Sphincter of Oddi dysfunction

Last revised by Henry Knipe on 14 Jan 2024

Sphincter of Oddi dysfunction is where a structural stenosis or dyskinesia of the sphincter of Oddi obstructs drainage from the common bile duct (CBD).

This disorder is also known as post-cholecystectomy syndrome and suspected functional biliary sphincter disorder 1,4.

The vast majority of affected patients are women.

The disorder presents with biliary-type abdominal pain or recurrent pancreatitis 1,6. It is most commonly diagnosed post-cholecystectomy for cholelithiasis or functional gallbladder disorder with persistent or worsening pain 1,6. It can be diagnosed without a prior cholecystectomy 1,6,7 but there is a very small evidence base for this 1.

The Milwaukee classification attempts to provide an anatomical basis to the clinical presentation 3,5 but was recommended to be abandoned by the Rome IV consensus (c.2016) 1 although remains in current use (c.2023) 7.

According to the Rome IV consensus, Sphincter of Oddi dysfunction is considered in patients with persistent biliary pain post-cholecystctomy with two conditions defined 1:

  • corresponds to Milwaukee type 1

  • benefit from sphincterotomy

  • corresponds to Milwaukee type 2 and incorporates post-cholecystectomy syndrome

  • diagnosis is based on the following three criteria being met with additional criteria providing further support of the diagnosis

    • Rome IV criteria for biliary pain

    • elevated liver enzymes or dilated bile duct, but not both

    • absence of bile duct stones or other structural abnormalities

    • supportive criteria

The CBD is often dilated (>8 mm). In the setting of prior cholecystectomy, this is not specific for sphincter of Oddi dysfunction. However, in the appropriate clinical context, namely biliary pain and normal liver function tests, a dilated bile duct is supportive of the diagnosis 1.

CT can also demonstrate dilated bile or pancreatic ducts. CT can be used to document recurrent attacks of acute pancreatitis.

MRCP may be used to exclude choledocholithiasis and other structural abnormalities, as the exclusion of these is required to diagnose biliary sphincter of Oddi dysfunction 1.

The static images and time-activity curves in a hepatobiliary scintigram (HIDA scan) can be evaluated in a semi-quantitative manner 2. With sphincter of Oddi dysfunction, there is increased time to hepatic peak, delayed biliary visualization, delayed clearance of radiotracer from the dilated bile ducts, and prolonged biliary to bowel transit.

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