Biliary motor dysfunction

Introduction Biliary tract dyskinesis syndrome is also known as Oddi sphincter dysfunction, Oddi sphincter insufficiency, Oddi sphincter relaxation, Vater ampullary insufficiency. Intrinsic is generally divided into three types: functional, pathological, and mechanical, but cholecystitis, cholelithiasis, and biliary ascariasis are more common. Including dysfunction of biliary tract (dyskinesis), that is, abnormal biliary emptying speed; dysfunctional biliary tract (dystonia), that is, biliary muscle tone abnormality; biliary ataxia (ataxic), that is, coordination disorder between various parts of biliary tract.

Cause

(1) Causes of the disease

1. Gallbladder motor function enhancement

Such dysfunction is generally associated with an allergic reaction to the gallbladder or inflammation of the gallbladder.

(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, and it can be normal, accelerated or delayed.

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 adjacent organs such as papillitis, duodenitis, bulbar ulcers, duodenal parasites such as Giardia, Nematode infections, etc.

(two) pathogenesis

1. 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 gallbladderguinal duct tubecholedochal pancreatic ductduodenum, The biliary system accepts the bile secreted by the liver and 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 lead to dysfunction of the biliary system.

The Oddi sphincter consists of three parts, the common bile duct sphincter, the pancreaticobiliary sphincter and the ampullary sphincter. The ampullary sphincter is the ring muscle and the other two parts have both the ring muscle and the oblique muscle. The smooth muscle of the gallbladder wall is divided into two layers: the inner longitudinal and the outer ring; the common hepatic duct and the cystic duct also have some smooth muscles, but much less than the common bile duct and gallbladder. There is no consensus on the role of bile flow; the pancreatic duct is close to twelve. The intestine submucosa forms the biliary and pancreatic ampulla, about 2 to 17 mm, through the nipple opening in the duodenum descending segment, a few of the pancreatic duct and the common bile duct do not meet, but open in the duodenum.

The bile flow of the extrahepatic biliary tract conforms to the principle of fluid mechanics. The pressure is equal to the flow rate multiplied by the resistance. Therefore, in the case where the pressure is relatively fixed, the resistance increases and the flow rate decreases. The resistance in the biliary system is largely related to the Oddi sphincter tone. The sphincter pressure exceeds 10 to 30 mmHg of the biliary tract, and the pressure can reach 100 mmHg in the contraction of 2 to 8 times/min. Some of the aforementioned distal biliary system structures generate a certain amount of 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 injuries can also affect the entry of 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 inside and outside the body. Under normal circumstances, bile flow in the extrahepatic biliary tract can be affected by some of the following intrinsic 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) Condensation of gallbladder and bile.

(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) The amount of cholecystokinin released, the efficiency of transport, and the rate of inactivation.

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

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 in 15 minutes.

5 After gently pressing the gallbladder area by hand, the gallbladder can be emptied, but suddenly press hard.

6 After removal of 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 increase in frequency 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 cause the gallbladder to contract and reduce the tension and contraction of the Oddi sphincter including the pancreatic sphincter. The secretin has no significant effect on the biliary sphincter, 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, hormones and peptides studied by animal experiments include gastrin, pentagastrin, histamine and prostaglandin E1. Both histamine and prostaglandin E1 can reduce the contractile viability of the sphincter, and prostaglandin E2, motilin and bombesin have similar effects. Serotonin and endorphin have different effects on different parts of the Oddi sphincter.

The study of the effects of some drugs on sphincters. Butyl porphyrin blocks the contractile activity of the sphincter and reduces the basal pressure; sublingual nitroglycerin reduces the basal pressure and contraction amplitude of the sphincter, but does not reduce the frequency; morphine increases both the frequency of contraction and the base pressure; Zosin (analgesic) only increased the basal pressure, while buprenorphine (buprenorphine) had no effect on the sphincter; pethidine reduced the frequency of contraction; stability did not affect the basal pressure and contractile activity; for Oddi In patients with sphincter dyskinesia, nifedipine (heart pain) can reduce various activities of the sphincter, but it does not have this effect in normal people; local perfusion of ethanol in the biliary tract can significantly increase the basal pressure, but ethanol enters the body through the stomach and intravenously. The effects are different.

an examination

Related inspection

Venous cholangiography biliary stent drainage (ERBD) cholangiography

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

1. Pain: The core symptom of biliary tract disease is pain. Pain can originate from the dilated common bile duct, but the pain is often found in the upper abdomen and right rib, or in the lower sternum, interscapular region, or even under the back. Pain is not related to diet, but can also occur after a meal. Pain may also be caused by Oddi sphincter spasm, its nature and location are very similar to biliary colic, but the attack time is short, only a few minutes to half an hour, the number of episodes is more, more than a day; 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; no onset of fever or jaundice. Upper right abdominal pain caused by esophagus, small intestine, large intestine or heart disease can also be mistaken for biliary pain. In addition to the presence of acute inflammation, signs do not help to determine biliary motility disorders.

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

3. Oily food: It shows a decrease in tolerance to fatty foods. Some patients are intolerant of fried foods or high-fat diets, and may have symptoms such as diarrhea and abdominal pain.

4. Signs: tenderness in the upper abdomen or upper right abdomen, Murphy sign can be positive. It is generally thought to be associated with increased pressure in the bile duct and inflammation of the bile duct.

1. 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 which gallbladder angiography, manometry and timed biliary drainage are of great value.

2. Types of biliary dysfunction: biliary dysfunction is often referred to as dyskinesia, dystonia, or ataxia. In fact, these terms have their own connotations. Dyskinesia refers to the abnormality of the emptying speed of the bile duct; the lack of muscle tension mainly refers to the decrease of tension; the 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 the sacral gallbladder, accounting for about 31% of biliary dyskinesia. In the fasting state, the shape of the gallbladder is slender, the contour of the funnel is clear, and the volume is significantly reduced. The rate of emptying depends mainly on the contraction of the gallbladder wall and the resistance of the Oddi sphincter, so the emptying speed can be normal and can be accelerated or slowed down.

(2) Hyperactive gallbladder: This type accounts for about 5%. Mainly manifested by the speed of exercise and reaction, the degree of emptying after 15 minutes of meal was significantly higher than normal, and the gallbladder was not common at 60 minutes. The size, shape (and volume) of the gallbladder in the fasting state is normal, indicating that the tension is normal.

The above two causes of gallbladder dyskinesia include: disorder of the neural network in the gallbladder wall; hypersensitivity of the gallbladder; early stage of gallbladder inflammation. When inflammation occurs in the gallbladder wall and fibrosis occurs, 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) Inactive gallbladder: also known as "lazy gallbladder", accounting for about 8%. This type is characterized by an increase in the volume of the gallbladder in the fasting state, and the appearance resembles a "U" shape, and the contraction and emptying of the gallbladder after the fat meal are slowed down. However, in patients with chronic acalculous cholecystitis, if there is a thinning of the gallbladder wall and severe damage to the mucosa, the gallbladder is not even seen at all.

(5) Gallbladder wall fibrosis: This type is seen in chronic acalculous cholecystitis, with an incidence of about 60%. Since the cystic duct has been occluded and the gallbladder mucosa still functions normally, the gallbladder is reduced in size, unclear in outline, and there is no change in the gallbladder after fat meal.

(6) Oddi sphincter tension reduction: this type accounts for about 4%. After the sphincter tension is lowered, the gallbladder does not fill well, and the resistance decreases after the gallbladder contracts, and the bile flow rate increases. Therefore, the gallbladder often shows poor, and the emptying of the fat after meals is accelerated. In the Oddi sphincter flaccid state, 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. Increased Oddi sphincter tension, often referred to as sputum, is mostly due to neuropsychiatric factors, but can also be caused by inflammation of surrounding organs. The volume of the gallbladder in the fasting state sometimes increases, sometimes normal, and the emptying speed of the fat after meal increases as the fasting volume increases.

The inflammatory or irritating state affecting the abdomen of the sessile pot mainly includes allergic reactions, duodenitis, duodenal ulcer, and duodenal parasitic infection. In these cases, edema may occur in the duodenal papilla, Oddi sphincter may appear paralyzed, and intra-biliary pressure may increase, which may lead to different degrees of gallbladder volume expansion. In the case of a significant contraction of the gallbladder, gallbladder emptying is delayed due to increased resistance.

Oddi sphincter dyskinesia is seen in both idiopathic recurrent pancreatitis and chronic pancreatitis. In chronic pancreatitis, the pancreatic duct and its sphincter pressure are increased. This increase does not rule out the effect of increased 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 unclear. At the same time, the role of the pancreatic 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 scarring, ampullary and pancreatic head tumors, and chronic pancreatitis. These lesions can increase the pressure of the common bile duct, which in turn leads to gallbladder enlargement and delayed emptying.

4. Diagnostic procedure for biliary dysfunction: biliary dysfunction is a general term for biliary movement changes, which can be identified by special diagnostic methods, except for organic diseases that can cause motor disorders. One of the important diagnostic tools is the various radiological examinations described above, and the timing of timing bile drainage is also of value. Oddi sphincter or duodenal fistula should be suspected if the incubation period exceeds 12 min; if the incubation period is less than 2 min, the Oddi sphincter tension is insufficient. Delayed bile B indicates insufficient gallbladder motility or abnormal cystic duct; B bile efflux time is more than 30 min. In interpreting these results, it is important to consider whether these results are affected by the drug; mood and tension also have an effect, repeat testing if necessary or apply smooth muscle relaxants as described in the previous exam. Gallbladder abnormalities can be classified by reference to the aforementioned examination. Oddi sphincter dyskinesia and diagnosis can be classified into the following three categories according to the classification of Hogan and Geenen.

(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 help, but it is not necessary.

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

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

Diagnosis of biliary motility dysfunction must first rule out organic diseases of the biliary tract. Abnormal gallbladder motor function can be based on clinical manifestations and gallbladder angiography, depending on the shape, volume and emptying of the gallbladder. Oddi sphincter spasm is a relatively common motor dysfunction, and its diagnosis depends on the relevant examination techniques. In the venous cholangiography, the common bile duct was widened. After subcutaneous injection of morphine 10 mg, continuous venous cholangiography showed a widening of the common bile duct. After morphine induced pain, such as inhalation of isoamyl nitrite, the pain quickly disappeared. The widened common bile duct diameter recovered; 8 hours after the normal injection of morphine, the serum ALT and AST values could be increased by 1 time; when the ERCP was examined, the Oddi sphincter could not pass the general caliber probe, and sometimes the smallest probe with a diameter of 2 mm was also Can not pass; Oddi sphincter manometry, when the catheter passes through the Oddi sphincter, the pressure suddenly increases by 5 ~ 10mmHg, such as increased more than 10mmHg, which suggests Oddi sphincter spasm.

Differential diagnosis

1. Lower common bile duct stones: need to be identified with papillary sphincter spasm and organic lesions involving the common bile duct. It can be identified by duodenoscopy retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC).

2. Gallbladder (tube) stones: can lead to gallbladder expansion, need to be distinguished from high-grade gallbladder and low-dynamic gallbladder. Imaging diagnosis (B-ultrasound, CT, and MRI) can be found in gallbladder (tube) stones.

3. Chronic pancreatitis: its clinical manifestations 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.

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

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