Surgery
A 55-year-old man was admitted with a 2-year history of recurrent upper abdominal pain attacks.
History confirmed a recurrent colicky pain aggravated my morphine or its analogues (see lab results and report). Blood pressure 110/70 mmHg Heart rate 96 /min Respiratory rate 18 /min Temperature 36.6 °C Test Result Normal Values Indirect bilirubin 5 3.2-12.1 mol/L Direct bilirubin 10 1.5-6.5 mol/L Total bilirubin 15 3.5-16.5 mol/L Alkaline phosphatase 250 39-117 IU/L Amylase 150 24-151 IU/L Ultrasound abdomen: Prominent common bile duct along with dilated minimal dilatation of intrahepatic ducts. Which of the following is the most likely diagnosis?
Explanation
Core Concept: Sphincter of Oddi dysfunction causes intermittent biliary-type obstruction due to dyskinesia or spasm of the sphincter. Morphine can aggravate symptoms by increasing sphincter tone. Mild cholestatic liver enzyme elevation and common bile duct dilation may occur without an obvious stone.
Clinical Presentation:
- Recurrent episodic right upper quadrant or epigastric colicky pain
- Pain may be aggravated by opioids, especially morphine
- Transient elevation of bilirubin or alkaline phosphatase
- Common bile duct dilation without visible obstructing stone
Diagnosis:
- First-line: Liver function tests, abdominal ultrasound, and MRCP to exclude choledocholithiasis or other structural causes.
- Gold standard/most accurate: Sphincter of Oddi manometry.
Management:
- Acute: Analgesia with non-opioid agents when possible, antispasmodics, and supportive care.
- Long-term/Definitive: Medical therapy with smooth muscle relaxants in selected cases; ERCP with sphincterotomy for confirmed significant dysfunction or recurrent biliary-type episodes.