Functional disorders of the biliary tract

Functional gastrointestinal disorders have been defined as a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. In the case of the biliary tract, however, it is often difficult to dissociate purely functional conditions from subtle structural changes and in many instances these may merge; thus the term dysfunctional disorders of the biliary tract has been adopted to embrace all of the motility disorders regardless of potential etiology factors. Gallbladder (GB) and sphincter of Oddl (SO) dysfunction are the two disorders of the biliary tract which may be symptomatic. GB dysfunction is a disorder of gallbladder contractility which produces biliary type pain in the absence of significant abnormalities to explain the symptoms. Assessment of GB emptying and pain provocation tests have been used to identify GB dysfunction; of these investigations, the demonstration of a reduced GB ejection fraction with CCK scintigraphy appears promising for selecting a subgroup of patients with SO dysfunction. Cholecystectomy appears to be the most appropriate treatment for GB dysfunction. SO dysfunction is an abnormality of SO contractility which may manifest itself clinically with recurrent biliary and/or pancreatic pain and/or recurrent acute pancreatitis. An abnormal SO manometry in the absence of structural abnormalities other than dilated duct(s) at ERCP, identifies SO dysfunction. SO manometry also differentiates patients with SO stenosis from those with SO dyskinesia. Fatty meal ultrasonography and the assessment of the cholescintigraphic hilum- duodenum transit time are indirect non-invasive investigations which appear useful for screening patients with symptoms of SO dysfunction. Endoscopic sphincterotomy is indicated in patients with SO dysfunction and biliary disorders; sphincteroplasty and septoplasty are to be preferred in patients with dysfunction and pancreatic disorders.