Spasm of the sphincter of Oddi still occurs during cholecystectomy. Some reports indicate that the spasm, induced by morphine, can be reversed by injection of naloxone, nalbuphine, and glucagon. Others maintain that nitroglycerin or nifedipine can relax the sphincter of Oddi muscle. We recently encountered spasm of the sphincter of Oddi during a laparoscopic cholecystectomy and treated it successfully with intravenous nitroglycerin.

SPASM of the sphincter of Oddi still occurs during cholecystectomy. Some reports indicate that the spasm, induced by morphine, can be reversed by injection of naloxone, 1nalbuphine, 2and glucagon. 3Others maintain that nitroglycerin 4or nifedipine 5can relax the sphincter of Oddi muscle. We recently encountered spasm of the sphincter of Oddi during a laparoscopic cholecystectomy and treated it successfully with intravenous nitroglycerin.

Case Report

A 52-yr-old woman weighing 55 kg was scheduled to undergo elective laparoscopic cholecystectomy. Her blood pressure was 140/100 mmHg, and her heart rate was 80 beats per minute and regular at the time of admission. She had no history of medication for hypertension. Laboratory data, including liver function test results, were within normal limits. Drip infusion cholecystography provided clear visualization of the gallbladder and biliary ducts.

The preanesthetic medication consisted of meperidine (35 mg intramuscularly), atropine (0.5 mg intramuscularly) and famotidine (20 mg intramuscularly). In the operating room, the usual monitors were put in place. After a single epidural injection of morphine (2 mg/4 ml normal saline), general anesthesia was induced with thiopental (100 mg intravenously) followed by vecuronium (5 mg intravenously) and maintained with isoflurane (0.3–1.0%) and nitrous oxide–oxygen (fractional inspired oxygen tension, 0.33). Nicardipine was administered to control blood pressure because the patient remained hypertensive (170/100 mmHg) after induction. The first cholangiogram via  the cystic duct tube showed obstruction to the flow of radiographic contrast at the terminal end of the common bile duct (fig. 1). This was confirmed with a second cholangiogram. Because we speculated that the obstruction might be the result of spasm of the sphincter of Oddi induced by epidural morphine, we injected naloxone (0.2 mg intravenously). However, a third cholangiogram, performed 5 min late, showed continued obstruction. We then administered nitroglycerin (0.1 mg) at 0.01 mg/min for 20 min intravenously in place of the nicardipine, and we finally achieved satisfactory passage of contrast material to the duodenum (fig. 2). The postoperative course of the patient was uneventful. The next day, the C tube was removed after excellent flow of contrast material to the duodenum had been confirmed.

Fig. 1. The first cystic duct cholangiogram. The intrahepatic biliary tract and common bile duct are visualized dilated by dye injection. The narrowing appearance of the distal common duct, with its tapering bird-beak shape, and the absence of radiographic dye flow into the duodenum are shown.

Fig. 1. The first cystic duct cholangiogram. The intrahepatic biliary tract and common bile duct are visualized dilated by dye injection. The narrowing appearance of the distal common duct, with its tapering bird-beak shape, and the absence of radiographic dye flow into the duodenum are shown.

Fig. 2. The final cystic duct cholangiogram after injection of nitroglycerin. Free flow of contrast medium into the duodenum can be seen, and the whole biliary tract is of normal size.

Fig. 2. The final cystic duct cholangiogram after injection of nitroglycerin. Free flow of contrast medium into the duodenum can be seen, and the whole biliary tract is of normal size.

Discussion

Several factors that may cause intraoperative spasm of the sphincter of Oddi have been reported. These include perioperative usage of opioids, operative manipulation of the common bile duct, and injection of cold or irritating contrast medium. 6We used meperidine, which has been shown to be less likely to induce spasm, 7,8as part of the preanesthetic medication. Although we cannot rule out completely the effect of epidural morphine on the sphincter, ineffectiveness of naloxone indicates that another cause is more likely. The chief cause of the spasm in our case might be operative manipulation or irritation caused by the contrast medium.

Nitroglycerin can relax vascular smooth muscles, including that of the gastrointestinal tract. Moreover, it is reported to have a dilating effect on the sphincter of Oddi. 4Nitroglycerin has been used to facilitate endoscopic removal of common bile duct stones 9and to reverse the spasm induced by narcotic usage. 10On the other hand, it has been suggested that nifedipine can reduce the pressure of the sphincter and may have therapeutic potential for the treatment of sphincter of Oddi dyskinesia. 5Our case seems to indicate that nicardipine may have a less dilating effect on the sphincter than does nitroglycerin. In summary, this report shows that, when the spasm of the sphincter of Oddi occurs during laparoscopic cholecystectomy, anesthesiologists can take an active part in treating it effectively with intravenous nitroglycerin.

References

1.
Richard LM, Oscar JV, Robert KS, Gale ED: Naloxone reversal of choledochoduodenal sphincter spasm associated narcotic administration. A nesthesiology 1978; 48: 437
2.
Harold KH, Neal WF: Opioid-induced spasm of the sphincter of Oddi apparently reversed by nalbuphine. Anesth Analg 1992; 74: 308–10
3.
Jones RM, Fiddian-Green R, Knight PR: Narcotic-induced choledochoduodenal sphincter spasm reversed by glucagon. Anesth Analg 1980; 59: 946–7
4.
Staritz M, Poralla T, Ewe K, Meyer Zum Büschenfelde K-H: Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure. Gut 1985; 26: 194–7
5.
Guelrud M, Mendoza S, Rossiter G, Ramirez L, Barkin J: Effect of nifedipine on sphincter of Oddi motor activity: Studies in healthy volunteers and patients with biliary dyskinesia. Gastroenterology 1988; 95: 1050–5
6.
Chessick KC, Black S, Hoye SJ: Spasm and operative cholangiography. Arch Surg 1975; 110: 53–7
7.
Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th edition. New York, McGraw-Hill, 1995, pp 532
8.
Elta GH, Barnett JL: Meperidine need not be proscribed during sphincter of Oddi manometry. Gastrointest Endosc 1994; 40: 7–9
9.
Staritz M, Poralla T, Dormeyer HH, Meyer Zum Büschenfelde K-H: Endoscopic removal of common bile duct stones through the intact papilla after medical sphincter dilation. Gastroenterology 1985; 88: 1807–11
10.
Velosy B, Madacsy L, Lonovics J, Csernay L: Effect of glyceryl trinitrate on the sphincter of Oddi spasm evoked by prostigmine-morphine administration. Eur J Gastroenterol Hepatol 1997; 9: 1109–12