Hubert A. Shaffer

Human sphincter of Oddi motility and cholecystokinin response following liver transplantation

The reported incidence of sphincter of Oddi dysfunction following orthotopic liver transplantation has ranged from 3% to 7%. If sphincteric dysfunction is unrecognized, therapy may be inappropriate; when recognized, extensive surgery may be required. To prospectively identify patients with sphincteric dysfunction, we performed sphincter of Oddi motility studies through the t-tube tract three months after transplantation. Baseline sphincter motility and response to intravenous cholecystokinin were evaluated. The results of 10 subjects are reported; nine had normal basal sphincter pressure (16±5.8 mm Hg), and all had normal frequency (3.6±1/min), amplitude (86±31 mm Hg), and duration (4.5±1 sec) of phasic contractions. One subject had an elevated basal pressure (47 mm Hg). All, including the subject with elevated basal pressure, demonstrated a normal response to intravenous cholecystokinin with significant inhibition of phasic contraction frequency and amplitude. We demonstrate that simultaneous studies of the sphincter and duodenum can be obtained via the t-tube tract, providing the opportunity for prospective evaluation of sphincteric function. We conclude that sphincter of Oddi function usually remains normal following liver transplantation with choledochocholedochostomy.

Gastrointestinal foreign bodies and strictures: Radiologic interventions

Food impaction and foreign body ingestion are significant and sometimes life-threatening medical problems. As described in part 1 of this monograph, a variety of techniques and instruments are available to diagnose and treat these conditions. The radiologist interested in interventional procedures can find ample opportunities to participate in the management of esophageal obstructions by applying radiographic and fluoroscopic techniques to the diagnosis and removal of foreign bodies and food impactions. The recommended radiologic procedures are relatively safe, cost-effective, and efficient methods of addressing these serious situations. Stricture formation in the gastrointestinal tract is another significant medical problem that can often be managed nonoperatively by the radiologist. Fluoroscopically guided balloon dilatation has become an accepted method of effectively treating a large variety of strictures. As described in part 2 of this article, the technique is easy to perform, usually with very little inconvenience to the patient, and the risks of complications are very low. The procedure is relatively inexpensive and does not require the acquisition of any specialized or high-technology equipment. Also, the technique can be performed easily by any radiologist with interest in interventional procedures on the gut. A wide use of the fluoroscopic methods for treatment of impacted foreign bodies and strictures of the gastrointestinal tract is recommended.

Fluoroscopically guided balloon dilation of the esophagus.

Balloon dilation has become a common method for treating a variety of esophageal conditions. When properly performed, it is an effective procedure with a high rate of success. Fluoroscopically guided balloon dilation offers distinct advantages over endoscopically performed balloon dilation or blindly performed bougienage, as it allows for better visual control of the procedure and morbidity is low. In our experience, fluoroscopically guided esophageal balloon dilation is safe and easy to perform, provided that the operators are aware of the potential complications and the procedure is properly tailored to the patients underlying condition. At our institution, over the course of 25 years we have performed more than 2300 fluoroscopically guided esophageal balloon dilations to treat a multitude of disorders including strictures of benign and malignant etiology, anastomotic strictures, radiation-induced strictures, tight gastric fundoplication wraps, esophageal webs and rings, achalasia, and anastomotic leaks. Over the years that we have performed the procedure, we have adapted our technique to maximize postprocedural outcomes and utilize available technology. In this article, we describe our current technique, present the various conditions amenable to balloon dilation, and emphasize modifications for each condition. We also discuss potential problems and complications that we have experienced in our practice.

Effect of Octreotide on Human Sphincter of Oddi Motility Following Liver Transplantation

The effect of octreotide on sphincter of Oddimotility was investigated in six liver transplantpatients, employing percutaneous (through the T-tubetract) manometry. Continuous and simultaneous sphincter of Oddi and duodenal motor activities wererecorded before and for 60 min after the administrationof octreotide (100 μg subcutaneously) and after theinjection of cholecystokinin (0.02 μg/kgintravenously). With octreotide, contraction frequency andbasal pressure significantly increased (P < 0.05).This effect lasted more than 60 min, long afteroctreotide-induced duodenal migrating motor complexphase III activity had ceased. Sphincter of Oddicontraction amplitude and duration were unaffected byoctreotide. Subsequent cholecystokinin administrationtransiently reduced sphincter of Oddi basal pressure and contraction frequency. We conclude thatoctreotide significantly increases sphincter of Oddibasal pressure and contraction frequency. This effect isdistinct from octreotide induction of migrating motor complex phase III activity, persists for aprolonged period, and is inhibited bycholecystokinin.

Bull's-eye lesions: a new gastrointestinal presentation of mastocytosis.

Systemic mastocytosis is a rare disorder that infrequently affects the GI tract. Bowel involvement in mastocytosis is characterized by thickened folds and small mucosal nodules, and there is an increased incidence of peptic ulcer disease and malabsorption. This paper describes a new case of mastocytosis that presented radiographically as 1.0–1.5 cm gastric and duodenal nodules. Some of the duodenal nodules were bulls-eye lesions with central collections of barium. Mastocytosis, along with primary neoplasms, aberrant pancreas, eosinophilic granuloma, and metastases should be included in the differential for bulls-eye lesions of the GI tract.

Radiographic examination of the stomach and duodenum: comparison of single-, double- and biphasic-contrast methods

We compared retrospectively three groups of 150 patients who had undergone radiologic examinations of the stomach and duodenum. Each group was examined with a different barium suspension and radiographic technique: single-contrast (SC), double-contrast (DC), or biphasic-contrast (BC). The radiographs of each study were evaluated for technical quality and visualization of lesions. The number of X-ray exposures, films, and the amount of fluoroscopic time for each study were tabulated. The total radiation dose and cost for each technique were calculated. The BC examinations required the greatest number of radiographic exposures and X-ray films; however, cost was highest for the DC method. Fluoroscopy was significantly longer during the DC procedures, and the total radiation dose was also highest with this technique. Gaseous distention and barium coating of the stomach were equally good for the BC and DC groups, but X-ray penetration of the barium suspension during compression filming was significantly better in the BC and SC groups. Areae gastricae were most frequently seen during the BC studies and artifacts from excess secretions, barium flocculation or gas bubbles were least commonly present using this technique. Significantly more lesions were demonstrated in the stomach with the BC technique than with the other methods; however, the number of lesions found in the duodenum was the same for each technique.