Biliary sphincterotomy resets pancreaticobiliary pain refractory to intrasphincteric Botox injections in functional biliary pain.

Background: The management of Type III sphincter of Oddi dysfunction or functional biliary pain (FBP) is challenging. A strategy of intermittent intrasphincteric botulinum toxin (Botox) injections into the sphincter of Oddi can alleviate pancreaticobiliary pain. In patients who lose response to intermittent Botox injections, endoscopic biliary sphincterotomy (ES) could potentially reset pain facilitating ongoing management of symptoms.

Methods: A retrospective review of case notes over a seven-year period (2014-2021) was performed. All patients underwent blood tests, gastroscopy, trans-abdominal ultrasonography, cross-sectional imaging with magnetic resonance cholangiopancreatography (MRCP)/computed tomography (CT) and endoscopic ultrasound (EUS) to rule out alternative causes for their symptoms of pancreaticobiliary pain. A diagnosis of FBP was made in patients with typical post-cholecystectomy pain and normal liver function tests and bile duct size on imaging. Patients with symptomatic FBP underwent intermittent endoscopic Botox injections to the sphincter of Oddi. Patients who lost response to Botox injections underwent ES and were followed up in an outpatient setting to assess response.

Results: One hundred and thirty (128 female, 2 male) patients with FBP underwent a mean of four (2-8) Botox injections over the study period. Of 130 (90%) patients, 117 reported a significant improvement in pain on post procedure review with 81% of patients managing to discontinue opioid medication post procedure. Fifty-one out of 130 (39%) lost response to Botox injections after a median of six (range 5-11) sessions (median eight months between sessions [range 6-18 months]) and continued to have ongoing pancreaticobiliary pain and subsequently underwent biliary ES. Forty-one out of 50 (82%) reported a clinical improvement in their symptoms of pancreaticobiliary pain following ES, with response persisting at follow-up for up to mean of eight (5-15) months and no further hospital attendances due to severe pancreaticobiliary pain.

Conclusion: ES can reset pancreaticobiliary pain in FBP once Botox injection therapy to the sphincter of Oddi becomes ineffective and may provide ongoing relief of symptoms.