Tests
■Ultrasound accurate for gallstones and bile duct dilation; unex-
plained dilation of the common bile duct associated with SOD pre-
dicts a favorable response to sphincterotomy
■Hepatobiliary scintigraphy using technetium-99m labeled dyes may
reveal delayed biliary drainage; clearance rates in patients with SOD
overlap with those in a normal controls; scintigraphy may be falsely
positive in patients who have extrahepatic biliary obstruction, or
falsely negative in patients with intermittent bile flow obstruction.differential diagnosis
■Cholelithiasis, pancreatitis, chronic intestinal pseudoobstruction,
biliary or pancreatic malignancies, irritable bowel syndrome, peptic
ulcer disease and non-ulcer dyspepsia should be considered.management
What to Do First
■Exclude acute cholecystitis, pancreatitis and cholangitisGeneral Measures
■For severe attacks, admit the patient for hydration, NPO, analgesia;