The modified Milwaukee classification system is used to divide patients into three categories based on diagnostic criteria.
These categories are relevant to clinical practice in the utilization of diagnostic and therapeutic ERCP.
The diagnostic criteria includes:
1-biliary-type pain,
2-serum liver enzyme levels more than 1.1 times the upper limit of normal on one occasion
3-Bile duct dilation to greater than 10 mm.
Type I SOD:
patients experience pain accompanied by elevation of liver enzymes and biliary dilation.
Type II SOD:
patients have pain and either elevated enzymes or biliary dilation, but not both.
Type III SOD have biliary-type pain without bile duct dilation or abnormal liver enzymes.
Endoscopic manometry shows increase baseline press of the sphenter of Oddi ( over 40 mmHg).There is a significant risk of procedure related pancreatitis which can be reduced by placement of a prophylactic pancreatic stent.
For type I, ERCP and sphenterotomy is a successful treatment in 90% with 5% risk of pancreatitis after stent placement.
For type II, ERCP and sphenterotomy is a successful treatment in 60% with 15% risk of pancreatitis.
Many experts advocate empirical sphincterotomy for patients with SOD types I and II due to the high risk of complications in patients undergoing biliary manometry.
Because the response rate to sphincterotomy is less than 10% when the results of biliary manometry are normal (and 55% to 60% when the results are abnormal), biliary manometry is advocated before sphincterotomy for those with type III SOD.
Treatment with botullinum inj, TCA and nifidipine is unsatisfactory .
These categories are relevant to clinical practice in the utilization of diagnostic and therapeutic ERCP.
The diagnostic criteria includes:
1-biliary-type pain,
2-serum liver enzyme levels more than 1.1 times the upper limit of normal on one occasion
3-Bile duct dilation to greater than 10 mm.
Type I SOD:
patients experience pain accompanied by elevation of liver enzymes and biliary dilation.
Type II SOD:
patients have pain and either elevated enzymes or biliary dilation, but not both.
Type III SOD have biliary-type pain without bile duct dilation or abnormal liver enzymes.
Endoscopic manometry shows increase baseline press of the sphenter of Oddi ( over 40 mmHg).There is a significant risk of procedure related pancreatitis which can be reduced by placement of a prophylactic pancreatic stent.
For type I, ERCP and sphenterotomy is a successful treatment in 90% with 5% risk of pancreatitis after stent placement.
For type II, ERCP and sphenterotomy is a successful treatment in 60% with 15% risk of pancreatitis.
Many experts advocate empirical sphincterotomy for patients with SOD types I and II due to the high risk of complications in patients undergoing biliary manometry.
Because the response rate to sphincterotomy is less than 10% when the results of biliary manometry are normal (and 55% to 60% when the results are abnormal), biliary manometry is advocated before sphincterotomy for those with type III SOD.
Treatment with botullinum inj, TCA and nifidipine is unsatisfactory .
Of the following, which medication is most likely to increase the basal sphincter of Oddi pressure?
ReplyDelete1-Diazepam
2-Morphine
3-Midazolam
4-Meperidine
5-Verapamil
2 correct!
Numerous medications have been studied with respect to their effect on SOD because there are implications for the patient undergoing SOD manometry. Narcotics, such as morphine, stimulate the sphincter of Oddi and increase the basal pressure. Based on this observation, some experts advocate using morphine provocation tests to diagnose SOD. The exception is meperidine, which does not affect sphincter of Oddi pressure when used at a moderate dose (1 mg/kg). Calcium channel blockers such as verapamil relax the sphincter of Oddi. Diazepam does not affect sphincter of Oddi pressure, but midazolam may lower basal pressure in hypertensive sphincters and should be avoided when performing biliary manometry because it may confound results.
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