SUPEROXIDE D SPLITT FREEFree radicals are strongly associated with many pathological processes in the body. SOD is the only antioxidant enzyme that scavenges the superoxide anion by converting this free radical to oxygen and hydrogen peroxide, thus preventing peroxynitrite production and further damage. Patients with postcholecystectomy pain should be evaluated for another etiology of their pain or potentially a complication of the prior surgery.įei Wang, Yu-Qing Zhang, in Advances in Protein Chemistry and Structural Biology, 2015 4.3.2 Superoxidase For this reason, routine ERCP is not recommended for patients with SOD and certainly not for patients with pain only in the absence of objective criteria. 26 In this study, endoscopic sphincterotomy was actually worse than sham intervention in preventing recurrence of abdominal pain. SUPEROXIDE D SPLITT TRIALThe EPISOD study by Cotton and colleagues was a large randomized clinical trial of patients with postcholecystectomy pain and little or no objective evidence for biliary obstruction, with patients randomized to sphincterotomy or sham intervention. 122Īlong with changes in understanding of SOD, treatment for the condition has changed substantially. SOD type III was characterized by pain alone however, this diagnosis has largely been discarded in clinical practice due to the lack of objective findings to support its existence. SOD type II (sphincter dysfunction) is associated with either abnormal laboratory test results or a dilated bile duct. SOD type I (sphincter stenosis) is associated with objective abnormalities in laboratory test results, often during an attack, and an abnormally dilated extrahepatic bile duct on an imaging study. Sphincter of Oddi manometry may be performed during ERCP by passing a water-perfused or solid-state catheter into the bile duct or pancreatic duct to measure the biliary or pancreatic sphincter pressure, respectively. 120,121 All types are characterized by intermittent biliary-type abdominal pain. SOD was historically classified as type I, II, and III based on varying degrees of imaging and laboratory abnormalities (see Chapter 63). Mark Feldman MD, in Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 2021 SOD These findings do not support ERCP and sphincterotomy for these patients. 176 The trial concluded that in patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy versus sham sphincterotomy did not reduce disability due to pain. For patients with type 3 SOD, the results of a large rigorously conducted multicenter RCT, the EPISOD trial, has been published. 175 Although one could debate if idiopathic recurrent AP can be labeled as type 2 SOD, a large number of patients with abdominal pain after cholecystectomy, but no objective evidence of biliary or pancreatic disease is subjected to ERCP, sphincter of Oddi manometry, and biliary and or pancreatic sphincterotomy with a diagnosis of type 3 SOD. 174 The arguments against SOD as a cause of AP include: (1) the lack of any prospective controlled blinded trials in the treatment of this disorder (2) the short duration of follow-up in the observational reports (3) the high risk of pancreatitis (25% to 35%) associated with ERCP, sphincter of Oddi manometry, and pancreatic sphincterotomy in patients with suspected SOD (4) the extremely variable natural history of idiopathic recurrent pancreatitis, which may mask the minimal effects of therapy 175 and (5) the relative dearth of data determining the normal range of pancreatic sphincter pressure that is the basis for the pathogenesis of SOD. SUPEROXIDE D SPLITT SERIESThe main argument in favor of this entity as a cause of AP is the many observational series that report that endoscopic pancreatic sphincterotomy or surgical sphincteroplasty reduces recurrent attacks of pancreatitis. Investigators who study patients with recurrent AP report that SOD (usually defined as a basal pancreatic sphincter pressure >40 mm Hg) is the most common abnormality discovered, occurring in approximately 35% to 40% of patients. Mark Feldman MD, in Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 2021 SOD (See Chapter 63)
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