Biliary Tract Dyskinesis Syndrome

　　I. Gallbladder motility function enhancement: This kind of dysfunction is generally related to allergic reactions of the gallbladder or gallbladder inflammation.

　　1. Hyperactivity of gallbladder motility function:The gallbladder tension is normal, but there is an exaggerated response to the fat meal, so the gallbladder emptying is accelerated, and most of it is emptied within 15 minutes after the meal.

　　2. High gallbladder tension:The gallbladder has high muscle tension, but the emptying time is not affected, and it can be normal, accelerated, or delayed.

　　Two, Decreased Gallbladder Motility Function

　　1. Decreased gallbladder motility function:The gallbladder tension is normal, but the contraction after meals is weakened, and the emptying is slow.

　　2. Decreased gallbladder tension and reduced motility function:The gallbladder tension decreases and the volume increases when fasting, and the emptying is slow after meals.

　　Three, Oddi Sphincter Dysfunction

　　1. Low tension of Oddi sphincter:The gallbladder is not well filled during cholecystography.

　　2. Oddi sphincter spasm:It is often caused by mental factors, but it can also be secondary to the lesions of adjacent organs, such as papillitis, duodenitis, bulb ulcer, duodenal parasites such as Entamoeba histolytica, Strongyloides stercoralis infection, and other infections.

　　It is prone to complications such as cholecystitis, gallstones, biliary ascariasis, and other diseases. Biliary motility dysfunction is an abnormality in the emptying speed of the bile duct; hypotonia mainly refers to the reduction in tension; ataxia refers to the dysfunction of the synergistic action of various parts of the bile duct. Among them, the hyperkinetic gallbladder is characterized by an increase in movement and reaction speed, with a disorder of the neural network within the gallbladder wall; gallbladder hypersensitivity; leading to gallbladder inflammation. When the gallbladder wall becomes inflamed and fibrotic, the gallbladder presents a contraction state, that is, the formation of chronic non-calculous cholecystitis.

　　Most patients are elderly women, with right hypochondriac pain as the main symptom; they often have symptoms such as nausea, bloating, poor appetite, and vomiting of oil. Complications may include chills, fever, jaundice, and other symptoms.

　　1. Most patients are elderly women, with right hypochondriac pain as the main symptom; they often have symptoms such as nausea, bloating, poor appetite, and vomiting of oil. Complications may include chills, fever, jaundice, and other symptoms.

　　1. It commonly occurs in obese women, so attention should be paid to having a good living habit. Fat intake should be reduced, including lard, egg yolks, animal internal organs, oysters, butter, cakes, fried foods, etc. Use less oil-frying and deep-frying in cooking, and try to use boiling, stewing, and steaming methods as much as possible, with vegetable oil as the main cooking oil.

　　1. Morphine-Neostigmine Stimulation Test (Nardi Test): Morphine has the effect of causing SO contraction. After subcutaneous injection of 10mg of morphine, 1mg of neostigmine is injected subcutaneously as a cholinergic secretagogue. The morphine-neostigmine stimulation test is a widely used and traditional diagnostic method for SOD. If the patient experiences typical abdominal pain, accompanied by a 4-fold increase in AST, ALT, AKP, amylase, or lipase, it is considered a positive test. This test has low specificity and sensitivity in predicting SOD, and there is a very poor correlation with the prediction of the effect after sphincterotomy, so its application is limited and is often replaced by more sensitive tests.

　　2. Ultrasonic examination of the diameter of extrahepatic bile ducts and main pancreatic duct after secretion stimulation. After a high-fat meal or the application of CCK, gallbladder contraction, increased bile excretion by hepatocytes, and relaxation of the SO cause bile to enter the duodenum. Similarly, after a high-fat meal or the application of secretin, stimulation of pancreatic juice secretion causes the SO to relax. If the SO function is abnormal and causes obstruction, the common bile duct or main pancreatic duct may dilate under the pressure of the secretory fluid, and can be monitored by ultrasound. Obstructions of the sphincter and distal biliary-pancreatic ducts caused by other reasons (stones, tumors, stenosis, etc.) can also cause dilation of the common bile duct or main pancreatic duct and need to be ruled out. It should also be noted whether there is pain-induced stimulation. To date, research in this area is limited, and these non-invasive tests and the effects of SOM or sphincterotomy show only slight correlation. Because of intestinal gas, routine percutaneous ultrasound often cannot visualize the pancreatic duct. Although endoscopic ultrasound has the advantage of being able to visualize the pancreas, Catalano et al. reported that the sensitivity of endoscopic ultrasound after secretin stimulation in the diagnosis of SOD is only 57%.

　　3. Quantitative hepatobiliary scintigraphy (HBS) estimates bile excretion from the bile ducts through the hepatobiliary scintigraphy. When the outflow of bile is obstructed due to sphincter disease, tumor, or stones (and liver parenchymal disease), it causes abnormal excretion of radionuclides. There is still controversy over the clear criteria for defining a positive (i.e., abnormal) result, but the most widely applied is the duodenal arrival time greater than 20 minutes and the time from the porta hepatis to the duodenum greater than 10 minutes. Most studies suffer from the defect of lacking correlation with the results of SOM or sphincterotomy. However, one study clearly suggests a significant correlation between hepatobiliary scintigraphy and the basic pressure of the SO. In summary, it seems that patients with bile duct dilation and obvious obstruction may have positive scintigraphy results. Esber et al. found that even after CCK stimulation, the scintigraphy results of patients with mild obstruction (Hogan-Geenen classification II and III) were usually normal. Recently, there have been reports of adding morphine stimulation to hepatobiliary scintigraphy. Forty-three patients with SOD diagnosed as type II and III underwent hepatobiliary scintigraphy with and without morphine, and later underwent biliary fluid manometry. Standard hepatobiliary scanning cannot distinguish between normal and abnormal SOM patients. However, after morphine stimulation, there were significant differences in the maximum activity time and excretion percentage at 45 minutes and 60 minutes. Using the 15% excretion interruption value at 60 minutes, the sensitivity and specificity of the hepatobiliary scintigraphy amplified by morphine stimulation in detecting elevated SO basic pressure were 83% and 81%, respectively. Lacking more definitive data, the conclusion drawn now is that the non-invasive diagnostic method for SOD has relatively low or unclear sensitivity and specificity, and is not recommended for clinical use unless more certain methods (such as manometry) are unsuccessful or cannot be performed. Because of the associated risks, invasive ERCP and manometry should only be used for patients with obvious clinical symptoms. Generally, if there is an abnormality in sphincter function, it is not recommended to perform the following invasive evaluations for SOD patients unless definitive treatment (sphincterotomy) is intended.

　　4. Cholangiography Cholangiography is very important for excluding stones, tumors, or other biliary obstructive diseases that have symptoms similar to SOD. Once high-quality cholangiograms exclude these diseases, dilation and/or slow emptying of the bile ducts often suggest obstruction at the sphincter level. Cholangiograms can be obtained by various methods. Intravenous cholangiography has been replaced by more accurate methods, such as spiral CT cholangiography or magnetic resonance cholangiography, which seem to be promising. Direct cholangiography can be obtained by percutaneous methods, intraoperative methods, or more traditional ERCP. Although there are some controversies, if the diameter of the extrahepatic bile duct is over 12mm (after cholecystectomy), it should be considered as dilation. Drugs that affect bile excretion and the relaxation or contraction of the SO sphincter can affect the excretion of contrast agents. To obtain accurate excretion time, it is necessary to avoid the use of such drugs. Because the common bile duct has an angle from front to back, the patient must lie on his or her back to exclude the gravitational effect of the引流液 passing through the sphincter. Although there is no good definition of the normal excretion time of contrast agents when lying on the back, if the bile duct cannot empty all the contrast agents within 45 minutes after cholecystectomy, it is usually considered abnormal. Endoscopic examination of the papilla and the surrounding area can provide important information for the diagnosis and treatment of SOD patients. Occasionally, papillary cancer can be misdiagnosed as SOD. Papillary biopsy should be performed for suspected cases. In assessing suspected SOD patients, the X-ray characteristics of the pancreatic duct are also important. Pancreatic duct dilation (in the head >6mm and in the body >5mm) and prolonged contrast agent excretion time (prone position ≥9min) can provide indirect evidence of the presence of SOD.

　　These foods are good for patients with biliary motor dysfunction syndrome:

　　A diet high in calories, protein, high sugar, and low in fat. The patient's diet should be light and easy to digest, with an emphasis on eating more vegetables and fruits, and a reasonable dietary combination, paying attention to adequate nutrition. In addition, patients should also pay attention to avoiding spicy, greasy, and cold foods.

　　1Medication treatment

　　Mild cases can be treated with sedatives and anticholinergic drugs, such as diazepam (Valium), atropine, anisodamine (654-2), and others, which may be effective; isosorbide dinitrate and nitroglycerin also have a relaxing effect on smooth muscles, thus they can relieve spasm of the sphincter and exert a function, but they may cause systemic adverse reactions and may develop resistance to long-term use, rendering them ineffective; glucagon, cholecystokinin, and bombesin may be effective, but due to their high cost, inconvenience of use, and potential allergic reactions, their widespread use is limited; calcium channel blockers such as nifedipine (Procardia) can also be used to relieve sphincter spasm.

　　Patients with pain, chronic non-calculous cholecystitis, and possibly infection should be treated with antibiotics that can act in bile, such as rifampin; patients with duodenitis, hypergastrinemia, or peptic ulcer coexisting with biliary motility disorders can be treated with drugs that inhibit gastric acid secretion and protect the gastric and duodenal mucosa, and for those with hypochlorhydria, 0.5% hydrochloric acid can be added orally to stimulate appetite if necessary.

　　SecondSurgical Treatment

　　1. Oddi sphincter balloon or water balloon dilatation:Some patients with suspected Oddi sphincter dyskinesia were treated with balloon dilatation (Gruntzig balloon) and pseudo-dilatation respectively. The baseline pressure of the Oddi sphincter in all patients was normal, and there was no significant difference in efficacy between the two groups. However, since the diagnosis of these patients was not confirmed, and no studies on dilatation for those with increased baseline pressure were conducted, the current conclusion can only be said that balloon dilatation may be ineffective for patients with normal Oddi sphincter baseline pressure. The efficacy of water balloon dilatation cannot be concluded due to unreasonable classification of patients and the use of controls.

　　2. Sphincterotomy:Endoscopic sphincterotomy is applied soon after biliary stone removal, and this technology has begun to be used to treat biliary pain caused by sphincter dyskinesia in patients with a baseline sphincter pressure over 40mmHg, more than 90% of whom can achieve good therapeutic effects. However, in patients with a baseline pressure below 40mmHg, the pain relief rate is less than 40%, and the relief rate in simulators is about 30%, but there are a few reports that the baseline pressure is unrelated to efficacy. Most reports indicate that there are certain complications, with an incidence rate of about 16%, so this operation should be carried out after careful consideration. In general, sphincterotomy is effective for patients with a baseline pressure of the Oddi sphincter over 40mmHg, especially for patients with so-called post-gallbladder surgery syndrome, while the efficacy is poor for those with normal static pressure. Due to the higher incidence rate of complications and poor efficacy of pancreatic sphincterotomy, most scholars believe that it is not suitable to perform this operation.

　　3. Surgical Treatment:Most patients experience varying degrees of relief of clinical symptoms after general treatment and drug treatment. If patients still cannot relieve symptoms after conservative treatment, and it is not suitable to perform endoscopic sphincterotomy, surgical treatment should be considered.