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Sphincter of Oddi Dysfunction - Risk Factors, Symptoms, Diagnosis, and Treatment

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Sphincter of Oddi dysfunction is a rare disorder characterized by pancreatitis and obstructive jaundice. The article presents its causes and treatments.

Medically reviewed byDr. Jagdish Singh
Published At October 20, 2022
Reviewed AtJune 14, 2024

Introduction:

The sphincter of Oddi is the smooth muscle lining the ends of the common bile duct and pancreatic duct. It allows the bile and pancreatic juice to flow into the intestine during food intake. The sphincter of Oddi dysfunctions is a rare issue and is often overlooked due to differential diseases.

A physiological restriction of pancreaticobiliary flow at the level of the sphincter of Oddi causes recurrent pancreatitis or chronic biliary discomfort, which is known as sphincter of Oddi dysfunction (SOD).

However, its identification and treatment can help improve a patient's quality of life. Some of the symptoms are pancreatitis, cholecystectomy, obstructive jaundice, and transaminitis. The treatment of choice for the disorder is reducing basal pressure and valve resistance. It occurs mainly in females aged between 20 and 50. In cases of pancreatitis, the prevalence of sphincter dysfunction is as high as approximately 72 percent.

Which Diseases Are the Risk Factors for Sphincter of Oddi Dysfunction?

Some of the diseases that can predispose the sphincter to Oddi dysfunction are,

  • Gallbladder Agenesis: A rare condition of congenital absence of gallbladder. Usually asymptomatic, it can lead to the sphincter of Oddi dysfunction.

  • Cholelithiasis: Also known as gallstones. These are hard deposits of digestive fluids formed in the gallbladder.

  • Cholecystectomy: Surgical removal of gallbladder due to severe inflammation or any infection.

  • Irritable Bowel Syndrome: Usually a large intestine disorder that causes abdominal pain, gas, bloating, diarrhea or constipation. In some severe cases, it can lead to dysfunction of the sphincter of Oddi.

  • Gallstone Lithotripsy: This is a non-surgical treatment procedure that is carried out when gallstones are very small and the gallbladder is functioning.

  • Liver Transplantation: The procedure replaces a diseased and damaged liver with a healthy liver from a living donor.

  • Hypothyroidism: Deficiency of some crucial thyroid hormones due to the production of hormones by the thyroid gland.

  • Alcohol Use Disorder: It is a chronic disorder characterized by uncontrolled consumption of alcohol.

What Is the Pathophysiology of the Sphincter in Oddi Dysfunction?

The main three functions of the sphincter of Oddi are regulating bile flow to the duodenum, promoting gallbladder filling between digestive cycles, and preventing reflux to the pancreatic or bile duct. The dysfunction can be due to sphincter stenosis or dyskinesia.

  • Sphincter Stenosis: Any trauma from the stone in the duct can lead to the narrowing of the sphincter.

  • Sphincter Dyskinesia: The alteration in sphincter function due to motility disorders and congenital syndromes.

What Are the Symptoms Observed in the Sphincter of Oddi Dysfunction?

  • In most cases, the patient complains of biliary pain, which is located in the right upper quadrant and epigastric and radiates to the back and shoulder.

  • The pain generally lasts 30 minutes to a few hours and resolves spontaneously.

  • The pain is followed by vomiting and nausea.

  • Recurrent pancreatitis can also be observed.

How to Evaluate the Sphincter of Oddi Dysfunctions?

  • Abdominal imaging, such as ultrasound or computed tomography scan, does not play many roles in identifying sphincters of Oddi dysfunction but helps to rule out other similar disorders.

  • Endoscopic Retrograde Cholangiopancreatography (ERCP) with manometry is the standard gold test for dysfunction of the sphincter of Oddi. The basal sphincter pressure on manometry required for diagnosing the sphincter of Oddi dysfunction is more than 35 (millimeter of mercury) mmHg to 40 mmHg.

  • The three diagnostic criteria used to classify sphincter of Oddi dysfunction are:

  • Common bile duct dilation (greater than 12 millimeter on ERCP and greater than 10 millimeter on ultrasound).

  • Transaminitis (greater than two times the upper limit of normal on two or more chances).

  • Biliary pain.

Depending on these three categories, the patients are classified as:

Type I Sphincter of Oddi Dysfunction: All three categories are present.

Type II Sphincter of Oddi Dysfunction: Biliary pain with any of the other two categories is present.

Type III Sphincter of Oddi Dysfunction: Only biliary pain is observed.

  • Laboratory Tests: They are also essential, such as comprehensive metabolic panel (CMP), lipase, and amylase, to evaluate hepato- pancreatic dysfunction.

  • Nardi Test: This is a functional test used to confirm the diagnosis of sphincter of Oddi dysfunction. It involves the simultaneous administration of morphine and neostigmine. Morphine causes biliary contraction, whereas neostigmine leads to contraction of the sphincter of Oddi. If the patient suffers from a sphincter of Oddi dysfunction, the forward pulsion of bile will produce the symptoms.

  • Biliary Scintigraphy: A noninvasive procedure performed after stimulation with cholecystokinin. The scoring is done in numerical values, where more than five scores are considered abnormal.

  • Secretin-Enhanced Magnetic Resonance Cholangiopancreatography(MRCP): The secretin hormone stimulates the secretion of pancreatic and hepatic juice. This helps visualize the pancreaticobiliary ductal anatomy better for MRCP. This technique is preferred as it overrules the complications of ERCP with manometry.

What Is the Treatment of Sphincter of Oddi Dysfunction?

  • The main motive for treating dysfunction is reducing basal pressure and resistance of the valve.

  • Noninvasive Methods: These include tricyclic antidepressants, glyceryl trinitrate, calcium channel blockers, and somatostatin.

  • Tricyclic Antidepressants: Amitriptyline, Norpramin, and Doxepin.

  • Calcium Channel Blockers: Amlodipine and Felodipine.

  • Somatostatin: Octreotide and Lanreotide.

  • Invasive Interventions: It includes Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy.

What Are the Complications of Sphincter of Oddi Dysfunction?

Problems with the sphincter of Oddi dysfunction management are typically connected to endoscopic examinations and ERCP. There is an inherent risk of perforation, anesthetic morbidities, and post-ERCP pancreatitis.

Which Diseases Possess Similar Symptoms With Sphincter of Oddi Dysfunction?

As stated earlier, the dysfunction of the sphincter of Oddi is considered a diagnosis of exclusion. Some of the diseases with symptoms similar as that of the sphincter of Oddi dysfunction are:

  • Choledocholithiasis - A minimum of one gallstone in the common bile duct.

  • Cholangiocarcinoma - Malignancy affecting the common bile duct.

Conclusion

Sphincter of Oddi dysfunction is characterized by pancreatitis, obstructive jaundice, and pain in the upper quadrant and epigastric region. Some of the common risk factors are gallbladder genesis, cholecystectomy, and irritable bowel syndrome. The treatment options include noninvasive modalities like the use of medications and invasive methods such as Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy

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Frequently Asked Questions

Sphincter of Oddi dysfunction is caused by scarring, strictures, spasm, or relaxation of the valve. Because of this, the pancreatic and bile juice can not flow in the forward direction resulting in the backup of digestive juices, which in turn results in severe abdominal pain.
The symptoms of sphincter of Oddi dysfunction include:
 
Severe pain in the abdomen.
Vomiting.
Nausea.
Diarrhea.
Chills. 
 
If the sphincter of Oddi dysfunction is left untreated, the sphincter will not relax properly, and the duct stays tightly closed or spasms, resulting in blocking the flow of the juice of the duodenum. The juices may back up and cause increased pressure inside the duct. This worsens the symptoms. 
Sphincter of Oddi dysfunction does not decrease the affected person’s life expectancy but can very much reduce his quality of life. People with severe cases of this condition may have a lower life expectancy.
Sphincter of Oddi dysfunction can be treated by following options:
 
Medicines - Calcium channel blockers and nitrates are helpful in alleviating symptoms. 
Endoscopic Therapy - this treatment option is used if medications are useful in relieving the symptoms.
The diagnosis starts by ruling out any other cause of abdominal pain. Then the doctor will perform a sphincter of Oddi manometry to examine the sphincter of Oddi. Other diagnostic tests include blood tests, ultrasound, ERCP (endoscopic retrograde cholangiopancreatography), and MRCP (magnetic resonance cholangiopancreatography).
The following foods should be avoided if suffering from sphincter of Oddi dysfunction:
 
Caffeinated drinks.
Chocolate.
Alcohol.
Fried and fatty food.
Spicy food.
Fibrous raw vegetables.
Red meat and pork.
Sphincter of Oddi dysfunction is a rare clinical condition often left undiagnosed and untreated, but when identified, the treatment options have the potential to improve the patient’s quality of life.
 
Magnesium is a natural muscle relaxant and has many health benefits. Magnesium sulfate is a calcium antagonist that may produce relaxation with or without contraction. It can be administered orally or through the intraduodenal route. 
The sphincter of Oddi is a muscle located in the second portion of the duodenum that allows the flow of bile and pancreatic juice between the pancreas and small intestine. To be specific, it is located around the exit of the bile duct and pancreatic duct in the duodenum.
 
Type 3 of the sphincter of Oddi dysfunction has no clear lab findings. The only sign of this type is abdominal pain. It is quite difficult to diagnose this type than other types and hence harder to treat. 
 
Alcohol ingestion plays a significant role in the sphincter of Oddi dysfunction. It may cause reflux of bile and activate enzymes and other substances in the pancreatic duct leading to inflammation of the pancreas and the sphincter.
 
Although the sphincter of Oddi dysfunction is mostly present in patients with their gallbladders removed. But there is increasing evidence of its existence in patients with the intact gallbladder.
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Dr. Jagdish Singh from iCliniq
Dr. Jagdish Singh

Medical Gastroenterology

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