PTU-078 Delays in the diagnosis and management of patients with suspected sphincter of oddi dysunction

Abstract

Introduction: Sphincter of oddi dysfunction (SOD) is difficult to diagnose and treat. Biliary manometry is considered to be the gold standard for diagnosing SOD but is not widely available. A significant number of patients, that we think are likely to have sphincter oddi dysfunction, present to our hospitals with recurrent upper abdominal pain. They have multiple investigations, recurrent A+E attendances and repeated admissions without a clear diagnosis or definitive treatment. Our aim was to identify this patient group in order to streamline their investigations and allow definitive treatment at an early stage, prevent readmission and save resources. Methods: A retrospective case note review of patients across three hospitals in South Yorkshire, in whom the final diagnosis was SOD based on their clinical presentation and investigations. Results: We reviewed 40 case notes in total. 88% of patients were female with a median patient age of 40 (18-75 years) Patients on average presented to A+E 6 times (0-50), median number of inpatient admissions was 4 (0-20) with additional outpatient clinic appointments. 70% (28/40) of patients have previously undergone cholecystectomy, with 100% continuing to have similar pain to that prior to surgery. The most common provisional diagnosis at presentation was bile duct stones (38%). Median duration of symptoms was 3 years (range 5 months-23 years). 35% (14/40) of patients initially presented to the surgeons. 100% of patient had abdominal USS (1-5) and 63% had undergone at least one OGD. All patients had a MRCP (range 1-4), 17 (43%) patients had a CT abdomen (0-4) and 12 (30%) patients underwent a HIDA scan. Patients were categorised into SOD type 1 (22%), type 2 (56%) or type 3 (22%) on their clinical presentation and investigations. 28% (7/40) of patient had a trial of Botox, 48% (19/40) underwent ERCP and biliary sphincterotomy with 53% (10/19) having symptomatic improvement. The remainder were managed on medial therapy. Conclusion: There is a significant group of patients, who have recurrent abdominal pain, recurrent admissions, undergo multiple investigations and trials of medical therapy without a definitive diagnosis being made. In addition, these patients are often subjected to invasive interventions such as ERCP and sphincterotomy with the potential risk of serious complications. This audit highlights the need for a designated service to streamline work-up and management of these patients: both to reduce cost and to improve outcomes.