Approach to Biliary Pain

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Approach to Biliary Pain – A Medical Student Clinical Pearl

Katie Oxford, Med III

Reviewed by: Dr. Colin Rouse

Copyedited by: Dr. Mandy Peach

Case

Mr. X is a 20-year-old male, who has presented to the ER on multiple occasions with RUQ pain. This pain was constant, severe (8/10), and was exacerbated by eating. This pain started a few months ago, is not radiating, and is variable in duration. The patient had become increasingly frustrated due to multiple trips to the ER.

The patient has had no vomiting or nausea, no change in bowel movements. On review of systems, no abnormalities are noted. Vitals are stable.

Investigations:

On ultrasound and CT done during prior visits no gallstones were present within the gallbladder or within the biliary tree, but the common bile duct was dilated. The gallbladder appears normal on all imaging studies performed thus far, however the patient continues to have pain.

On physical exam, there were no concerns on inspection (no scars, visible masses, signs of liver disease, ascites). Normal bowel sounds were heard, and the abdomen was soft and non-tender on palpation. Murphy’s sign was negative. LFT’s, amylase and lipase studies were normal.

Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD) is within the differential diagnosis for patients who present with recurrent biliary pain, with no apparent source 1. This disease process can present with biliary as well as pancreatic obstructive symptoms 2. There are multiple propositions as to the pathogenesis of this disease; it may be due to stenosis at the ampulla, or it could be caused by sphincter of oddi hypertension (either due to hypertrophy, or increased smooth muscle response to stimuli) 2.

Rome IV criteria for functional biliary sphincter of Oddi disorder5:

●Criteria for biliary pain are fulfilled

●Absence of bile duct stones or other structural abnormalities

●Elevated liver enzymes or dilated bile duct, but not both

 

Supportive criteria include

●Normal amylase/lipase

●Abnormal sphincter of Oddi manometry

●Abnormal hepatobiliary scintigraphy

 

It is important to avoid invasive testing in patients with suspected SOD, as their risk for post-ERCP pancreatitis is high 2.

There are several methods that can be used to assess patients for SOD:

Endoscopic ultrasound
Transabdominal ultrasound
MRCP
Hepatobiliary Scintigraphy (HIDA) can be used to evaluate patients for SOD. 2

Additionally, cholecystokinin or secretin can be used in conjunction with the above tests in order to provoke the dysfunction 2

Back to our case:
In a case of RUQ pain, there are a few disease processes to keep in mind 3:

Differential Diagnoses:
• Cholecystitis
• Cholelithiasis
• Cholangitis
• Colitis
• Diverticulitis
• Abscess
• Hepatitis
• Mass
• Pneumonia
• Functional Gallbladder Disorder
• Abscess
• Embolus
• Nephrolithiasis
• Pyelonephritis

Because Mr. X had pain that resembled biliary colic very closely, yet multiple previous imaging studies and lab studies showed no signs of acute cholecystitis,  cholelithiasis, pancreatitis, or liver disease, it was thought that perhaps sphincter dysfunction could be the root cause of the problem.

HIDA Scans:

Hepatobiliary Scintigraphy (HIDA) is a nuclear medicine procedure involved IV injection of a radiotracer which is excreted into the biliary system. This allows for the visualization of the bilirubin metabolic pathway and can be used to diagnose various biliary pathologies 4

After discussion with the patient and reassurance, a HIDA scan was ordered in order that confirmed suspicions of SOD.

Management 6:

The goal is to relieve pain. There are 3 main approaches:

  1. pharmacological: calcium channel blocker and nitrates to reduce basal sphincter of oddi pressure and relaxation of the sphincter.
  2. endoscopic sphincterotomy: particularly beneficial in those with elevated sphincter of oddi pressure
  3. surgical sphincterotomy

The patient was referred to gastroenterology and initiated on a calcium channel blocker in the interim.

References:

 

  1. Bistritz L, Bain VG. Sphincter of Oddi dysfunction: Managing the patient with chronic biliary pain [Internet]. Vol. 12, World Journal of Gastroenterology. WJG Press; 2006. p. 3793–802.
  2. Small AJ, Kozarek RA. Sphincter of Oddi Dysfunction. Vol. 25, Gastrointestinal Endoscopy Clinics of North America. W.B. Saunders; 2015. p. 749–63.
  3. Cartwright SL, Knudson MP. Evaluation of Acute Abdominal Pain in Adults [Internet]. Vol. 77, American Family Physician. 2008 Apr.
  4. Snyder E, Kashyap S, Lopez PP. Hepatobiliary Iminodiacetic Acid Scan [Internet]. StatPearls. StatPearls Publishing; 2021.
  5. Cotton, P. B., Elta, G. H., Carter, C. R., Pasricha, P. J., & Corazziari, E. S. (2016). Rome IV. Gallbladder and Sphincter of Oddi Disorders. Gastroenterology, S0016-5085(16)00224-9. Advance online publication. https://doi.org/10.1053/j.gastro.2016.02.033
  6. Catalano, M. F, Thosani, N. (2021). Treatment of Sphincter of Oddi Dysfunction. Retrieved from UptoDate https://www.uptodate.com/contents/treatment-of-sphincter-of-oddi-dysfunction?search=sphincter%20of%20oddi%20dysfunction%20treatment&source=search_result&selectedTitle=1~136&usage_type=default&display_rank=1

 

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