How the sphincter works and what is disrupted
The sphincter of Oddi regulates the flow of bile and pancreatic juice into the intestine and prevents the reflux of intestinal contents back into the ducts. There are two types of violation. In the functional version, the muscle contracts excessively, the spasm creates an obstacle, the pressure in the duct increases, and pain appears. With the structural variant, a cicatricial narrowing forms in the sphincter area after inflammation, passage of a stone, or intervention. Separately, there is a biliary type, when the outflow of bile is affected, and a pancreatic type, in which the outflow from the pancreas is disrupted and repeated pancreatitis is possible.
- Functional muscle spasm
- Structural scar narrowing
- Biliary type with pain in the right hypochondrium
- Pancreatic type with attacks of pancreatitis
- Increased pressure in the ducts as a cause of pain
Symptoms
The main symptom is attacks of pain in the right hypochondrium or in the upper abdomen, which last for at least half an hour, are repeated at different intervals and are not associated with body position, stool or taking medications that reduce acidity. The pain often radiates to the back and right shoulder blade, may be accompanied by nausea and vomiting, and often occurs at night or after fatty foods. Between attacks, the person usually feels normal. With the pancreatic type, the pain is girdling, and amylase increases in tests during an attack.
- Attacks of pain lasting half an hour
- Localization in the right hypochondrium or in the pit of the stomach
- Recoil to the back and right shoulder blade
- Nausea and vomiting at the height of pain
- Association with fatty foods, attacks at night
- Feeling good between attacks
Why does it occur after gallbladder removal?
The gallbladder serves as a reservoir that smoothes out pressure fluctuations in the ducts. After its removal, this buffering function is lost, and any excessive contraction of the sphincter is immediately reflected by increased pressure and pain. In addition, before the operation, some people already had biliary motility disorders, which the operation does not eliminate. This is why pain after cholecystectomy persists or returns in a significant proportion of patients. However, before explaining them to the sphincter, it is imperative to exclude an abandoned or newly formed stone in the duct.
- Loss of bladder reservoir function
- Initial ductal motility disorders
- Retained or new stone in the common bile duct
- Scar changes after inflammation
- Associated functional bowel disorders
Diagnostics
The key to diagnosis is examination during an attack: liver enzymes, bilirubin and amylase are determined, because their temporary increase with a return to normal confirms the connection of pain with outflow disorders. Ultrasound examination allows you to evaluate the diameter of the common bile duct and exclude stones. If there is insufficient clarity, magnetic resonance cholangiography or endoscopic ultrasound examination is performed. Sphincter manometry is rarely used and only in specialized centers, since it itself can provoke pancreatitis.
- Liver enzymes and bilirubin during an attack
- Blood amylase and lipase
- Ultrasound assessing the diameter of the bile duct
- MR cholangiography
- Endoscopic ultrasound
- Gastroscopy to exclude peptic ulcer
Treatment
They start with a conservative approach: split meals with limited fatty and fried foods, giving up alcohol, normalizing weight. The doctor may prescribe antispasmodics, and when combined with functional intestinal disorders, drugs that affect motility and pain perception. Endoscopic dissection of the sphincter really helps, but only with a proven outflow disorder with changes in tests and dilation of the duct; with unconfirmed dysfunction, the effect is questionable, and the risk of pancreatitis is real. Therefore, the decision about this intervention is made carefully and in a specialized center.
- Small meals, limiting fatty foods
- Quitting alcohol, losing weight
- Antispasmodics as prescribed by a doctor
- Treatment of associated bowel disorders
- Endoscopic papillosphincterotomy according to strict indications
- Observation by a gastroenterologist over time