Biliary motor dysfunction

Introduction to biliary dysfunction Biliary tract dysfunction (biliarytractdyskinesissyndrome) includes dysfunction of biliary dysfunction (dysinesis), abnormal biliary tone (dystonia, abnormal biliary muscle tone) and biliary ataxia (ataxic) ). basic knowledge Sickness ratio: 0.0001% Susceptible people: no specific population Mode of infection: non-infectious Complications: diarrhea, abdominal pain

Causes of biliary motility dysfunction

(1) Causes of the disease

1. Gallbladder motor function enhancement These dysfunctions are generally associated with allergic reactions of the gallbladder or gallbladder inflammation.

(1) gallbladder motor hyperfunction: normal gallbladder tension, but hyperactive movement of the fat meal, so the gallbladder emptying accelerated, 15 minutes after the meal, most of the emptying.

(2) Gallbladder tension is too high: the muscle tension of the gallbladder is too high, but the emptying time is not affected, it can be normal, accelerate or delay.

2. Gallbladder motor function is reduced

(1) Gallbladder motor function decline: normal gallbladder tension, but postprandial contraction is weakened, and emptying is slow.

(2) decreased gallbladder tension and decreased motor function: when the fasting, the gallbladder tension is reduced, the volume is increased, and the emptying after meals is slow.

3.Oddi sphincter dysfunction

(1) Oddi sphincter tension is too low: gallbladder filling is poor when gallbladder angiography.

(2) Oddi sphincter spasm: mostly due to mental factors, but can also be secondary to lesions in adjacent organs, such as papillitis, duodenitis, bulbar ulcers, duodenal parasites such as Giardia, Nematode infections, etc.

(two) pathogenesis

Biliary system (32%):

Basis of biliary system movement The anatomical structure of the intrahepatic and extrahepatic biliary system is as follows: bile ducthexel tube interlobular bile ducthepatic ducthepatic duct gallbladdercabiliary tubecholedochal pancreatic ductduodenum, biliary system acceptance The bile secreted by the liver functions as a storage, concentration and transporter, and regulates the rate at which bile enters the upper small intestine. This process can be affected by many factors inside and outside the body and can cause dysfunction of the biliary system.

Oddi sphincter (20%):

The Oddi sphincter consists of three parts, namely the common bile duct sphincter, the pancreaticobiliary sphincter and the ampullary sphincter. The ampulla sphincter is the ring muscle, the other two parts have both the ring muscle and the oblique muscle, and the gallbladder wall smooth muscle is divided into the inner longitudinal and outer rings. Two layers; the common hepatic duct, the cystic duct also has some smooth muscles, but much less than the common bile duct and gallbladder, its role in bile flow is not consistent; the pancreatic duct forms a biliary and pancreas in the submucosal submucosa , about 2 ~ 17mm, through the nipple opening in the duodenum descending segment, a few people do not meet the pancreatic duct and the common bile duct, but open in the duodenum.

Bile flow in the extrahepatic biliary tract (13%):

The bile flow of the extrahepatic biliary tract conforms to the principle of fluid mechanics. The pressure is equal to the flow velocity multiplied by the resistance. Therefore, when the pressure is relatively fixed, the resistance increases and the flow velocity slows down. The resistance in the biliary system is largely related to the Oddi sphincter tension. The sphincter pressure exceeds 10 to 30 mmHg of the biliary tract. In the contraction of 2 to 8 times/min, the pressure can reach 100 mmHg. Some of the aforementioned distal biliary system structures generate a certain pressure and determine the flow of bile from the bile duct into the duodenum or gallbladder, or Temporarily stored in the biliary tract, stones and their damage and other damage can also affect the bile into the gallbladder.

2. Factors affecting the motor function of the biliary system The movement of the biliary system is affected by various factors in and out of the body. Under normal circumstances, the bile flow in the extrahepatic biliary tract can be affected by some of the following internal factors:

(1) Pressure of liver bile secretion, pressure in the bile duct.

(2) The amount of liver bile.

(3) Degree of biliary closure.

(4) Gallbladder wall elasticity, gallbladder muscle tension and contraction function.

(5) Gallbladder concentrating function, bile viscosity.

(6) Tension and reactivity of the bile duct sphincter.

(7) Tension and movement of the duodenal wall.

(8) Closure of the duodenal papilla.

(9) Effects of digestive tract peristalsis and other parts of the digestive tract on the biliary system.

(10) release amount of cholecystokinin, transport efficiency and inactivation rate, and the like.

Among the above complex and interrelated factors, some factors are particularly important, including:

1 bile secretion pressure and Oddi sphincter resistance are important factors in determining biliary function.

2 The gallbladder regulates the pressure of the extrahepatic biliary tract, and its shape and volume change with the pressure in the bile duct tree.

3 The gallbladder receives thin bile and slowly enters it, and concentrates and stores it.

4 After the normal gallbladder is stimulated by a fat meal, the concentrated bile can be discharged halfway within 15 minutes.

5 After the gentle and continuous compression of the gallbladder area, the gallbladder can be emptied, but suddenly press hard,

6 After removing the functional gallbladder, the common bile duct can undergo a certain degree of expansion.

The amplitude, duration and frequency of the gastrointestinal tract peristalsis are also closely related to the bile duct base pressure and bile flow. However, after the peristaltic impulse exceeds a certain value, the frequency increase or duration may not promote bile flow, or even May make it slow down.

Many hormones and peptides have an effect on the Oddi sphincter. The effect of cholecystokinin on the sphincter is extensive. It can make the gallbladder contract, reduce the tension and contraction amplitude of the Oddi sphincter including the pancreatic sphincter, and the secretin has no effect on the biliary sphincter. It has obvious effects, but it has an inhibitory effect on the pancreatic sphincter, while the biliary sphincter only exerts an inhibitory effect at the drug dose. In addition, the hormones and peptides studied by animal experiments have gastrin, pentagastrin, Histamine and prostaglandin E1, histamine and prostaglandin E1 all reduce the contractile viability of sphincters. Prostaglandin E2, motilin and bombesin have similar effects. Serotonin and endorphin are different in different parts of Oddi sphincter. The role.

The study of the effects of some drugs on sphincters, butyl anisodamine can block the contractile activity of sphincters and reduce the basal pressure; sublingual nitroglycerin can reduce the basal pressure and contraction amplitude of sphincters, but not reduce the frequency; morphine increases both contraction The frequency also increases the basal pressure; pentazocine (analgesic new) only increases the basal pressure, while buprenorphine (buprenorphine) has no effect on the sphincter; pethidine reduces the frequency of contraction; Nitrate activity has no effect; for Oddi sphincter dyskinesia, nifedipine (heart pain) can reduce the various activities of the sphincter, but not for normal people; local biliary tract perfusion of ethanol can significantly increase the base pressure, but ethanol The effects of entering the body via the stomach and the intravenous route are different, and the above results and the effects of other drugs.

Prevention of biliary motility dysfunction

Treatment and prevention of related diseases that cause biliary dysfunction.

Biliary dysfunction complication Complications, diarrhea, abdominal pain

The disease may have complications such as diarrhea and abdominal pain.

Symptoms of biliary dysfunction dysfunction common symptoms jaundice anorexia nausea appetite decreased appetite loss bloating limbs cold limb gallbladder wall fibrosis gallbladder contractile dysfunction

The disease is more common in women, its clinical manifestations are very similar to gallstones, mainly for abdominal pain, paroxysmal cramps in the upper abdomen or right upper abdomen, some patients may be accompanied by nausea, vomiting, can be induced by eating greasy food, often lasting 2 ~3h, the symptoms are relieved after the antispasmodic drug.

1. The core symptom of painful biliary tract disease is pain. The pain can be caused by the dilated common bile duct, but the pain is often located in the upper abdomen and right rib. It can also be located in the lower sternum, interscapular region, or even under the back. Pain and diet. Irrelevant, but it can also occur after a meal. The pain may also be caused by Oddi's sphincter spasm. Its nature and location are similar to those of biliary colic, but the attack time is short, only a few minutes to half an hour, and the number of episodes is more, one day. Multiple times; seizures and mental factors such as anxiety, nervousness, emotional instability, etc.; inhalation of isoamyl nitrite or sublingual nitroglycerin 0.6mg, the pain can be quickly stopped; morphine 10mg subcutaneous injection can induce pain; Right upper abdominal pain caused by fever or jaundice, esophagus, small intestine, large intestine or heart disease can also be mistaken for biliary pain. Except for acute inflammation, physical signs are not helpful for judging biliary motility disorders.

2. Symptoms of dyspepsia include loss of appetite, hernia, upper abdominal fullness and other symptoms of upper abdominal discomfort.

3. The greasy food is characterized by reduced tolerance to fatty foods. Some patients cannot tolerate fried foods or high-fat diets, and may have symptoms such as diarrhea and abdominal pain.

4. Signs of upper abdominal or upper right abdomen tenderness, Murphy sign can be positive, it is generally believed that it is associated with increased pressure in the bile duct and inflammation of the bile duct.

Examination of biliary dysfunction

Liver function and pancreatic enzyme examination: abdominal pain, alkaline phosphatase and transaminase increased significantly, and no abnormal findings of cholangiography suggest that there may be Oddi sphincter dysfunction, but in fact the clinical situation is not so typical, liver function Mild damage is neither specific nor sensitive, and even with morphine and neostigmine, typical pain is often inconsistent with impaired liver function and elevated pancreatic enzymes.

1. Imaging examination

(1) Gallbladder angiography: In the fasting state, the shape and volume of the gallbladder and the rate of gallbladder emptying after fat meal can reflect the comprehensive effects of various factors controlling bile flow, thus providing a basis for determining whether the function of the biliary system is normal. After a certain condition of gallbladder imaging examination, the volume of gallbladder can be calculated. After 2 to 3 days of low-fat diet, 6 tablets of pantoiodic acid tablets are taken. After 14 hours, gallbladder spots are taken in the fasting state, and the patient takes the right position immediately. Photograph and develop, then take the left anterior oblique film separately when the tube is 50cm and 100cm away from the film; then, mix the 3 egg yolks into 200ml whole milk, add a spoonful of sugar and take it orally (Boyden test), right After 15 minutes of lying, take 15 minutes and 60 minutes after the meal, and then use the transparent paper to trace the gallbladder shadow, and then put it on the paper with special lines. The gallbladder shadow is divided into many segments, and the diameter of each segment is measured. The corresponding volume, the sum of the volume of each segment is the total volume, and the correction factor (correction factor) can be calculated for the purpose of eliminating the error.

In the fasting state, the normal gallbladder is mostly pear-shaped, a few are spherical, the average volume is 32ml±5ml, the volume after 15min is 16ml±3ml, and 60min is 8ml±2.5ml. According to this, the volume is 32ml±5ml. The tension in the shape of pear or sphere is normal tension, and the gallbladder volume is reduced by 50% and 75% at 15 min and 60 min after fat meal, respectively, indicating that the gallbladder contraction and motor function are normal.

The shape and volume of the gallbladder on an empty stomach depends on: the amount of hepatobiliary secretion; the pressure of hepatic bile secretion; the permeability of the hepatic duct, cystic duct and common bile duct; the internal pressure of the common bile duct; the resistance of the Oddi sphincter; the tension of the gallbladder and Dilatation; the ability to concentrate the gallbladder mucosa.

The rate of gallbladder emptying after fat meal depends on: the formation of a sufficient amount of cholecystokinin; the absorption and transport of cholecystokinin by blood flow; the contractile capacity of gallbladder muscle; the viscosity of bile; the permeability of bile duct; Oddi sphincter Relaxation.

(2) retrograde cholangiopancreatography: retrograde cholangiopancreatography is the best examination method for the secretion of bile and pancreatic juice. It can be confirmed whether there is mechanical or organic change, but it is of little value in confirming motor dysfunction. Oddi sphincter Abnormal function is not easy to be found by this examination. It is suggested that the prone position should be taken after retrograde cholangiopancreatography. The delay of the patient's contrast agent efflux (more than 45 minutes) can be used as a means of judging the disorder of bile emptying, but due to the contrast agent. The amount of injection and the interference of factors such as pre-existing drugs have not yet been unified, and its value needs further discussion.

(3) Radionuclide scanning: Nuclide scanning is a useful method to confirm partial obstruction of common bile duct. After 4 hours of fasting, the patient was injected with radionuclide (99mTc) and recorded for 90min. The examination revealed a delay in emptying. The sensitivity and specificity of partial obstruction are 67% and 85%, respectively. Contrary to normal people, in the case of common bile duct obstruction, the common bile duct can be expanded after a fat meal or intravenous injection of cholecystokinin (CCK). Dynamic radionuclide scanning, if the delay of choledochal emptying is detected, has certain value for demonstrating partial obstruction of the common bile duct. It has recently been found that it is important to calculate the percentage of gallbladder emptying after injection of CCK, especially the repetition ratio of emptying ratio at 45 min. Preferably, however, radionuclide scanning has its drawbacks, that is, the delay of radionuclide discharge may occur in the late stage of substantial liver disease, and the price is expensive and gamma-ray irradiation is also a disadvantage.

(4) Ultrasound examination: Ultrasound examination revealed that the diameter of the common bile duct did not change after a normal person entered the fat meal or intravenous octapeptide cholecystokinin, while in Oddi sphincter dysfunction, the diameter could be increased by 2 mm or more (1 mm Diameter change is the allowable range of measurement error), patients with gallbladder or liver disease can carry out this test, and the safety and value are relatively cheap, the lack of human factors has a greater impact, check the operator's technical and subjective factors can be Affected the results of the examination, and reported that the sensitivity and specificity were 67% and 100%, respectively, but few large case studies confirmed that, despite this, because the examination is harmless and painful, the price is lower, so it is expected to be one An important screening and examination method, it is worth mentioning that 3% to 4% of asymptomatic patients after cholecystectomy can see common bile duct dilatation.

2. Manometry can be used to check the activity of the Oddi sphincter. In the past, indirect manometry was used, that is, in the operation, the post-operative pressure measurement method. These examination methods are non-physiological and therefore cannot show sphincter pressure. Rapid changes, in 1975, some scholars began to use direct pressure measurement, that is, the end of the hole with a catheter inserted through the endoscope, and then gradually improved to a three-cavity three-hole catheter, can simultaneously measure three pressures, each separated by 2mm The basis of direct pressure measurement is that Oddi sphincter contraction can produce a pressure corresponding to its contraction in the pressure measuring system, which is converted into an electrical signal by an extracorporeal transducer, and is recorded after being expanded. At present, endoscopic manometry is considered It is the gold standard for evaluating the function of Oddi sphincter. Before the examination, it should be calmed with diazepam, avoiding the use of anticholinergic drugs, anesthetics and glucagon, which can affect the function of sphincter; firstly, the duodenum is measured after insertion of the three-lumen cannula. Press and calibrate to zero, then extend the catheter into the nipple under the side view endoscope. Note that the cannula can move flexibly within the sphincter range to avoid sharp corner bends. The cannula can be placed in the common bile duct by injecting contrast agent or aspirating bile. The cannula is slowly withdrawn and the three holes are located in the ampulla sphincter area, and the pressure is again measured for 5 to 10 minutes and recorded, including the base pressure and contraction wave; The duodenal pressure is measured again after the nipple. The duodenal pressure can also be monitored by a certain method. After accurately recording the basic pressure and the contraction wave, the drug should be given to further determine the sphincter response, if the base pressure is significantly increased (more than 40 mmHg). Inhibitory drugs should be given to distinguish whether fixed lesions lead to increased pressure or non-fixed lesions such as sputum, but it must be emphasized that such distinctions are not all possible, with basic pressure, contraction waves and rapid passage. After the data, inhalation of isoamyl nitrite (1 ampoules) or sublingual nitroglycerin, such as basal and intermittent contraction waves reduced or disappeared, suggesting the possibility of muscular nerve disorders; if there is no change or pressure increase, then It is suggested that there may be a fixed stenosis. Both drugs have a systemic reaction at the above doses, but isoamyl nitrite is superior because of its short duration of action, Oddi Determination about pressure and muscle contraction.

Although Oddi sphincter manometry is technically difficult, it is reproducible, and some artifacts may occur in the tracing. This occurs mainly in sphincter motility, catheter displacement, presence of air bubbles in the pressure measurement system, or leakage of the catheter. Holes, etc., need to be clarified by ERCP before performing this operation, and it is necessary to carry out pressure measurement. Before the pressure measurement, it is necessary to confirm whether or not the contrast agent flows out from the pancreatic duct. The operation of the manometry is relatively safe, and the improved method is adopted. After the suction catheter, the risk of complicated pancreatitis is greatly reduced, and the pressure measurement can be continued for a long time.

3. Timing bile drainage with magnesium sulfate or olive oil as a stimulant, record the time and amount of bile outflow in each period of time, the gallbladder can play a normal function, the sphincter has a "close period", also known as the incubation period, sustainable 2 12min, Buri should appear 8min after A bile appears. If the time does not match this, there may be biliary system dysfunction.

Diagnosis and diagnosis of biliary motility dysfunction

Diagnostic criteria

1. Clinical manifestations.

2. Examination of motor function of biliary system Many methods have been used for the examination of motor function of biliary system, but the diagnostic value is different. Among them, gallbladder angiography, manometry and timed biliary drainage are of great value.

3. Types of biliary dysfunction biliary motility dysfunction is often referred to as dyskinesia in general, lack of muscle tone or ataxia. In fact, these terms have their own connotations. The dyskinesia refers to the abnormality of bile duct emptying speed. Insufficient muscle tone mainly refers to the decrease of tension; ataxia refers to the disorder of the synergistic action of various parts of the biliary tract. The main types of biliary dysfunction are as follows:

(1) Hypertonic gallbladder: hypertonic gallbladder is a spastic gallbladder, accounting for 31% of biliary dyskinesia. The gallbladder is slender in the fasting state, the funnel-shaped contour is clear, the volume is significantly reduced, and the emptying speed is mainly Depending on the contraction of the gallbladder wall and the resistance of the Oddi sphincter, the emptying speed can be normal and can be accelerated or slowed down.

(2) hyperactive gallbladder: this type accounts for about 5%, mainly manifested in the speed of exercise and response, the degree of emptying after 15 minutes of meal is significantly higher than normal, 60 minutes of common gallbladder, fasting gallbladder size, shape (and The volume is normal, indicating that its tension is normal.

The above two causes of gallbladder dyskinesia include: disorder of the neural network in the gallbladder wall; hypersensitivity reaction of the gallbladder; early stage of gallbladder inflammation, when the gallbladder wall is inflamed and fibrotic, the gallbladder is in a contracted state, so-called Chronic acalculous cholecystitis.

(3) hypoactive gallbladder: This type accounts for about 13%, mainly manifested as gallbladder contraction and emptying after fat meal, while the gallbladder can maintain normal tension, and the volume and shape are normal under fasting conditions.

(4) Non-dynamic gallbladder: also known as "lazy gallbladder", accounting for about 8%. This type is characterized by an increase in gallbladder volume in the fasting state, and the appearance is like a "U" shape. The gallbladder contraction and emptying after fat meal slows down. However, patients with chronic acalculous cholecystitis may not even see the gallbladder at the same time if the gallbladder wall is thinned and the mucosa is severely damaged.

(5) gallbladder wall fibrosis: this type is seen in chronic acalculous cholecystitis, the incidence rate is about 60%, because the cystic duct has been occluded and the gallbladder mucosa can still function normally, so the gallbladder volume is reduced, the outline is unclear, and the fat meal There was no change in the posterior gallbladder.

(6) Oddi sphincter tension is reduced: this type accounts for about 4%. After the sphincter tension is lowered, the gallbladder can not be filled well, and the resistance decreases after the gallbladder contracts, and the bile flow rate is accelerated. Therefore, the gallbladder often shows poor, and the fat discharge after meal is accelerated. In the Oddi sphincter flaccid state, the gallbladder angiography was negative.

(7) Oddi sphincter tension and its surrounding lesions: Oddi sphincter tension is often closely related to its surrounding lesions, sometimes the clinical characteristics of the two are very similar, a total of about 24%, can change the dynamics of the gallbladder, Oddi sphincter Increased tension, often referred to as sputum, mostly due to neuropsychiatric factors, but also due to inflammation of the surrounding organs, the gallbladder volume in the fasting state sometimes increases, sometimes normal, when the fasting volume increases, fat meal The rear emptying speed is increased.

Inflammation or irritation affecting the abdomen of the sessile pot mainly includes allergic reactions, duodenitis, duodenal ulcer, duodenal parasitic infection, etc., in these cases, duodenal papilla may appear edema Oddi sphincter can appear sputum, and there may be increased pressure in the bile duct, which can lead to different degrees of gallbladder volume expansion. In the case of obvious contraction of the gallbladder, gallbladder emptying is delayed due to increased resistance.

Oddi sphincter dyskinesia is seen in idiopathic recurrent pancreatitis, also in chronic pancreatitis. In chronic pancreatitis, the pancreatic duct and its sphincter pressure are increased. This increase does not rule out the increase in pancreatic juice volume and viscosity. In addition, the increase in pressure is the cause of pancreatitis, or the result of edema or scarring caused by pancreatitis is still unclear. At the same time, the role of pancreatic duct sphincter in the development of pancreatitis is unclear.

(8) organic lesions involving the common bile duct: these lesions account for about 5%, including duodenal papillary scar stenosis, ampullary and pancreatic head tumors and chronic pancreatitis, these lesions can make common bile duct pressure Elevation, which in turn leads to gallbladder enlargement and delayed emptying.

4. Diagnostic procedures for biliary dysfunction biliary dysfunction is a general term for biliary movement changes, which can be identified by special diagnostic methods, but should exclude organic diseases that can cause motor disorders. One of the important diagnostic tools is the aforementioned Various radiological examinations, timing of bile drainage, also have a certain value, such as Oddi sphincter or duodenal fistula should be suspected if the incubation period is more than 12 min; if the incubation period is less than 2 min, it indicates that Oddi sphincter tension is insufficient, B bile delay It is suggested that the gallbladder is not motility or the cystic duct is abnormal; the bile outflow time is more than 30min. It is very important to explain whether these results are affected by drugs. It is very important to have emotions and tensions. Repeated examinations or as described in the previous examination, application of smooth muscle relaxants, gallbladder abnormalities can be classified according to the above examination, Oddi sphincter dyskinesia and diagnosis according to Hogan and Geenen classification can be divided into the following three categories.

(1) The first type of Oddi sphincter dyskinesia: in addition to biliary pain, patients also have:

Abnormal liver function 12 or more times (alkaline phosphatase and aspartate aminotransferase exceeded the upper limit of normal value by more than 2 times).

2 Retrograde cholangiopancreatography in the contrast agent drainage time prolonged, more than 45min.

3 The common bile duct has an expansion diameter of 12 mm or more. Most of these patients are Oddi sphincter stenosis rather than motor dysfunction. Manometry can be helpful, but it is not necessary.

(2) The second type of Oddi sphincter dyskinesia: these patients also have biliary pain, but only 1 to 2 of the 1 to 3 abnormalities in the previous category, the cause can be either stenosis or motor dysfunction, It is necessary to carry out pressure measurement.

(3) The third type of Oddi sphincter dyskinesia: such patients have only biliary pain, there are no 1-3 abnormalities mentioned above, the cause may be Oddi sphincter motor dysfunction, but mostly due to intestinal functional diseases or other causes Before the biliary pressure measurement, diseases other than the biliary system should be excluded.

Diagnosis of biliary motility dysfunction must first exclude organic diseases of the biliary tract. Abnormal gallbladder motor function can be made according to clinical manifestations and gallbladder angiography, depending on gallbladder morphology, volume and emptying. Oddi sphincter spasm is a common motor function. Obstacle, the diagnosis is based on the relevant examination technique. The common bile duct can be seen in the venous cholangiography. After the subcutaneous injection of morphine 10mg, continuous venous cholangiography can also show the widening of the common bile duct diameter; after morphine induced pain, Such as inhalation of isoamyl nitrite, the pain can quickly disappear, the widened common bile duct diameter recovered; 8 hours after the normal injection of morphine, serum ALT, AST value can be increased by 1 time; ERCP examination, Oddi sphincter can not pass the general caliber Strips, sometimes even the smallest probe with a diameter of 2mm can not pass; Oddi sphincter manometry, when the catheter passes through the Oddi sphincter, the pressure suddenly increases by 5 ~ 10mmHg, such as increased by more than 10mmHg, which suggests Oddi sphincter spasm.

Differential diagnosis

1. The lower part of the common bile duct should be differentiated from the papillary sphincter and the organic lesion involving the common bile duct. It can be performed by retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). Identification.

2. gallbladder (tube) stones can lead to gallbladder expansion, need to be distinguished from high-grade gallbladder and hypokinetic gallbladder, imaging diagnosis (B-ultrasound, CT and MRI) can be found in gallbladder (tube) stones, thus confirming the diagnosis.

3. The inflammation and infection around the ampulla of the ampulla can be similar to the increase of Oddi sphincter tension, but it can be confirmed by endoscopy.

4. The periampullary and pancreatic head tumors can be distinguished from the Oddi sphincter tension by B-ultrasound, endoscopy, PTC and other imaging examinations and surgical exploration.

5. The clinical manifestations of chronic pancreatitis can be similar to biliary motility dysfunction, but the former can have a large number of fat droplets and undigested muscle fibers in the feces. A number of imaging examinations can reveal changes in the shape of the pancreatic duct and pancreas.

6. The clinical manifestations of atypical angina and myocardial infarction may be similar to biliary motility dysfunction, but electrocardiogram and/or myocardial zymography can detect corresponding changes in heart disease.

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