Comparison of Secretin-Stimulated Magnetic Resonance Pancreatography and Manometry Results in Patients with Suspected Sphincter of Oddi Dysfunction

Rationale and Objectives

To measure main pancreatic duct diameter (PDD) with magnetic resonance pancreatography (MRP) before and after secretin injection in patients with suspected sphincter of Oddi dysfunction (SOD) and to determine if the diameter change is predictive of sphincter of Oddi manometry (SOM) results.

Materials and Methods

We identified all patients during the study period referred for SOM for clinically suspected SOD; patients with an intact sphincter and without contraindication to MRP examination were considered for study entry. Consenting patients underwent MRP, including dynamic imaging of the pancreatic duct after intravenous administration of porcine secretin followed by SOM during endoscopic retrograde cholangiopancreatography. MRP was defined as abnormal when PDD remained increased by ≥1.0 mm from baseline 15 minutes after secretin injection. SOM was abnormal when basal sphincter pressure (SP) was ≥40 mm Hg. Mean PDD before and after secretin administration was compared within normal and abnormal SP groups with two-tailed unpaired t -test; the mean difference between baseline and peak PDD and duration of ≥0.5 mm increase in PDD was compared between groups with two-tailed t -test. P < .05 was considered significant.

Results

Of 70 patients referred for SOM, 30 met all entry criteria, gave consent to participate, and underwent both MRP and SOM. Ten of 30 patients (33%) had normal SP; 20 (67%) were abnormal. PDD increased significantly after secretin injection (normal SP, 1.62 ± 0.73 to 2.78 ± 0.77 mm, P < .01; abnormal SP, 1.45 ± 0.26 to 2.32 ± 0.75 mm, P < .01). There was no difference between normal and abnormal SP groups in amount of PDD increase (1.15 ± 0.75 vs. 0.88 ± 0.72 mm; P = .33) or duration of ≥0.5 mm increase in PDD (5.28 ± 8.76 vs. 13.60 ± 13.00 minutes; P = 0.07).

Conclusions

In patients with suspected sphincter of Oddi dysfunction, magnetic resonance pancreatography demonstrated PDD increase following secretin injection but did not predict the results of manometry.

Sphincter of Oddi dysfunction (SOD) is increasingly recognized as a cause for upper abdominal pain and idiopathic pancreatitis ( ). Sphincter of Oddi manometry (SOM) is the reference standard for the diagnosis of SOD and can be performed by endoscopic retrograde cholangiopancreatography (ERCP), transcutaneously (usually via a T-tube tract), or intraoperatively. A basal sphincter pressure ≥40 mm Hg is considered abnormal ( ).

However, SOM is a costly, invasive procedure that is not widely available and is associated with significant morbidity (e.g., post-ERCP pancreatitis) ( ). Consequently, several less-expensive and less-invasive tests have been evaluated, including morphine-prostigmine provocative test (Nardi test) and quantitative hepatobiliary scintigraphy. Unfortunately, each of these tests has limitations. The Nardi test has low sensitivity and specificity in predicting the presence of SOD ( ). Compared to SOM as the reference standard, two recent reports showed hepatobiliary scintigraphy has a sensitivity of only 25% to 49% and a specificity of 78% to 90% for diagnosing SOD ( ). Furthermore, hepatobiliary scintigraphy does not image the pancreatic duct.

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Materials and methods

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Magnetic Resonance Pancreatography

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Endoscopic Retrograde Cholangiopancreatography/Sphincter of Oddi Manometry

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Image Analysis

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Statistical Analysis

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Results

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Table 1

Demographic Characteristics and Procedure Indications between Normal and Abnormal Pancreatic Manometry Groups

Normal SOM Abnormal SOM_P_ -Value Number 10 20 Male/female 4/6 4/16 .38 Mean (SD) age (y) 54 (17) 48 (13) .26 Indication Idiopathic recurrent AP 3 (30%) 5 (25%) 1.00 Single episode AP 0 2 (10%) .54 Abdominal pain without AP 7 (70%) 13 (65%) 1.00 Clinical SOD classification type II 5 (50%) 12 (60%) .71 Clinical SOD classification type III 5 (50%) 8 (40%) .71 Prior cholecystectomy 5 (50%) 9 (45%) 1.00

AP: acute pancreatitis; SOD: sphincter of Oddi dysfunction; SOM: sphincter of Oddi manometry.

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Table 2

Main Pancreatic Duct (PD) Diameter (mm) and Percent Change From Baseline Before and at Various Time Points (minutes) After Secretin Stimulation

SOM N 0 1 2 3 4 5 6 7 10 15 20 30 Normal 10 1.62 1.95 2.78 2.50 2.40 2.19 2.20 2.10 1.91 2.00 1.80 2.00 (20%) (71%) (54%) (48%) (35%) (36%) (30%) (18%) (24%) (11%) (24%) Abnormal 20 1.45 1.82 2.00 2.32 2.02 1.70 1.84 1.68 1.52 1.49 1.57 1.53 (26%) (38%) (61%) (39%) (17%) (27%) (16%) (5%) (3%) (8%) (6%) Overt CP* 9 2.17 2.58 2.82 3.07 2.70 2.63 2.58 2.48 2.33 2.29 2.35 2.38 (19%) (30%) (41%) (24%) (21%) (19%) (14%) (7%) (6%) (8%) (10%)

CP: chronic pancreatitis.

Overt CP was defined as mild to severe chronic pancreatitis change by ERCP, according to the Cambridge classification.

Table 3

Mean (SD) Pancreatic Ductal Diameter Before and After Secretin Administration for Patients with Normal Pancreatic Sphincter of Oddi Manometry (SOM), Abnormal SOM, and Overt Chronic Pancreatitis (CP) ⁎

Normal SOM a (n = 10) Abnormal SOM b (n = 20) Overt CP c (n = 9) Presecretin 1.62 (0.73) 1.45 (0.26) 2.17 (0.94) Maximum postsecretin 2.78 (0.77) 2.32 (0.75) 3.07 (1.19) Percent increase 71% 61% 41%

P- Values for comparisons of change in mean diameter were .33 (a vs b), .54 (a vs c), and .92 (b vs c).

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Table 4

Comparison of Means (SDs) of Main Pancreatic Duct (PD) Measurements Between Patients with Normal and Abnormal sphincter of Oddi Manometry (SOM) Results

Normal SOM (n = 10) Abnormal SOM (n = 20)P -Value Presecretin diameter (mm) 1.62 (0.73) 1.45 (0.26) .33 Maximum postsecretin diameter (mm) 2.78 (0.77) 2.32 (0.75) .13 Maximum diameter change (mm) 1.15 (0.70) 0.88 (0.72) .33 Time to maximum diameter (min) 2.51 (1.02) 2.89 (1.57) .52 Time to ≥0.5-mm change (min) 1.38 (0.52) 1.80 (1.14) .33 Duration of >0.5-mm change (min) 13.60 (13.00) 5.28 (8.76) .07

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Table 5

Pancreatic Duct Response to Secretin (MRCP) versus Sphincter of Oddi manometry (SOM) for Diagnosis of Sphincter of Oddi Dysfunction

MRCP SOM Normal Abnormal Total Normal 9 18 27 Abnormal 1 2 3 Total 10 20 30

MRCP sensitivity = 10%; MRCP specificity = 90%.

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Table 6

Duodenal Filling Grade Among Normal Pancreatic Sphincter of Oddi Manometry (SOM), Abnormal SOM, and Overt Chronic Pancreatitis (CP) Patients

Grade Normal SOM (n = 10) Abnormal SOM (n = 20) Overt CP (n = 9) 1 0 0 0 2 1 (10%) 2 (10%) 3 (33%) 3 9 (90%) 18 (90%) 6 (67%)

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Discussion

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Summary

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