Introduction Pain relief following the peri-ampullary injection of Botulinum toxin A may offer a safe alternative to biliary manometry that accurately identifies patients with Type 2/3 Sphincter of Oddi Dysfunction (SOD) who will benefit from endoscopic sphincterotomy.
Methods From 2007 to 2012, patients with probable biliary or pancreatic type 2 or 3 Sphincter of Oddi Dysfunction based on Rome III revised Milwaukee criteria underwent injection of 100 units Botox divided into four quadrants close to the major papilla. Response was characterised as complete (CR), partial (at least 50% improvement) (PR) or no response (NR) using a 10-point Likert Scale. Patients that showed either CR or PR were offered an endoscopic sphincterotomy when symptoms returned or worsened.
Results 91patients with median age 39 (22–64), 92.3% female were studied.
93% patients with suspected Type 2 biliary SOD (n = 15) had prior cholecystectomy: 73% had a response to Botox (5CR, 6PR). 7 underwent ES for recurrent symptoms, 2CR and 5PR (100% responders). The time from Botox to ES ranged from 12 to 42 weeks (median 20 weeks). Of the 7 who underwent ES 4 of the responders had no further intervention, 3 underwent extension of their ES for recurrent symptoms within 5 to 8 months. Of 3 NR to Botox who underwent ES only 1 responded. Of the NR none had any further intervention.
84% patients with suspected Type 3 biliary SOD (n = 64) had prior cholecystectomy: 53% had a response to Botox (17CR, 23PR). 26 underwent ES for recurrent symptoms, 8CR and 15PR (88% responders). Of 13 Botox NR who underwent ES, only 3 responded (23%). The time range from Botox to ES ranged from 6 to 58 weeks (median of 17.5 weeks). Of the 26 who underwent ES and were CR or PR 18 had no further intervention and 8 had extended ES for recurrent symptoms within 2 to 30 months. Of the 3 responders to ES but not Botox 2 had further ES 1 with CR and 1 NR.
83% patients with suspected Type 3 pancreatic SOD (n = 6) had prior cholecystectomy: 83% had a response to Botox (4CR, 1PR). 2 underwent ES within 12 to 19 weeks post Botox, and both responded with one having extension of ES for recurrent symptoms with a PR.
Conclusion Botox injection identifies patients likely to respond to ES avoiding the risks of manometry. Manometry may be helpful in a proportion of Botox non-responder in whom SOD is still suspected.
Disclosure of Interest None Declared.
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