Introduction The management of Type III sphincter of oddi dysfunction or functional biliary pain syndrome remains challenging and the EPISOD study established that there is no role for biliary or pancreatic endoscopic sphincterotomy in the management of this condition. Intra-sphincteric botulinum toxin injection has been reported to be effective in alleviating symptoms.

Aim To examine the utility of intra-sphincteric botulinum toxin injection in the management of Type III sphincter of oddi dysfunction.

Method A prospective observational study was conducted in patients with Type III sphincter of oddi dysfunction, as defined by typical pancreatobiliary pain in a post-cholecystectomy setting. The diagnosis of Type III sphincter of oddi dysfunction was established using the modified Milwaukee criteria. All patients additionally underwent cross-sectional imaging (CT/MRI), EUS and had a positive morphine-TBIDA scan (reproduction of symptoms on intravenous Morphine injection and delayed excretion of dye from the bile duct). 100 units of botulinum toxin was injected into the ampullary sphincter, identified sonographically at EUS or endoscopically A numeric pain rating scale (NPS) (0–10, linear scale) was used to determine response to treatment. Symptoms were assessed prospectively in an outpatient setting.

Results Over a period of 3 years, 45 patients (43 females, mean age 44 (23-73) years) underwent intra-sphincteric botulinum toxin injection using an echoendoscope (EUS) or a duodenoscope (66 procedures, mean 1.4 procedures per patient (range 1–6).. There were no procedure-related complications.

On follow up (mean 10 (range 1–45) months, pancreatobiliary pain scores reduced from a mean value of 7 to 3 (t=16.7, df 64, p<0.001, paired t-test), with 15 (33%) reporting complete cessation of pain. Opiate analgesic requirements reduced significantly in 31 (69%) of patients. Repeat botulinum toxin injection was performed in 18 (40%) patients at a mean of 5 (1.6–12.8) months with recapture of pain control. Hospital attendances due to symptoms were reduced significantly.

Conclusion Intra-sphincteric botulinum toxin injection seems to be a useful adjunct in the management of Type III sphincter of oddi dysfunction.

Disclosure of Interest None Declared