Diagnostic challenge of sphincter of oddi dysfunction in postcholecystectomy pain syndromes.

To the Editor: Persistent abdominal pain after cholecystectomy is not uncommon. An increasing number of laparoscopic cholecystectomies are contributing to the growing number of patients with postcholecystectomy recurrent pain syndromes. Sphincter of oddi dysfunction (SOD) is one of the causes for this entity. However, diagnosing SOD is often difficult. (1-4) Sphincter of oddi manometry (SOM) is the gold standard. Endoscopic retrograde cholangiopancreatography (ERCP) is another invasive procedure commonly used to diagnose this condition. Since these two modalities are invasive and are associated with complications, simple noninvasive imaging techniques are needed for the diagnosis of SOD, such as the quantitative hepatobiliary study (QHBS) by Sostre et al, (1) utilizing cholecystokinin and a scoring system.

We present our experience with all of these modalities in the diagnosis of SOD. It is a retrospective review of postcholecystectomy patients who presented with persistent abdominal pain and underwent QHBS, ERCP and SOM between 2003 and 2004. A total of 24 QHBS studies (22 patients) were identified. ERCP results were available for 13 patients. SOM was performed in 7 patients. There were 17 females and 5 males ranging in age from 17 to 78. There were a total of 19 QHBS studies performed using Sostre's protocol. Three out of nineteen had positive and 16/19 had negative QHBS scores. All three patients with positive QHBS also had positive ERCP, and one also had a positive SOM. When QHBS is positive there is a good correlation with ERCP and SOM. Out of the 16 negative QHBS studies, 8 had an ERCP, of which 4 were positive and 4 were negative. When QHBS is negative, however, there is only a 50% agreement with ERCP.

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In our review, most patients who had negative QHBS studies did not undergo further invasive gastrointestinal procedures and were followed conservatively. Hence, we have outlined appropriate steps to take for a diagnosis of SOD (Fig.).

In conclusion, diagnosis of SOD is difficult and challenging. Before considering more invasive procedures, simple noninvasive techniques are helpful. QHBS by Sostre is simple, noninvasive and easy to perform in the management of postcholecystectomy pain syndromes.

V. Vijayakumar, MD

E.G. Briscoe, BS, CNMT, ARRT

Nuclear Medicine Section, Department of Radiology, University of Texas Medical Branch, Galveston, TX

References

1. Sostre S, Kalloo AN, Spiegler EJ, et al. A Noninvasive test of sphincter of oddi dysfunction in post-cholecystectomy patients: The Scintigraphic score. JNucl Med 1992;33:1216-1224.

2. Ganatra RH, Rees J, Kerwat R, et al. Sphincter of Oddi dyskinesia: Role of cholecystokinin cholescintigraphy. Nucl Med Commun 2000;21:211-212.

3. Piecinni G, Angrisano A, Testini M, et al. Diagnosing and Treating Sphincter of Oddi Dysfunction: A Critical Literature Review and Reevaluation. J Clin Gastroenterol 2004;38:350-359.

4. Craig AG, Peter D, Sac cone GT, et al. Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction. Gut 2003;52:352-357.