Functional gall-bladder and sphincter of oddi disorders

Functional disorders of the biliary tree include gall-bladder dyskinesia and sphincter of Oddi dysfunction (SOD). Both present as recurrent epigastric and right upper quadrant pain reminiscent of biliary colic, in the absence of biliary stones. Gall-bladder dyskinesia is defined by an ejection fraction below 35% after slow infusion of a weight-based dose of cholecystokinin. The pathogenesis of pain is unclear; nevertheless, cholecystectomy is the therapy of choice. Data are mixed as to whether subnormal gall-bladder emptying predicts improvement after surgery in patients with pain of suspected biliary origin. SOD is defined as pain related to fixed or dynamic obstruction of the biliary or pancreatic ducts. It is commonly characterized by whether it involves the biliary and/or the pancreatic sphincter, and by the presence or absence of objective abnormalities of bile duct or pancreatic duct caliber or abnormalities of serum liver or pancreatic enzymes during pain. Diagnosis is classically made by manometric identification of basal sphincter pressures >40 mmHg during endoscopic retrograde cholangiopancreatography. SOD is treated by endoscopic sphincterotomy of the hypertensive sphincter(s). Prophylactic pancreatic stent placement is employed to reduce the risk of procedure-induced pancreatitis.