• Spasm: high basal sphincter pressure
• Tachyoddia: high frequency of phasic contractions (>10 per second)
• Bradyoddia: low frequency of phasic contractions (<1 per second)
• Nutcracker: phasic contractions that are prolonged (>10 seconds) and of a high amplitude (>300 mm Hg; normal is <30 mm Hg)
• Retrograde propagation of contractions

• Biliary dyskinesia is being recognized with increasing frequency in late childhood and the teenage years.
• Females are disproportionately more affected than are males.

• Acute cholangitis, cholecystitis, or cholelithiasis
• Hepatitis
• Peptic ulcer disease, Helicobacter pylori, gastritis from NSAIDs
• Reflux esophagitis
• Renal disease, UTI
• Pneumonia
• Pancreatitis
• Irritable bowel syndrome
• Lactose intolerance
• GI anatomical abnormalities (i.e., intestinal malrotation)

• The major symptom is pain, which is usually epigastric, radiating to the right upper quadrant and into the back.
• Pain is often related to a fatty type meal but may also occur spontaneously.
• Nausea and vomiting may accompany the pain.
• There may be an increased sensitivity toopiate-type medication (e.g., codeine and morphine). Even small doses of codeine, such as occurs in cough mixtures, may initiate a severe episode of pain.
• In some patients, the symptoms may be accompanied by a rise in serum amylase, and a diagnosis of recurrent pancreatitis is made.
• Pain is not relived by antacids, ranitidine, or dietary manipulations.
• There may be a history of cholecystectomy for a similar pain.

• Not febrile
• Mild tenderness in the right upper quadrant and epigastrium
• Remainder of physical examination usually normal

• Transiently abnormal liver transaminases (alkaline phosphatase)
• Abnormal amylase in association with pain episode is also an objective finding.
• The common bile duct may be dilated on ultrasonography, but, usually, no abnormal findings are seen.
• The gold standard for definitive diagnosis is abnormal findings on sphincter of Oddi manometry, generally done during endoscopic retrograde cholangiopancreatography (ERCP).
• Quantitative hepatic scintigraphy is sensitive for distal common duct obstruction, but it is only applicable in postcholecystectomy patients with normal liver function.

• Avoid narcotic analgesics because of their potential to exacerbate the symptoms as well as their addictive potential. Nonnarcotic analgesics (e.g., acetaminophen, aspirin, ibuprofen) may be used to relieve pain.
• Smooth muscle relaxants (e.g., trinitroglycerin and calcium channel blockers) may be effective in “spasm” or “nutcracker” sphincter.
• Laparoscopic cholecystectomy is the treatment of choice for biliary dyskinesia.
• Endoscopic sphincterotomy relieves symptoms in patients with abnormal manometric findings.

• Best response to therapy is seen in patients with sphincter of Oddi spasm or stenosis.
• Persistence of pain and disability despite endoscopic or surgical therapy may require referral to specialized pain management center.

Q: What should raise suspicion of the possibility of biliary pain?
A: Usually, female patient with fatty meal-related epigastric or RUQ pain that is nonresponsive to antacids. Liver enzymes and ultrasound may be normal.

Q: Can symptoms develop or recur after cholecystectomy?
A: Yes. Some patients get long-lasting relief after cholecystectomy, but others have recurrence of symptoms and are best treated with endoscopic sphincterotomy.

Q: What pain relievers should be avoided in biliary dyskinesia?
A: Narcotics, including codeine (Tylenol 1, 2, and 3), because these may stimulate spasm of the sphincter of Oddi and worsen symptoms. Some over-the-counter cough suppressants that contain codeine will cause similar symptoms

Q: What is an indication for referral?
A: Patients who are dependent on or fail to get relief with NSAIDs.

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