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Editor,—I read with interest the paper from Professor Johnson’s group (Gut1998; 43:571–4) questioning the value of the cholecystokinin (CCK) provocation test as a predictor of outcome following cholecystectomy in patients suspected of having acalculous biliary pain. The results of this study are predictable as in my experience tests of gall bladder function in this situation are not much better at outcome prediction than tossing a coin unless they are combined with a quantitative assessment of sphincter of Oddi function.
It is my practice when evaluating patients with suspected acalculous biliary pain to measure the gall bladder ejection fraction (GBEF) using a CCK stimulated HIDA (hydroxyindole diaminoacetic acid) scan. Patients with two separate GBEF values of <35% are offered endoscopic biliary manometry. Patients with normal manometry (basal pressure <40 mm Hg, mean peak wave pressure <140 mm Hg and contraction rate <9/min) of both biliary and pancreatic sphincters respond extremely well to cholecystectomy. Conversely, patients with abnormal manometry must be warned that sphincter of Oddi hypertension may result in post-cholecystectomy symptoms requiring treatment with calcium channel antagonists, botulinum toxin injection into the sphincter of Oddi or endoscopic sphincterotomy.
The modern biliary manometry catheter (Lehman catheter, Wilson Cook Ltd) with a distal aspiration channel has made endoscopic manometry of the sphincter of Oddi a safe procedure with an incidence of postprocedure acute pancreatitis of <5% even for patients with confirmed sphincter hypertension. Manometry of the hypertensive pancreatic sphincter should always be accompanied by short term pancreatic duct stenting as this reduces the incidence of acute pancreatitis in these patients dramatically.
I would suggest that the study from Smythe et al is incomplete without sphincter of Oddi function data and that we should not discard gall bladder function tests just yet.
Editor,—In reply, I would like to state that, while we agree that sphincter of Oddi hypertension may be an important contributor to the phenomenon of acalculus biliary pain, the purpose of the CCK provocation test is to select patients who might benefit from cholecystectomy. Whether subselection can be made on the basis of sphincter of Oddi testing remains to be seen but, certainly, the CCK provocation test should not be recommended as a selection tool for symptom relief after a cholecystectomy.
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