Introduction Management of type III sphincter of Oddi dysfunction (SOD) remains controversial. A recent large multi centre study of manometry and sphincterotomy in type III SOD (EPISOD)¹ found that sphincterotomy was no more effective than sham treatment. Botulinum toxin (botox) injection to the papilla has been shown to be safe and lead to improvement in symptoms, it may also predict response to sphincterotomy^.2

This study reviewed use of botox in patients with type III within a single tertiary centre to guide decision making.

Methods The endoscopy unit database was searched for cases between January 2008 to August 2013 who received botox for SOD. Records were reviewed to identify those who had type 3 SOD as per Rome 3 criteria. Response to botox was graded as no response, partial (reduction but not resolution of pain) or complete response. Complications, manometry and sphincterotomy results were recorded.

Results 63 patients had botox injection for SOD 46 were classified as type III and formed the study group. All received 100IU of botox. Following the procedure 3 of 46 patients required overnight observation for abdominal pain, there were no cases of pancreatitis. 14 patients had no response to botox, 7 partial response, 24 a complete response, 1 did not attend follow up.

Of those that had a complete response 14 patients proceeded to manometry; reasons not to proceed included failure to attend follow up (2) patient declined treatment (1) other co-morbidities (1). One underwent a second botox procedure with no relief in symptoms and was not offered further treatment, 5 patients (21%) were not offered manometry. Of those that proceeded to manometry, 10 (71%) had elevated pressures 8 biliary, 2 pancreatic. All proceeded to sphincterotomy with good response in 9 (64% of Botox responders). 3 of the 7 patients who partially responded proceeded to manometry; 1 of these had increased biliary pressures. 3 patients (18%)had an episode of pancreatitis following manometry.

Conclusion Response to botox appears to show moderate correlation with abnormal manometry findings and response to sphincterotomy. ERCP and manometry was associated with a significant risk of pancreatitis. Randomised sham controlled studies are required to ascertain whether a response to botox can accurately select patients who benefit from a sustained response to sphincterotomy.

References

1. Cotton P et al. Results of the EPISOD Multicenter Sham-controlled Trial of Sphincterotomy in Patients with Suspected Sphincter of Oddi Dysfunction Type III presented at ACG San Diego October 2013

2. Bryce GJ, et al. Ampullary botulinum toxin injection in biliary sphincter of oddi dysfunction. Pancreatology 2013;13(1):e3

Disclosure of Interest None Declared.