Background: Sphincter of Oddi dysfunction (SOD) is one cause of post-cholecystectomy syndrome and is a diagnostic and therapeutic challenge. The Modified Milwaukee classification divides patients with SOD into three categories. Type I patients have biliary pain, elevated liver function tests, and a dilated common bile duct. Type II patients have biliary pain plus one or two of the type I criteria. Type III patients have biliary pain alone. After seeing several patients with sickle cell disease who had concomitant papillary stenosis and common duct stones, we modified the definition of type I biliary dysfunction (SOD) to include patients with biliary stones and papillary stenosis (PS). PS is a structural abnormality in which there is a narrowing of a part or of the entire sphincter due to chronic inflammation and fibrosis. This study is meant to elucidate a relationship between type I SOD, papillary stenosis, cholelithiasis, choledocholithiasis and the role of endoscopic sphincterotomy (ES).
Materials and Methods: From 1989 to 2004, 39 patients (11 male, 28 female) with type I SOD and PS were treated by the same endoscopist at Detroit Receiving Hospital. Patient age ranged from 10 to 84 years (mean 55.2 years). The average length of follow-up was 37.6 months.
Results: Thirteen patients required ES after cholecystectomy for continuous biliary pain and/or jaundice including 4 patients during same admission. Five patients had no common bile duct (CBD) or gallbladder stones. The remaining 21 patients had gallstones, CBD stones or both with their type I SOD and PS. All 39 patients had CBD dilatation (average 1.44 cm) and elevated liver function tests. Further, severe stenosis of the distal CBD (papillary portion) was noted in all patients. Endoscopic cannulation of the duct was difficult in 25 patients, and 11 patients required guide-wire ES or pre-cut. ES was performed successfully in 34 of 35 (97.1%) patients. Four patients did not have ES due to comorbidity. Overall there were no complications. All 34 patients who underwent ES achieved symptomatic resolution, including three patients with sickle cell disease where sludge and stones frequently recur after cholecystectomy.
Conclusions: PS plays a key role and should always be considered in patients with type I SOD. All of our patients with type I SOD also had endoscopic evidence of PS and cholecystectomy with or without CBD exploration was insufficient as treatment in some patients. ES is a safe and effective modality for treatment of this disease and should be considered in any patient with type I SOD, especially those with biliary stones.